Comprehensive Clinical Psychology [Volume 9]

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Comprehensive Clinical Psychology. Volume 9 Copyright © 2000 Elsevier Science Ltd. All rights reserved. Editors-in-Chief: Alan S. Bellack and Michel Hersen Table of Contents Volume 9: Applications in Diverse Populations Close Preface Contributors Section I: Individuals with Disabling Conditions, , 9.01 Mental Retardation, Pages 1-17, Sarah W. Bisconer Janene N. Suttie SummaryPlus | Chapter | PDF (303 K) 9.02 Pervasive Developmental Disorders, Pages 19-35, Donald P. Oswald SummaryPlus | Chapter | PDF (335 K) 9.03 Learning Disabilities, Pages 37-55, Ivan L. Beale SummaryPlus | Chapter | PDF (345 K) 9.04 Visual Disabilities, Pages 57-68, Steven J. Lagrow and Steven Humphries SummaryPlus | Chapter | PDF (282 K) 9.05 Hearing Disabilities, Pages 69-83, Laurence Mckenna Gerhard Andersson SummaryPlus | Chapter | PDF (311 K) 9.06 Jail and Prison Inmates, Pages 85-104, Ronald Roesch, James R. P. Ogloff, Patricia A. Zapf and Stephen D. Hart Randy Otto SummaryPlus | Chapter | PDF (355 K) 9.07 Violent and ChronicOffenders, Pages 105-117, Isaac K. Wood SummaryPlus | Chapter | PDF (253 K) 9.08 Homelessness, Pages 119-135, Paul A. Toro SummaryPlus | Chapter | PDF (339 K) 9.09 Individuals with Traumatic Brain Injury, Pages 137-153, Stephen R. Hooper SummaryPlus | Chapter | PDF (338 K) 9.10 Street Gangs, Pages 155-167, David W. Thompson SummaryPlus | Chapter | PDF (265 K) Section II: Families, ,

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9.11 Families of Individuals with HIV Infection/AIDS, Pages 169-182, Marc J. Tassé Susan M. Havercamp SummaryPlus | Chapter | PDF (281 K) 9.12 Families of Individuals with Developmental Disabilities, Pages 183-197, Oliver C. Mudford and Gill McGrane SummaryPlus | Chapter | PDF (325 K) 9.13 Families of Alcoholics, Pages 199-218, Barbara S. McCrady, Elizabeth E. Epstein and Christopher W. Kahler SummaryPlus | Chapter | PDF (345 K) 9.14 Families of Children with Chronic Medical Conditions, Pages 219-233, Robert J. ThompsonJr. Lauren B. Raezer SummaryPlus | Chapter | PDF (283 K) 9.15 Families of Children with Serious Emotional Disturbance, Pages 235-252, Cynthia R. Ellis and Nirbhay N. Singh SummaryPlus | Chapter | PDF (323 K) 9.16 Family Lives of Lesbians and Gay Men, Pages 253-273, Charlotte J. Patterson SummaryPlus | Chapter | PDF (356 K) 9.17 Families of Divorce, Pages 275-289, Arnold L. Stolberg, Elizabeth Mullett and Eugene V. Gourley SummaryPlus | Chapter | PDF (301 K) Section III: Victims, , 9.18 Adult Victims of Child Sexual Abuse, Pages 291-306, Roger C. Katz Patti Lou Watkins SummaryPlus | Chapter | PDF (330 K) 9.19 Adult Victims of Physical Violence, Pages 307-324, Ron Acierno, Christina Byrne, Heidi S. Resnick and Dean G. Kilpatrick SummaryPlus | Chapter | PDF (337 K) 9.20 Victims of Domestic Violence, Pages 325-339, Amy Holtzworth-Munroe and Natalie Smutzler Ernest N. Jouriles and William D. Norwood SummaryPlus | Chapter | PDF (320 K) 9.21 Victims of Child Maltreatment, Pages 341-358, Sandy K. Wurtele SummaryPlus | Chapter | PDF (299 K) 9.22 Victims of Hate Crimes, Pages 359-374, Cheryl S. Al-Mateen, Dawn K. Lewis, and Nirbhay N. Singh SummaryPlus | Chapter | PDF (306 K)

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9.23 Victims of Disasters, Pages 375-390, Nigel Long, Kevin Ronan and Joyce Pereira-Laird SummaryPlus | Chapter | PDF (290 K) 9.24 Victims of War, Pages 391-406, Norman A. Milgram SummaryPlus | Chapter | PDF (330 K) Section IV: Perpetrators, , 9.25 Adult Sexual Offenders, Pages 407-420, William L. Marshall SummaryPlus | Chapter | PDF (281 K) 9.26 Perpetrators of Physical Violence and Abuse, Pages 421-436, Abram Rosenblatt and Jennifer A. Rosenblatt SummaryPlus | Chapter | PDF (331 K) 9.27 Perpetrators of Domestic Violence, Pages 437-452, Etiony Aldarondo SummaryPlus | Chapter | PDF (327 K) 9.28 Children with Aggressive Sexual Behavior, Pages 453-466, Barbara L. Bonner William E. Fahey SummaryPlus | Chapter | PDF (275 K) 9.29 Perpetrators of Racial Violence and Hatred, Pages 467-481, Alan S. W. Winton Nirbhay N. Singh and Kristen McAleavy SummaryPlus | Chapter | PDF (263 K)

Preface Volume 9 Introduction Clinical psychologists deal with the mental health problems of a wide variety of people. In an era of managed care, we need to demonstrate that we not only understand the mental health problems of our clients, but also that we can treat them as effectively and rapidly as possible. This requires us to integrate theory, research, and practice in a manner that will have the best outcomes for our clients as well as for the people who pay us for our services. Thus, knowledge of current basic and applied research in major areas of clinical psychology is paramount. However, the application of this knowledge across diverse populations is always a challenge because it entails understanding the complex transactions that take place among the biological, psychological, social, and cultural factors that modulate the behavior of individuals. There is a growing literature showing that the experience of being mentally ill is an interpretive enterprise, constructed by individuals according to their personal and cultural explanatory models of disease and mental disorders. For the most part, Western psychology has ignored sociocultural factors file:///D|/1/CCP/09/00.htm (3 of 18)17.10.06 11:03:19

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in its theoretical and clinical approaches to mental disorders. Like psychiatry, Western psychology appears to be bound by its commitment to a disease conception of mental disorders, assuming that mental disorders are largely biologically caused. This has resulted in the unfortunate situation where many clinicians believe that, because mental disorders are biologically caused, the etiology, manifestation, and treatment of the disorders are universal processes irrespective of the individual's cultural context. Research presented in this volume makes it clear that sociocultural variables are inextricably linked with all aspects of human behavior, and that understanding the nature and clinical import of these variables will enhance treatment outcome in diverse populations. This volume reflects the breadth of research and clinical knowledge that psychologists have contributed to over the past several decades. While other volumes in this series are devoted to specific topics, the strength of this volume lies in its breadth. It demonstrates our evolution as clinicians, researchers, and theorists, and shows that we have amassed a vast corpus of knowledge on normal and psychopathological behavior in children, adolescents, and adults. This volume is divided into four sections. The first section deals with a number of psychological disorders or life conditions that heighten the risk for mental health problems and psychological distress. The second section deals with families of various kinds, ranging from those who care for family members who have physical or mental disorders to families in which there are two mothers or two fathers. The third section deals with victims of physical or psychological distress; people who are victims of abuse, violence, hatred, disasters, and war. The fourth section deals with the perpetrators of abuse, violence, and hatred. Clearly, psychologists have made and continue to make major contributions not only to our knowledge of the nature of psychological disorders or life conditions that affect our behavior and interactions with others, but also to our clinical expertise in treating conditions that lead to mental health problems. The chapter authors were chosen because of their areas of expertise, as well as their contribution to the field of clinical psychology in general. They have written their chapters with a sense of exploration and excitement. Each chapter makes a solid contribution to our knowledge and points us in the right direction for future work. I am most grateful to my eminent contributors, who provided me with excellent manuscripts to work with and indulged my editorial changes. This is their book. Individuals with Disabling Conditions This section has 10 chapters that deal with various psychological disorders or life conditions that may lead to mental health problems in children and adults. Sociocultural, metabolic, chromosomal, and genetic factors are responsible for the majority of disorders that lead to mental health problems in most people. For example, all of these factors have been implicated in mental retardation and developmental disabilities. The etiology of mental retardation can be traced to sociocultural factors in the majority of people who have this disorder. Above everything else, mental retardation is a disorder of learning, although people with the disorder may have organic, psychiatric, and purely medical problems as well. Although there has always been a controversy regarding the treatment of people with mental retardation, and the best place to provide this treatment, this is a relatively minor issue now. The majority of people with mental retardation

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live and work in our communities, and Western society is heavily invested in relocating to the community the few that remain in institutions. Recently, there has been much interest in using personcentered planning processes to transition people with mental retardation to the community and to provide them with social, behavioral, and other necessary supports and safety nets so that they can have an enhanced quality of life. Issues in the area of pervasive developmental disabilities are similar to those in mental retardation generally. People with pervasive developmental disorders have neuropsychiatric syndromes that are evident in childhood and persist throughout the life span. Given that the primary behavioral feature of people with pervasive developmental disorders is a marked impairment in social interaction skills, people with these disorders do not necessarily have to be institutionalized for their care. Again, as with mental retardation, learning is the key issue, and the majority of interventions are based on learning theory. For example, structured teaching and behavioral interventions appear to work well with the majority of people with this disorder. Psychopharmacological interventions may be paired with learning-based treatments if there is a clear rationale for using psychotropic medication based on the psychiatric condition of the individual. Alternative and complementary treatments such as megavitamins have been used, but their efficacy has not been clearly established in large, wellcontrolled studies. As the name implies, learning disability is also a learning-based disorder. It has been defined as learning problems that specifically affect one or more skill areas, such as reading, writing, or social skills in persons who are otherwise normally skilled and educated. Typically, learning disabilities originate as a developmental disorder of childhood, although they can be acquired through the life span as a result of brain trauma. Dyslexia is the best known learning disability, and is characterized by a singular inability to read. Depending on the definition of the disorder, its prevalence varies from a low of 2% in some countries to a high of 20% in others. Further, the disorder is recognized in some countries (e.g., UK, Canada, US) but not in others (e.g., New Zealand). A broad range of treatments have been advanced, but few have a solid research base to recommend them. In addition, a number of alternative treatments have been advocated for learning disabilities (e.g., special diets, tinted glasses, gross motor exercises, and cranial manipulation), but without much research support. The loss of function due to visual impairment can lead to a number of visual disabilities which may impose limitations on the range of activities an individual can engage in. Regardless of whether the visual disabilities are progressive or nonprogressive, individuals with visual disabilities need to adjust to their impairment and restricted functioning. Psychologists are often able to assist individuals undergoing these changes to make an easier transition from a sighted to partially sighted or totally unsighted world. A primary role for the psychologist is to assist individuals with visual disabilities to overcome the psychological and emotional distress that often accompanies severe visual impairment and blindness. The distress often manifests as anxiety, devaluation, demoralization, and depression, with older people finding it harder to adjust to the onset of visual impairment than their younger peers. Similar problems are associated with people who experience hearing disabilities. Hearing disorders are typically caused by damage to or interference with any part of the auditory pathway from the outer ear to the brain. Although the field of hearing disabilities falls within the general areas of audiological medicine and otolaryngology, most clinical psychologists have concentrated only on the file:///D|/1/CCP/09/00.htm (5 of 18)17.10.06 11:03:19

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psychological issues related to hearing loss and tinnitus. That is, they have focused on psychological issues related to acquired hearing loss, the causes of which may range from common influenza-type infections to cerebral tumors. Current research suggests that although hearing impairment per se does not cause severe psychological distress, it is more likely that a vulnerability for psychological disorder may interact with it to produce the psychological consequences. As with visual disabilities, there is a need to better understand the mental health outcomes associated with hearing disabilities and the role that clinical psychologists can play in the assessment and treatment of these problems. Jail and prison inmates are a sizable population in any society, with some of them having mental health problems that are serious enough to require treatment. The prevalence of mental illness in jail and prison inmates varies from about 3% to 59%, depending on the diagnostic criteria and data collection methodology used. Further, there is a perception by mental health professionals that the number of people with mental illness entering jails and prisons is gradually increasing. One strand of thought is that as the financial resources in the general field of mental health decrease, the number of people in jails and prisons with mental illness increases because the mental health service delivery system cannot adequately accommodate all of them. In addition to mental health problems, many individuals in jails and prisons are also substance abusers. Incarcerated substance abusers are not seen as a problem by the authorities because most prisoners have very limited access to alcohol and drugs in jails. However, when substance abusers are jailed, there is a need for involvement by psychologists because rapid drug withdrawal poses significant psychological distress and could be life threatening. Psychologists can also be key mental health professionals in jails and prisons in a number of different contexts, including the assessment and treatment of mental disorders in inmates, pretrial assessments for competency to stand trial, assessments of competency to be executed, assessment for an insanity defense, and risk assessment for aggressive and violent behavior. Violent and chronic offenders also form a sizable group in our society. The number of crimes committed by youthful offenders has been increasing at a very rapid pace over the last few years. For example, while the prevalence rates have remained static for adult offenders, the total number of juvenile arrests has been increasing by about 5% each year; arrests for weapons violations increased by over 10%, and the arrest rates for weapons violations increased by about 14%. Juveniles who engage in violent offenses typically engage in one or more of the following: murder, manslaughter, and rape or sexual assault. In addition, they may engage in armed robbery, malicious wounding, and aggravated physical assault. The majority of violent and chronic offenders begin engaging in these behaviors in late childhood and early adolescence and continue into adulthood. Many of these violent and chronic offenders have mental health and substance abuse problems that are typically left unattended when they are incarcerated for their offenses. As with the jail and prison inmates, clinical psychologists have a major role in the mental health care of violent and chronic offenders, particularly the juvenile offenders. People who are homeless provide another example of a population that has largely unmet mental health needs. The prevalence of homelessness has been difficult to estimate because of the enormous methodological problems involved. In the US, it is likely that up to 7¯8% of people have experienced at least one episode of homelessness. While further research on its prevalence may give us a better notion of the size of the problem, many researchers feel that further resources should not be spent in this endeavor; by almost anyone's standards, the problem of homelessness has reached unacceptable

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proportions, and we should put all of our efforts toward ameliorating or, at the very least, containing the problem. In terms of mental health, there are a number of good studies which suggest that the rates of psychiatric disorders in this population are rather high. For example, the rates of affective disorders among homeless adults range from 14% to 30%, with depression accounting for the majority of these disorders. The rate of post-traumatic stress disorder (PTSD) is also very high¯¯almost 40% in one study¯¯and the prevalence of anxiety disorders ranges from 10% to 39%. While most lay people think that the majority of homeless adults have schizophrenic disorders, its prevalence in this population is much less, under 10%. In addition, a rather high proportion of homeless adults (up to 75%) have a lifetime diagnosis of substance abuse disorder, although about 30¯50% of those with a lifetime diagnosis of substance abuse have few or no symptoms of the disorder. Of course, this means that some homeless adults have a severe mental illness as well as a substance abuse disorder. Further, about 15% of homeless adults have a cognitive impairment. All of this means that this is a large population of individuals in need of mental health services, although the issue of funding these services remains to be solved. Traumatic brain injury affects the overall functioning of an individual. Its overall incidence rate is about 386 per 100 000, with a 2:1 male to female ratio. Research on the severity of traumatic brain injury for children under 15 years of age suggests that about 5% are fatal, 6% are severe, 8% are moderate, and 81% are mild in nature. Although higher rates of traumatic brain injury have been reported in minority populations when compared to Whites, it is likely that the association is more with socioeconomic status rather than race per se. Other risk factors for traumatic brain injury in children include psychosocial problems, specific learning problems, lower academic achievement, and teacher-reported problems (e.g., hyperactivity, depression, and antisocial behaviors). In addition, there is a suggestion in the literature that those already with a traumatic brain injury are at increased risk because of the sequelae incurred from the first one. Most traumatic brain injuries in adults occur as a result of motor vehicle accidents, with motorcycle accidents being four times as common as other motor vehicle accidents. Accidents in the home account for most of the injuries in children. Psychologists are involved in assessing the neurocognitive and psychosocial outcomes of traumatic brain injury. Typically, they work with physicians to rule out medical conditions (e.g., post-traumatic seizures, spasticity, ataxia) that may make differential assessment difficult. In addition, psychologists assist in intervention, such as in cognitive rehabilitation and educational programming. Although there is a substantial body of research work in the general area of gangs, much less has been written about street gangs. Police reports indicate that about 57% of all US cities with populations of over 25 000 people and almost 90% of cities with populations of 150 000 have youth gang problems. Further, research suggests that gang-related crimes have been increasing dramatically over the last several decades. Psychologists have been involved in the assessment and treatment of street gangs. However, this has not been an area of much vigorous activity because of the inherent political and social problems. It is difficult to work with gang members, and seldom do gang members voluntarily seek treatment. Because street gangs are a social problem, psychologists have contributed to large-scale efforts at controlling gangs, such as in street worker and group cohesiveness programs. Further, they have been active in designing and implementing prevention file:///D|/1/CCP/09/00.htm (7 of 18)17.10.06 11:03:19

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programs, such as the school-based BUILD program in Chicago. This is an area of research and practice that psychologists should be more heavily invested in because it is a growing, socially significant problem. In summary, disabling conditions in individuals can occur through a myriad of factors, and psychologists have much to contribute in the prevention, assessment, and treatment of these conditions. Families This section consists of seven chapters that deal with various aspects of families and mental health. Families provide the backbone of our society, as well as our mental health service delivery systems. After decades of blaming families for virtually all of the problems faced by our children, we have come to realize that blaming families provides neither a good theoretical basis for understanding psychopathology nor a useful rationale for intervening with those who have psychological disorders severe enough to warrant treatment. In addition, caring for a family member with psychological or physical disabilities invariably affects all members of the family. Further, family upheavals, such as parental divorce, and nontraditional family structures, such as having two mothers or two fathers, affect the nature of family dynamics. Caring for a family member with HIV/AIDS is an arduous task, both psychologically and physically. Two types of families are involved; those that the individuals with HIV/AIDS refer to as their "family of choice" and families in the traditional sense. When individuals with HIV/AIDS are alienated by their parents and siblings, they often seek the assistance of their partners and friends. These partners and friends eventually take on the role of "family" and provide informal caregiving to the person. Both types of family members are responsible for providing medical, psychological, emotional, and financial support. Parents and siblings often face adjustment problems when they learn that a family member, usually a gay male, has HIV/AIDS because they learn not only that their son or brother has a potentially deadly disease, but it may also often be the first time that they learn that he is gay. In cases where the homosexuality of the person has previously been accepted by the family, the impact of learning about the HIV/AIDS diagnosis is less severe. Families often begin by keeping their family member's HIV/AIDS diagnosis a well-guarded secret because they do not wish to face the stigma associated with AIDS and homosexuality. They can overcome their fears and concerns by accepting the diagnosis and their child's homosexuality, and reintegrating the child into the family, if needed, or by keeping the family intact through the inevitable long-term consequences of HIV infection and AIDS. Further, families often respond by turning their grief and anger at their child's lover or partner, accusing the person of being responsible for their child's HIV infection. This typically leads to tension and stress among the child, the lover or partner, and the family members. Additional stress is caused by the family's lack of knowledge regarding the risk of being infected and the costs of medical and psychological care, not to mention the time the family must spend in the physical care of the infected child. Providing educational, financial, medical, psychological, and social support to both the family members and the person with HIV/AIDS greatly reduces the family's burden and psychological sequelae of caring for a person with HIV/AIDS.

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Caring for children with developmental disabilities, serious emotional disturbance, or chronic medical conditions places families under immense stress. Chronic family stress may sometimes lead to out-of-home placements for either respite or long-term care and, in some families, it may place the child at risk for abuse and neglect. Further, it may lead to changes within the family, such as parental divorce, lower rates of remarriage, reduced marital satisfaction and psychological well-being, social isolation, and increased financial burden. Although caring for children with disabilities or with chronic medical conditions is not necessarily a negative experience for all families, most family members experience psychological distress at some point that may be severe enough to require professional therapy. The role of the clinical psychologist is to facilitate the family members' acceptance of the circumstances, and to provide them with coping skills so that they can maintain their physical and psychological well-being. Sometimes individual therapy may be necessary for psychiatric problems, such as for depression and anxiety, and group or family therapy may be necessary to deal with family issues. While there are no easy solutions to a family's problems, it behooves the psychologist to understand the family dynamics and the family's view of the issues involved, as well as their criteria for acceptable family functioning. This provides the psychologist with the basis for collaborating with the families and jointly finding the solutions for their problems. Alcoholism is a major problem in many countries, and excessive alcohol use has serious consequences on family and marital functioning. In the US, the estimated lifetime prevalence rate of alcoholism is about 14% and the one-year prevalence is about 7%. However, the rate is probably much higher for those individuals who have problems related to alcohol use but do not meet the DSMIV criteria for alcohol abuse and dependence. Further, it has been estimated that almost one in every four persons in the US has a first-degree blood relative who is an alcoholic. As a society, we pay a heavy price for alcoholism. In addition to about 5% of deaths that can be associated with its use, heavy alcohol use is also associated with various medical problems (e.g., liver damage, various cardiac conditions, immune system depressions, damage to the endocrine system and reproductive function) and neurological effects. Further, it has been associated with high-risk behaviors and suicide. In addition to the personal problems that alcohol is associated with, the consequences of living with an alcoholic family member are also burdensome. For example, the divorce rate of alcoholics is about four times that of the general population, and there are major disruptions in family life, including increased marital and parent-child conflicts. Family members of alcoholics experience high levels of psychological distress, such as depression and anxiety, and children of alcoholics appear to function less well than children from nonalcoholic families. Psychologists have been very active in conceptualizing the problem of alcohol abuse and its effects on family functioning. In addition to the older, psychodynamic theories, three fairly robust explanatory models (i.e., cognitive-behavioral, family systems, family disease models) have been developed in the last 25 years that are based on social learning theory, general systems theory, and the disease model of alcoholism. These models help us to understand the relationship between alcohol use and family functioning, as well as provide the basis for understanding the functioning of individuals within the family. About 1.4% of women and 2.8% of men in the US (i.e., about 5.5 million people) identify themselves as lesbian or gay. These figures are much higher if we include all people who have had at least one file:///D|/1/CCP/09/00.htm (9 of 18)17.10.06 11:03:19

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same-sex sexual partner since 18 years of age. In addition, there are about 27 million heterosexual people who have a lesbian or gay relative. These figures indicate that there are a substantial number of families of lesbians and gay men. Current research shows that these families share the same sociodemographic characteristics as heterosexual families. Most of the children in lesbian and gay families were born to parents in a heterosexual relationship, and their parent or parents subsequently identified themselves as lesbian or gay. Given that increasing numbers of lesbians and gay men are choosing parenthood, a substantial number of children are conceived by means of donor insemination. Further, some lesbians and gay men adopt children to complete their families. Although it is limited, the research on family lives of lesbians and gay men and their children is strikingly clear. First, there are substantial numbers of lesbian and gay couples and parents in our society. Second, even in the face of societal discrimination and bigotry, these families are thriving and do not have any serious psychological adjustment problems. Third, the family environment is as supportive and nurturing of their children's psychosocial growth as that found in the best heterosexual families. Research shows that psychosocial development among children born to lesbian mothers and gay fathers is essentially normal, suggesting that the structural aspects of the family are not of great significance in their development. Given the meager status of our knowledge in this area, psychologists can play a leading role both in research and advocacy on behalf of the families and their children. Another structural issue with families concerns parental divorce. Parents of one and a half million children in the US are divorced each year and, of these children, 250 000 of them experience psychological distress severe enough to warrant treatment. Research shows that marital or parental conflict has been associated with a wide range of behavior problems in their children, including conduct disorder, delinquency and antisocial behavior, personality disorders, anxiety, withdrawal, and depression. Further, strong correlations have been reported between marital distress in the parents and cognitive functioning, social functioning, and children's grade point average. Although the mechanisms through which these adverse effects occur in the children have not been clearly explicated in the literature, several hypotheses have been advanced by researchers based on social learning, socialization, and family systems theories. Clearly, further research is needed to elucidate how marital distress produces these effects in the children, and how this knowledge can be used to minimize these effects. In summary, families face a number of burdens when caring for a member with psychological, medical, or physical disabilities. Further, children experience psychological distress when their parents have marital conflict. However, research shows that children of lesbian mothers and gay fathers do not have any psychological problems above and beyond those experienced by children from heterosexual families. In addition, the family lives of lesbians and gay men appear to be happy and fulfilled. Victims This section consists of seven chapters that deal with victims of abuse, violence, disasters, and wars. The consequences of child sexual abuse are psychologically harmful and long-lasting. Adult survivors of child sexual abuse are those who, as children, were forced into sexual activity or

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engaged in sexual activity with a much older person. The older person could have been a family member, relative, neighbor, or a stranger, and the sexual activity could have included anything from relatively unobtrusive sexual touching and seductiveness to rape and ritualized sexual abuse. The majority of victims of child sexual abuse are girls, with the abuse typically occurring when they are 10 or 11 years old. The long-term psychological sequelae of sexual abuse include PTSD, anger, social intimacy, and anxiety. In both females and males, it may also include fear, helplessness, isolation and alienation, self-blame, guilt, and shame or humiliation. Men also report problems with masculinity and a fear of homosexuality. However, it must be remembered that many victims of child sexual abuse grow up relatively unscathed psychologically, with a few reporting that they actually benefitted from the experience. Treatment for adult survivors of child sexual abuse is designed to help them cope with the long-term effects of their abuse, and to control their psychological distress. Several treatment models have been developed, including PTSD, traumagenic dynamics, eclectic, and cognitive-behavioral models. While each has been effective with some people, none have had rigorous testing under controlled conditions (e.g., random assignments to treatment and comparison groups). Many adults have been physically assaulted at least once in their lives. The prevalence of physical assault varies with gender, race, and age. Approximately 10-15% of adults in the US have reported being physically assaulted, with men having a higher prevalence rate than women. Men are more likely to be assaulted by strangers than known assailants, and women are more likely to be assaulted by people known to them. Caucasians are more likely to be physically assaulted than non-Caucasians, and younger people are more likely to be assaulted than older people. Further, those who have been assaulted once are at increased risk for being assaulted again. Physical assault of any kind may result in some psychological distress or psychopathology, including PTSD, depression, substance abuse, and panic disorder. Fortunately, psychologists have extensive experience in treating these disorders. One out of every eight women in the US experiences physical assault, and about two million women are severely assaulted by their male partners each year. Male violence against intimate female partners is a serious problem worldwide. Further, male violence against intimate female partners also results in serious psychological distress in the children living in such homes. The long-term psychological sequelae of male violence on intimate female partners include PTSD, depression, and lowered self-esteem. Children in homes where physical violence is perpetrated against the female partner suffer from both externalizing problems such as aggression and oppositional behavior and internalizing problems such as depression and anxiety. In addition, some of these children may also develop symptoms of PTSD. Child maltreatment is a very serious problem in many societies. In the US alone, three to five children die from child abuse and neglect every day, and those who survive suffer from a wide range of physical, psychological, and social problems. In 1994, almost three million children were reported to public child protective agencies as alleged victims of child maltreatment. Because of maltreatment, these children may become anxious, withdrawn, aggressive, inattentive, overly dependent, or sexually provocative. Further, they may have a wide range of associated impairments such as deficits in self-concept and self-esteem, dissociative behaviors and symptoms of PTSD, affect regulation deficits, internalizing psychological problems (e.g., depression and anxiety), and externalizing problems (e.g., aggressive behavior, noncompliance, impulsivity, and conduct problems). Psychologists can play an important role in the prevention and treatment of child maltreatment by file:///D|/1/CCP/09/00.htm (11 of 18)17.10.06 11:03:19

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implementing child-focused educational programs, and by working directly with maltreated children to reduce their psychological distress. Much has been written about victims of hate crimes, disasters, and wars. Hate crimes develop from prejudice and bigotry. Violence due to hatred begins with avoidance, leads to negative speech, and is followed by discrimination and physical attack and, in extreme cases, may ultimately end in ethnic cleansing and extermination. Hate crimes are not necessarily racially or ethnically motivated, though they may be directed at people who are culturally different from the perpetrators. Research is limited in terms of the long-term psychological sequelae of hate crimes, although symptoms of PTSD, depression, and anxiety are common in the victims. Victims of natural disasters (e.g., tornadoes, fires, floods, earthquakes, airline crashes) and wars may also suffer from a variety of psychological problems. The most common long-term psychological sequelae of disasters and wars on victims include PTSD, generalized anxiety disorder, obsessive-compulsive disorder, dysthymia, depression, and phobias. In addition, some victims may also have somatic disorders, substance abuse disorders, and generally poor mental and physical health. There is a paucity of well-controlled research on the psychological treatment of victims of hate, disasters, and wars, and even less on the outcome evaluation of prevention programs. In summary, a substantial segment of our society includes victims of abuse, violence, disasters, and wars. Although the mental health problems that these victims exhibit have many similarities, psychological treatments need to be individualized depending on the root causes of the disorders and psychological distress. Perpetrators This section consists of five chapters that deal with adult and child perpetrators of sexual offenses, and perpetrators of physical, domestic, and racial violence. The five major types of sexual offense that we have clinical data on include exhibitionism, voyeurism, frotteurism, child molestation, and rape. Exhibitionism is the unsolicited and deliberate exposure of the genitals to an unwilling audience. Almost all exhibitionists are men and, when men expose themselves to children, they are known as child molesters rather than exhibitionists. Voyeurism is peeping or watching unsuspecting persons who are in the act of undressing, are naked, or are making love. Again, mainly men are identified as voyeurs. Frotteurism is touching or rubbing against an unwilling person for sexual excitement. The prevalence of exhibitionism, voyeurism, and frotteurism has not been determined. Child molestation is the perpetration of sexual acts by an adult on a child. Although the majority of child molesters are men, there are increasing reports of female perpetrators as well. The prevalence of child molestation appears to be around 17% in the US. Sexual assaults (i.e., rapes) are almost always perpetrated by men, with most of the victims being women. Rape is usually accompanied by gratuitous violence against the victims. Further, rapists engage in other behaviors that are designed to humiliate and degrade the victims, causing severe psychological distress to them. Treatment is directed at both perpetrators and victims, with cognitive-behavioral methods having the best outcomes with perpetrators of sexual offenses. When compared to adult sexual offenders, we have only limited knowledge of child sexual offenders.

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These children engage in sexual behaviors that society finds disturbing and may produce negative consequences for the child. Sexually offensive behavior in these children can be grouped according to their level of seriousness: inappropriate sexual behavior, precocious sexual behavior (e.g., oral¯genital contact or actual intercourse between consenting preadolescents), and coercive sexual behavior (e.g., sexual acts in which coercion or force is threatened or used). Although the number of child sexual offenders is thought to be substantial, there are no prevalence figures for sexual behavior problems in children. Given the definitional and methodological problems involved, it is unlikely that we will be able to get national prevalence figures from epidemiological studies. Assessment and treatment of child sexual offenders includes both the child and his or her family. Treatment is broad-based and includes reducing the child's inappropriate sexual behaviors, improving the child's self-esteem, and addressing family problems. Although this is a major clinical and societal problem of great concern, our knowledge of the nature and treatment of child sexual offenses is rather limited, and psychologists have not been heavily invested in this area. Physical violence and abuse is a critical problem in many countries. Violence is often divided into whether it is reactive or instrumental in nature. People commit reactive violence because they perceive a threat or are provoked, and they commit instrumental violence to achieve an end or a goal. Reactive violent offenders typically harm people who are known to them; they are angry with their victims, and blame them for provoking the violence. Instrumental violent offenders are more pathological than reactive violent offenders; their acts of violence stem from a lack of concern and respect for others, as well as an absence of internalized social principles. Reactive violent offenses are more prevalent than instrumental violent offenses. Regardless of the actual type of violent acts committed, current research suggests that an interaction of biological, developmental, and environmental factors predispose people to commit violent acts. The prevalence of mental disorder among violent offenders is high and often left untreated while the perpetrator is in jail or prison. Although the reported rates vary, depending on the methodology and sample size used in the study, the prevalence of severe mental illness in need of treatment ranges between 5% and 16%, with another 16% having significant mental illnesses. Having a mental illness is a risk factor for perpetrators of violence, as they are more likely to be arrested at a crime scene than individuals without mental disorders. Further, not all individuals with mental illness are violent; research shows that up to 40% of individuals are reported to have committed a violent act against another individual two weeks prior to hospitalization for a mental illness. This may be an overestimation, because violent behavior is a factor that leads to hospitalization if the person is mentally ill. Psychologists have been active in the assessment and treatment of perpetrators of violence, especially if they have mental illness, but they have shown much less interest in developing large-scale, effective prevention programs. Domestic violence takes many forms, including intimidation, harassment and persecution, verbal aggression, denial of access to resources, sexual coercion and assault, physical assault, and torture. People who commit these acts belong to a heterogeneous group and cannot be easily categorized in terms of their gender, deviancy, or psychopathology. The true prevalence of domestic violence has been difficult to determine because of its very nature, but national surveys suggest that violence against women by men is a pervasive form of intimate violence. National surveys indicate that up to three million women are severely assaulted by their husbands or male partners, and almost a third of all homicides of women are perpetrated by their intimate male partners. Further, the rates of depression, suicide attempts, psychosomatic symptoms, and stress are four times higher among file:///D|/1/CCP/09/00.htm (13 of 18)17.10.06 11:03:19

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women who are assaulted by their partners compared to those who are not victims of domestic violence. Psychologists have developed a large number of intervention programs to treat men who engage in domestic violence, and current research indicates that many of these treatments are moderately effective. Perpetrators of racial violence are found in all sectors of our society, and its incidence is growing in many parts of the world because of increasing population, diversity, and political and social changes. Two types of explanations have been advanced to explain the nature of this type of violence: essentialist and historical-deterministic. Essentialist explanations point to causes that are intrinsic to our human nature, involve deep-seated tendencies, and are difficult, if not impossible, to overcome. Historical-deterministic explanations emphasize factors in our environment that change over time and situation, and often are reasonably amenable to manipulation, such as inadequate housing or poverty. Although there are several major theories of violence, none of them specifically focuses on racial violence and hatred. However, we do know something about the factors that have been implicated in the nature and development of violence. These include social and cultural factors which increase the probability that members of certain groups will be perpetrators of racial violence, individual biological and psychosocial characteristics, and predisposing factors. Relatively little research has been undertaken on effective large-scale and individual interventions, and even less on prevention. In summary, psychologists have a vital role to play in understanding the factors that lead people to commit violence against others. Further, they need to take a more active role in developing and evaluating treatment and prevention programs for perpetrators of violence. In general, the chapters in this volume highlight the vast array of psychological problems that afflict people in our society and the role that psychologists can play in their prevention and treatment.

Volume 9 Contributors ACIERNO, R. (Medical University of South Carolina, Charleston, SC, USA) *Adult Victims of Physical Violence AL-MATEEN, C. S. (Virginia Commonwealth University, Richmond, VA, USA) *Victims of Hate Crimes ALDARONDO, E. (Boston College, Chestnut Hill, MA, USA) Perpetrators of Domestic Violence ANDERSSON, G. (Uppsala University, Sweden) *Hearing Disabilities BEALE, I. L. (University of Auckland, New Zealand) Learning Disabilities

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BISCONER, S. W. (Eastern State Hospital, Williamsburg, VA, USA) *Mental Retardation BONNER, B. L. (University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA) *Children with Aggressive Sexual Behavior BYRNE, C. (Medical University of South Carolina, Charleston, SC, USA) *Adult Victims of Physical Violence ELLIS, C. R. (Virginia Commonwealth University, Richmond, VA, USA) *Families of Children with Serious Emotional Disturbance EPSTEIN, E. E. (Rutgers-The State University of New Jersey, Piscataway, NJ, USA) *Families of Alcoholics FAHEY, W. E. (Virginia Commonwealth University, Richmond, VA, USA) *Children with Aggressive Sexual Behavior GOURLEY, E. V. (Virginia Commonwealth University, Richmond, VA, USA) *Families of Divorce HART, S. D. (Simon Fraser University, Burnaby, BC, Canada) *Jail and Prison Inmates HAVERCAMP, S. M. (The Ohio State University Nisonger Center, Columbus, OH, USA) *Families of Individuals with HIV Infection/AIDS HOLTZWORTH-MUNROE, A. (Indiana University, Bloomington, IN, USA) *Victims of Domestic Violence HOOPER, S. R. (University of North Carolina, Chapel Hill, NC, USA) Individuals with Traumatic Brain Injury HUMPHRIES, S. (Massey University, Palmerston North, New Zealand) *Visual Disabilities JOURILES, E. N. (University of Houston, TX, USA) *Victims of Domestic Violence KAHLER, C. W. (Rutgers-The State University of New Jersey, Piscataway, NJ, USA) *Families of Alcoholics KATZ, R. C. (University of the Pacific, Stockton, CA, USA) *Adult Victims of Child Sexual Abuse file:///D|/1/CCP/09/00.htm (15 of 18)17.10.06 11:03:19

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KILPATRICK, D. G. (Medical University of South Carolina, Charleston, SC, USA) *Adult Victims of Physical Violence LAGROW, S. J. (Massey University, Palmerston North, New Zealand) *Visual Disabilities LEWIS, D. K. (Virginia Commonwealth University, Richmond, VA, USA) *Victims of Hate Crimes LONG, N. (Massey University, Palmerston North, New Zealand) *Victims of Disasters MARSHALL, W. L. (Queen’s University, Kingston, ON, Canada) Adult Sexual Offenders McALEAVEY, K. (Virginia Commonwealth University, Richmond, VA, USA) *Perpetrators of Racial Violence and Hatred McCRADY, B. S. (Rutgers-The State University of New Jersey, Piscataway, NJ, USA) *Families of Alcoholics McGRANE, G. (University of Keele, UK) *Families of Individuals with Developmental Disabilities McKENNA, L. (Guy’s Hospital and the Royal National Throat, Nose and Ear Hospital, London, UK) *Hearing Disabilities MILGRAM, N. A. (Tel Aviv University, Israel) Victims of War MUDFORD, O. C. (University of Keele, UK *Families of Individuals with Developmental Disabilities MULLET, E. (Virginia Commonwealth University, Richmond, VA, USA) *Families of Divorce NORWOOD, W. D. (University of Houston, TX, USA) *Victims of Domestic Violence OGLOFF, J. R. P. (Simon Fraser University, Burnaby, BC, Canada) *Jail and Prison Inmates OSWALD, D. P. (Virginia Commonwealth University, Richmond, VA, USA) file:///D|/1/CCP/09/00.htm (16 of 18)17.10.06 11:03:19

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Pervasive Developmental Disorders OTTO, R. (University of South Florida, Tampa, FL, USA) *Jail and Prison Inmates PATTERSON, C. J. (University of Virginia, Charlottesville, VA, USA) Family Lives of Lesbians and Gay Men PEREIRA-LAIRD, J. (Massey University, Palmerston North, New Zealand) *Victims of Disasters RAEZER, L. B. (Duke University, Durham, NC, USA) *Families of Children with Chronic Medical Conditions RESNICK, H. S. (Medical University of South Carolina, Charleston, SC, USA) *Adult Victims of Physical Violence ROESCH, R. (Simon Fraser University, Burnaby, BC, Canada) *Jail and Prison Inmates RONAN, K. (Massey University, Palmerston North, New Zealand) *Victims of Disasters ROSENBLATT, A. (University of California, San Francisco, CA, USA) *Perpetrators of Physical Violence and Abuse ROSENBLATT, J. A. (University of California, San Francisco, CA, USA) *Perpetrators of Physical Violence and Abuse SINGH, N. N. (Virginia Commonwealth University, Richmond, VA, USA) *Families of Children with Serious Emotional Disturbance; *Victims of Hate Crimes; *Perpetrators of Racial Violence and Hatred SMUTZLER, N. (Indiana University, Bloomington, IN, USA) *Victims of Domestic Violence STOLBERG, A. L. (Virginia Commonwealth University, Richmond, VA, USA) *Families of Divorce SUTTIE, J. N. (University of Hawaii at Manoa, Honolulu, HI, USA) *Mental Retardation TASS• M. J. (Universit u Qu c •ontr•, QC, Canada) *Families of Individuals with HIV Infection/AIDS file:///D|/1/CCP/09/00.htm (17 of 18)17.10.06 11:03:19

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THOMPSON, D. W. (Clinical Psychology Associates, Burlington, WI, USA) Street Gangs THOMPSON, JR., R. J. (Duke University Medical Center) *Families of Children with Chronic Medical Conditions TORO, P. A. (Wayne State University, Detroit, MI, USA) Homelessness WATKINS, P. L. (Oregon State University, Corvallis, OR, USA) *Adult Victims of Child Sexual Abuse WINTON, A. S. W. (Massey University, Palmerston North, New Zealand) *Perpetrators of Racial Violence and Hatred WOOD, I. K. (Virginia Commonwealth University, Richmond, VA, USA) Violent and Chronic Offenders WURTELE, S. K. (University of Colorado, Colorado Springs, CO, USA) Victims of Child Maltreatment ZAPF, P. A. (Simon Fraser University, Burnaby, BC, Canada) *Jail and Prison Inmates

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Copyright © 1998 Elsevier Science Ltd. All rights reserved.

9.01 Mental Retardation SARAH W. BISCONER Eastern State Hospital, Williamsburg, VA, USA and JANENE N. SUTTIE University of Hawaii at Manoa, Honolulu, HI, USA 9.01.1 INTRODUCTION

1

9.01.2 PHENOMENOLOGY

2

9.01.3 EPIDEMIOLOGY

3

9.01.4 ETIOLOGY

4

9.01.5 ASSESSMENT AND DIAGNOSIS

4 4 6 7

9.01.5.1 Intelligence 9.01.5.2 Adaptive Behavior 9.01.5.3 Psychopathology 9.01.6 TREATMENT

8 8 10

9.01.6.1 Behavioral Interventions 9.01.6.2 Psychopharmacology 9.01.7 FUTURE DIRECTIONS FOR RESEARCH AND PRACTICE

11

9.01.8 REFERENCES

16

disability is used, and in the UK, the term learning disability is used. Definitions of mental retardation are based on formulations developed by international leaders in the field (e.g., American Association on Mental Retardation (AAMR), American Psychiatric Association). According to the AAMR definition,

9.01.1 INTRODUCTION Mental retardation is a developmental disability characterized by subaverage intelligence and impairments in adaptive daily life skills. The disorder occurs before the age of 18 years, and is associated with numerous biological, environmental, and sociocultural causes. The concept of mental retardation and the language used to refer to mental retardation varies from culture to culture; therefore, policies and practices related to service eligibility, assessment and treatment modalities, and preventive measures tend to vary from culture to culture. Further, different terms may be used in some cultures to describe mental retardation. For example, in Australia, the term intellectual

Mental retardation refers to substantial limitations in present functioning. It is characterized by significantly subaverage intellectual functioning, existing concurrently with related limitations in two or more of the following applicable adaptive skill areas: communication, self-care, home living, social skills, community use, self-direction, health and safety, functional academics, leisure, and

1

2

Mental Retardation work. Mental retardation manifests before age 18. (Luckasson et al., 1992, p. 1)

In addition to the definition, four assumptions are considered essential to its application (Luckasson et al., 1992, p. 1): (i) valid assessment considers cultural and linguistic diversity as well as differences in communication and behavioral factors; (ii) the existence of limitations in adaptive skills occurs within the context of community environments typical of the individual's age peers and is indexed to the person's individualized needs for supports; (iii) specific adaptive limitations often coexist with strengths in other adaptive skills or other personal capabilities; and (iv) with appropriate supports over a sustained period, the life functioning of the person with mental retardation will generally improve. The AAMR classification system utilizes four levels of habilitation or support that parallels the individual's limitations (intermittent, limited, extensive, and pervasive). Intermittent supports typically are provided on a short-term, as-needed basis to facilitate life transitions (e.g., job loss, medical crisis). Limited supports typically are provided over longer periods of time in comparison to intermittent supports, but are still considered time limited (e.g., employment training, mobility training). Extensive supports are characterized by regular, long-term involvement in one or more life areas (e.g., long-term residential care, supported employment). Pervasive supports are characterized as constant, intensive, and often life sustaining supports provided long term across all life environments. The current Diagnostic and statistical manual of mental disorders (DSM-IV; American Psychiatric Association, 1994) defines mental retardation as follows: (i) significantly subaverage intellectual functioning: an IQ of approximately 70 or below on an individually administered IQ test (for infants, a clinical judgment of significantly subaverage intellectual functioning); (ii) concurrent deficits or impairments in present adaptive functioning (i.e., the person's effectiveness in meeting the standards expected for his or her age by his or her cultural group) in at least two of the following areas: communication, self-care, home living, social/interpersonal skills, use of community resources, self-direction, functional academic skills, work, leisure, health and safety); and (iii) onset before the age of 18 (p. 46). The DSM-IV definition utilizes four degrees of severity that reflect the level of intellectual impairment: IQ levels between 50±55 to ap-

proximately 70 characterize mild mental retardation, 35±40 to 50±55 characterize moderate mental retardation, 20±25 to 35±40 characterize severe mental retardation, and IQ levels below 20±25 characterize profound mental retardation. The AAMR classification and DSM-IV diagnostic systems include the same three criteria for diagnosis: significantly subaverage intellectual functioning, concurrent limitations in adaptive skills, and onset prior to age 18 years. Both systems operationally define ªsignificantly subaverage intellectual functioningº as a cut-off IQ score approximately two standard deviation units below a mean of 100 (between 70 and 75 or below), and ªconcurrent limitations in adaptive skillsº as two or more deficits in functional skill areas necessary to meet life's demands, as defined by the individual's age group, community setting, and sociocultural background. The two classification systems differ in that AAMR utilizes four levels of habilitation or support, which are not directly comparable to the levels of severity in DSM-IV (American Psychiatric Association, 1994). 9.01.2 PHENOMENOLOGY Persons with mental retardation have been noted in the literature from early Greek and Roman times, and have been labeled with a variety of descriptors: innocents, incapables, idiots, morons, cretins, dunces, and imbeciles. The term ªfeeble mindednessº was used as a generic term in the UK and the USA during the eighteenth and nineteenth centuries to describe a broad range of persons unable, for one reason or another, to function according to the perceived expectancies of normal participation in society (Scheerenberger, 1983). In 1910, the Committee on Classification of Feeble-Minded (under the auspices of the American Association on Mental Deficiency), defined three levels of feeble-mindedness: idiots, or those whose intellectual development did not exceed that of a normal two-year-old child; imbeciles, or those whose intellectual development did not exceed that of a normal 7-year-old child; and morons, or those whose intellectual development did not exceed that of a normal 12-year-old child (Scheerenberger, 1983). Internationally, general descriptors have varied. Scandinavia and Russia have used the term oligophrenia; the UK has used the term learning disabilities; The Netherlands and Hong Kong have used the term mental handicap; Australia and Singapore have used the term intellectual disability; and the USA and Japan have used the term mental retardation. Until the

Epidemiology advent of consumer participation and selfadvocacy in the 1990s, groups of persons with mental retardation were referred to as the mentally handicapped, the mentally deficient, or the mentally retarded. The ªPeople Firstº movement, however, redefined such terminology to emphasize the individuality of people over the disability; hence, the current use of such terms as a person with mental retardation, or people with a developmental disability. 9.01.3 EPIDEMIOLOGY The prevalence of mental retardation is estimated to be between 1% and 3% of the general population. Mental retardation is estimated to be between 1 and 1.6 times more common among males than females. Estimates vary depending on sampling procedures, the definition of mental retardation employed, and the assessment methods utilized. For example, prevalence rates are generally higher when a diagnosis of mental retardation is based only on intelligence, and lower when a diagnosis is based on intelligence and concurrent deficits in adaptive behavior. Prevalence rates vary by age, with the highest rate occurring between the ages of six and 16 years, or the years of formal education. The more severely impaired children and children with clearly identified conditions (e.g., Down syndrome) are typically diagnosed before the school years. Persons with mild levels of mental retardation often are not diagnosed until deficits are identified during the school years. Many of these individuals then lose their mental retardation diagnosis following their school years. This is most often due to an improvement in adaptive skill levels and a demonstrated ability to function in society (e.g., maintain employment). The prevalence of mental retardation also varies depending on the level of severity. An estimated 80% of mental retardation is classified as mild, 12% as moderate, 7% as severe, and 1% as profound. Severe and profound mental retardation are thought to be distributed uniformly across socioeconomic classes. Mild mental retardation is thought to be more common in lower socioeconomic classes or in underdeveloped regions of the world where poor prenatal care, immunization, nutrition, hygiene, and sanitation are common. The prevalence of comorbid psychiatric and behavioral disorders is estimated to be three to four times greater among persons with mental retardation than in the general population (American Psychiatric Association, 1994). Numerous epidemiological surveys since the mid-1980s indicate that between one-third and two-thirds of persons with mental retardation

3

also have a mental disorder. The prevalence of psychopathology tends to increase with the degree of mental retardation, suggesting that persons with more severe levels of mental retardation have a greater risk for mental illness (Kaplan, Sadock, & Grebb, 1994). An estimated 3% of persons with mental retardation have schizophrenia and up to 50% have a mood disorder (e.g., depression, mania). There is also a high rate of pervasive developmental disorders (e.g., autistic disorder, Rett's disorder, childhood disintegrative disorder, Asperger's disorder), particularly among persons with severe levels of mental retardation. The prevalence of severe behavior problems among persons with mental retardation is also well documented. Generally, persons with mild and moderate mental retardation and challenging behaviors tend to exhibit behaviors related to hyperactivity, low frustration tolerance, physical and verbal aggression, and other antisocial or socially inappropriate behaviors. Persons with severe levels of mental retardation often are not aware of or interested in their immediate environment and tend to display selfstimulatory, self-injurious, aggressive, and destructive behaviors. Severe behavior constitutes the single most important variable influencing placement in an institution and is a major factor in community placement failure (Aman & Singh, 1991). Use of psychotropic medication to address psychopathology and behavior problems among persons with mental retardation is well documented. Persons with mental retardation are among the most medicated populations in society (Aman & Singh, 1991). An estimated 30±70% of individuals living in institutional settings receive psychotropic medication, while an estimated 14±45% of individuals living in community settings receive psychotropic medication (Singh, Guernsey, & Ellis, 1992). Singh et al. (1992) conducted a comprehensive review of legislation and litigation that has arisen from the misuse and mismanagement of psychotropic medication with persons with mental retardation. They identified three areas of malpractice involving psychotropic medication: (i) negligence in diagnosis, (ii) negligence in administering the medication and monitoring for medication side effects, and (iii) failure to obtain informed consent by the client or an appropriate representative of the client. Litigation has occurred in cases where physicians have failed to: (i) review the drug regimen in a timely manner; (ii) justify the drug and dosage level; (iii) document the rationale for changes in medication (dose increases, change in therapeutic class); (iv) ensure that psychotropic medication does not interfere with the individual's

4

Mental Retardation

treatment program unless medically indicated; and (v) ensure that psychotropic medication is not used as a substitute for active treatment, as a punishment, or for staff convenience. The prevalence of medical or health-related conditions among persons with mental retardation may be significantly higher than in the general population, although some investigators dispute this view (Anderson, 1989). The medical conditions often are associated with the etiology of the mental retardation, and include neurological disorders, visual and hearing impairments, orthopedic conditions that affect mobility, and disorders that affect the heart, kidneys, lungs, or spine. Epilepsy is very common among persons with mental retardation, particularly among those with more severe levels of mental retardation. Individuals with mental retardation who are considered medically fragile often are vulnerable to malnutrition, metabolic disturbances, and infection (Luckasson et al., 1992). In the past, persons with mental retardation did not live as long as their peers without mental retardation, although mortality rates have gradually improved due to technological advances in medical sciences and nutrition, and improved life-style options. Mortality demographics from a 10-year cohort (1984±1993) of persons with mental retardation in New York showed that the average age of death for persons with mental retardation was 66.1 years, as compared with 70.4 years for people in the general population, and 55.8 years for people with Down syndrome (Janicki, Dalton, Henderson, & Davidson, 1996). 9.01.4 ETIOLOGY There are hundreds of known causes of mental retardation, and medical researchers continue to identify new entities that may be associated with mental retardation. Causes of mental retardation are typically classified into three broad categories: prenatal causes, perinatal causes, and postnatal causes (see Table 1) (Luckasson et al., 1992). A combination of biological, environmental, and psychosocial factors interact to cause mild levels of mental retardation, while a biological feature is typically identified in severe levels of mental retardation. In approximately 50% of persons with mild mental retardation, and in approximately 30% of persons with severe mental retardation, no definitive causative factors can be identified. A probable cause is found in approximately 65% of all persons with mental retardation. Multiple causes are identified in approximately 50% of all persons with mental retardation.

9.01.5 ASSESSMENT AND DIAGNOSIS The diagnosis of mental retardation has relied, in large part, on the administration and interpretation of standardized tests of intelligence and adaptive behavior. However, a diagnosis of mental retardation incorporates more than just standardized scores of intelligence and adaptive behavior. Typically, the assessment process includes interviews with people acquainted with the individual and observations of the individual in his/her natural settings. This section focuses on a review of standardized instruments used to diagnose mental retardation and comorbid psychopathology. Numerous assumptions must be addressed when utilizing standardized assessment measures (Anastasi, 1988; Luckasson et al., 1992; Morgenstern & Klass, 1991): (i) The examiner is appropriately trained, certified, or licensed to administer the tests, is familiar with a wide variety of tests, has significant experience working with persons with mental retardation at all levels of severity, at various ages, and from the represented cultural and linguistic backgrounds. (ii) The tests are norm-referenced for the population being tested. The tests are reliable and internally consistent over time. Estimates of reliability can be determined by the standard error of measurement, which establishes a range around the obtained score. Tests are valid for the population and culturally and linguistically appropriate for the individual being tested. (iii) The examiner determines that the test results reflect the individual's best performance effort. Factors such as anxiety, fatigue, poor motivation, poor concentration, physical illness, hearing or visual impairments, or inability to understand instructions because of cultural or language barriers reduce the validity of the test results and must be accounted for. (iv) The individual or his/her parent(s) or legal guardian must give informed consent for the assessment, can refuse all or any part of the assessment, can stop the assessment process at any time, can appeal any determinations made as a result of the assessment process (diagnoses, placement or treatment recommendations), and can request a reassessment by another examiner. 9.01.5.1 Intelligence The Wechsler scales include three individually administered scales of intelligence: Wechsler Preschool and Primary Scale of IntelligenceRevised (WIPPSI-R; Wechsler, 1989), Wechsler Intelligence Scale for Children-Third Edition (WISC-III; Wechsler, 1991), and Wechsler

5

Assessment and Diagnosis Table 1 Etiology of mental retardation. I. Prenatal causes A. Chromosomal disorders 1. Autosome 2. X-Linked mental retardation 3. Other X chromosome disorders B. Syndrome disorders 1. 2. 3. 4. 5. 6.

Neurocutaneous disorders Muscular disorders Ocular disorders Craniofacial disorders Skeletal disorders Other syndromes

C. Inborn errors of metabolism 1. 2. 3. 4. 5. 6. 7. 8. 9.

Amino acid disorders Carbohydrate disorders Mucopolysaccharide disorders Mucolipid disorders Urea cycle disorders Nucleic acid disorders Copper metabolism disorders Mitochondrial disorders Peroxisomal disorders

F. Other (nonspecific, unknown) II. Perinatal causes A. Intrauterine disorders 1. Acute placental insufficiency 2. Chronic placental insufficiency (marginal reserve) 3. Abnormal labor and delivery 4. Multiple gestation (smaller, later, or male infant) B. Neonatal disorders 1. Hypoxic-ischemic encephalopathy 2. Intracranial hemorrhage 3. Posthemorrhagic hydrocephalus 4. Periventricular leukomalacia 5. Neonatal seizures 6. Respiratory disorders 7. Infections 8. Head trauma at birth 9. Metabolic disorders 10. Nutritional disorders III. Postnatal causes

D. Developmental disorders of brain formation

A. Head injuries

1. 2. 3. 4. 5. 6.

1. Cerebral concussion (diffuse axonal injury) 2. Cerebral contusion or laceration 3. Intracranial hemorrhage 4. Subarachnoid (with diffuse injury) 5. Parenchymal

Neural tube closure defects Brain formation defects Cellular migration defects Intraneuronal defects Acquired brain defects Primary (idiopathic) microcephaly

E. Environmental influences

B. Infections

1. 2. 3. 4.

1. 2. 3. 4.

Intrauterine malnutrition Drugs, toxins, and teratogens Maternal diseases Irradiation during pregnancy

Encephalitis Meningitis Fungal infections Parasitic infestations

5. Slow or persistent virus infections C. Demyelinating disorders 1. Postinfectious disorders 2. Postimmunization disorders 3. Schilder disease D. Degenerative disorders 1. 2. 3. 4. 5. 6.

Syndromic disorders Poliodystrophies Basal ganglia disorders Leukodystrophies Sphingolipid disorders Other lipid disorders

E. Seizure disorders 1. 2. 3. 4.

Infantile spasms Myoclonic epilepsy Lennox±Gastaut syndrome Progressive focal epilepsy (Rasmussen) 5. Status epileptious-induced brain injury F. Toxic-metabolic disorders 1. 2. 3. 4.

Acute toxic encephalopathy Reye syndrome Intoxication Metabolic disorders

G. Malnutrition 1. Protein-calorie (PCM) 2. Prolonged intravenous alimentation H. Environmental deprivation 1. Psychosocial disadvantage 2. Child abuse and neglect 3. Chronic social/sensory deprivation I. Hypoconnection syndrome

Source: Luckasson et al. (1992, pp. 81±91).

Adult Intelligence Scale-Revised (WAIS-R; Wechsler, 1981). The Wechsler scales are widely used in the USA; however, they have been criticized for their low reliability with individuals with IQ scores less than 50, for being culturally biased, and for yielding lower scores with children who are culturally deprived (Kaplan et al., 1994). The Wechsler scales yield a standard score with a mean of 100 and a standard deviation of 15. The WIPPSI-R is appropriate for children ages 3 years to 7 years 3 months, the WISC-III is appropriate for children ages 6 years to 16 years 11 months,

and the WAIS is appropriate for persons ages 16±74 years. The Stanford±Binet, Fourth Edition (Thorndike, Hagen, & Sattler, 1986), is an individually administered measure of general intelligence for persons ages 2 years to 23 years 11 months. The scale yields a standard score with a mean of 100 and a standard deviation of 16. As such, a cutoff score reflecting 2 standard deviation units below the mean is lower (IQ of 68) when compared with the Wechsler scales. Like the Wechsler scales, the Stanford±Binet has been criticized for its low reliability with individuals with IQ

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Mental Retardation

scores less than 50, for being culturally biased, and for yielding lower scores with children who are culturally deprived (Kaplan et al., 1994). The Stanford±Binet does not assess for mental retardation in younger children, as the lowerlimit composite standard age score is 95 for children 2 years 0 months. The Gesell Developmental Schedules (Gesell, 1949), and Bayley Scales of Infant Development (Bayley, 1969) can be used when assessing for intellectual limitations in children younger than three years. The Gesell was originally published in 1940, and at the time, represented a pioneering attempt to provide a systematic, empirically based assessment of behavior development in young children. The test is appropriate for children ages four weeks to five years. Five major fields of behavior are assessed, including adaptive, gross motor, fine motor, language, and personal-social behavior. The data are obtained through observation of the child's responses to standard toys and stimulus objects, and by gathering information from the child's caretakers. The Bayley Scales of Infant Development are appropriate for assessing the developmental status of children ages 2 months to 2 years 6 months. The test consists of three scales: mental scale, motor scale, and infant behavior record. Standard scores are derived for the mental and motor scales with norms classified by halfmonth steps from 2 to 6 months and by onemonth steps from 6 to 30 months. The mental scale measures perception, memory, learning, problem solving, vocalization, and initial verbal communication and abstract thinking. The motor scale measures gross motor abilities (e.g., sitting, standing, walking, climbing stairs), and fine motor skills of the hands and fingers. The infant behavior record assesses emotional and social behavior, attention span, persistence, and goal directedness. The Gesell, Bayley, and Cattell Measurement of Intelligence in Infants and Young Children (Cattell, 1950) also have been recommended to assess the intellectual levels of older persons who fall in the severe and profound levels of mental retardation and, consequently, below the floors of the Wechsler and Stanford±Binet scales. All three measures provide a chronological assessment of social, adaptive, language, and motor areas of growth and development (Morgenstern & Klass, 1991). The Peabody Picture Vocabulary Test-Revised (PPVT-R; Dunn & Dunn, 1981) is an alternative measure for persons with physical or other disabilities that make oral and written responses difficult or impossible. The PPVT-R is appropriate for children ages 2 years 6 months to adulthood. Scores on the PPVT-R can be standardized to

reflect an equivalent Wechsler full scale IQ score (M = 100, SD = 15). When compared with the Wechsler scales and Stanford±Binet, the PPVTR measures a similar yet narrower range of attributes. Therefore, it should not be used as the only or primary source for classifying intellectual functioning (Morgenstern & Klass, 1991). The Kaufman Assessment Battery for Children (K-ABC; Kaufman & Kaufman, 1983) is appropriate for children ages 2 years 6 months to 12 years 6 months. The battery yields a mental processing composite score (M = 100, SD = 15) that is roughly equivalent to the Wechsler full scale IQ score, and subtest scores in four areas: sequential processing, simultaneous processing, nonverbal, and sociocultural. The K-ABC is considered a better predictor of intellectual ability in children with mental retardation, in comparison to the WISC-R. This is because the K-ABC measures intellectual ability without emphasizing academic and verbal skills, which is characteristic of the Wechsler scales (Morgenstern & Klass, 1991).

9.01.5.2 Adaptive Behavior Diagnostic standards for mental retardation emphasize both the individual's intellectual capability and his/her adaptive daily living skills in the areas of communication, self-care, home living, social skills, community use, selfdirection, health and safety, functional academics, leisure, and work (American Psychiatric Association, 1994; Luckasson et al., 1992). Historically, measures of intellectual capability have dominated the diagnosis of mental retardation even though previous definitions have specified that intelligence and adaptive behavior should have equal weight in diagnosis. The diagnostic standards implemented in the 1980s and 1990s specify that limitations must occur in two or more applicable adaptive skills areas in order to diagnosis mental retardation. Unlike measures of intelligence, however, there are no consistently used cutoff scores or precise age equivalent scores that structure the assessment process. Although there are numerous measures of adaptive behavior available (see Reschly, 1987, 1990 for a review), only two wellestablished instruments used in the diagnostic process are reviewed here. The Vineland Adaptive Behavior Scales (Sparrow, Balla, & Cicchetti, 1984) include a survey form, expanded form, and classroom form. The survey form is primarily used as a diagnostic and placement instrument for persons between the ages of birth and 18 years 11 months, and for low-functioning adults. The

Assessment and Diagnosis expanded form is used for preparing individualized educational or habilitative programs, and is appropriate for persons between the ages of birth and 18 years 11 months, and for lowfunctioning adults. The classroom form is used to assess adaptive behavior skills relevant to the classroom, and is appropriate for persons between the ages of 3 years and 12 years 11 months. The Vineland scales provide an overall level of functioning, or Adaptive Behavior Composite (ABC) score, and domain (subdomain) scores in the areas of communication (receptive, expressive, written); daily living skills (personal, domestic, community); socialization (interpersonal, play/leisure time, coping skills); and motor skills (gross motor, fine motor). The survey and expanded forms contain a maladaptive domain designed to assess maladaptive behavior. AAMD Adaptive Behavior Scale, Residential and Community Edition (Nihira, Foster, Shellhaas, & Leland, 1975) is designed to provide objective descriptions and evaluations of an individual's ability to cope with the natural and social demands of his/her environment. The instrument was standardized on over 4000 individuals, ages 3 to 69 years, living in institutional settings. There are no normative data for individuals living in community settings. The instrument is divided into two sections. Part I is organized developmentally and evaluates skills and habits in 10 behavioral domains: independent functioning, physical development, economic activity, language development, numbers and time, domestic activity, vocational activity, self-direction, responsibility, and socialization. Part II consists of 14 domains designed to assess aberrant behavior: violent and destructive behavior, antisocial behavior, rebellious behavior, untrustworthy behavior, withdrawal, stereotyped behavior and odd mannerisms, inappropriate interpersonal manners, unacceptable vocal habits, unacceptable or eccentric habits, selfabusive behavior, hyperactive tendencies, sexually aberrant behavior, psychological disturbances, and use of medication. While the instrument offers valuable information about a variety of adaptive behavior domains, the results should be validated through other observation and assessment procedures, especially if it is being used as a diagnostic tool.

9.01.5.3 Psychopathology The diagnosis of mental disorders is particularly difficult with persons with mental retardation because they may have a limited vocabulary to describe their symptoms or

7

express their feelings or concerns. Most commonly used psychometric evaluations have not been validated for use with persons with mental retardation. Many instruments require reading or vocabulary comprehension that is beyond the ability of most persons with mental retardation. A structured clinical assessment conducted by a psychologist trained in mental retardation has its own set of challenges due to individual differences in the client's verbal ability, attention span, and memory. Also, characteristics of the individual's mental retardation might be misinterpreted as psychopathology, resulting in an inappropriate psychiatric diagnosis. The challenge of obtaining a valid psychiatric diagnosis increases with the level of severity of mental retardation. A comprehensive assessment of mental illness in persons with mental retardation should include the following sources of information (Luckasson et al., 1992, p. 53): ª(a) interviews; (b) behavioral observation in everyday environments; (c) client and staff interviews; (d) formal psychometric evaluations, including social skills development, personality, and maladaptive behavior; and (e) medical and biological evaluations, including positron emission tomography and other types of neuroimaging assessment.º Since the mid-1980s, numerous measures have been developed to assess psychopathology and behavior problems in persons with mental retardation (see Aman, 1991 for a review of these instruments). Three instruments with established psychometric properties are described here. There are two versions of the Aberrant Behavior Checklists (ABC): ABC-Residential (Aman & Singh, 1986) and ABC-Community (Aman & Singh, 1994). The instruments are appropriate for use with individuals ages five years through adulthood. The instruments were designed to assess inappropriate and maladaptive behavior, and for use as a monitoring tool to evaluate treatment effects. The ABC-Residential was designed for persons with mental retardation living in institutional settings, and the community version was designed to provide a parallel measure for persons with mental retardation living in community settings. The instruments consist of five subscales: (i) irritability, agitation, crying; (ii) lethargy, social withdrawal; (iii) stereotypy; (iv) hyperactivity, noncompliance; and (v) inappropriate speech. Normative data for each subscale are available by age, gender, and level of mental retardation. The authors provide clear operational definitions of each item. The instrument can be administered by any trained individual who has regular contact with the client and knows him/ her well.

8

Mental Retardation

The Reiss Screen for Maladaptive Behavior (Reiss, 1988) was designed to assess for significant mental health problems in persons with mental retardation living in institutional and community settings. The instrument is appropriate for use with persons with mild through profound mental retardation, ages 12 years and older. The instrument consists of eight subscales: aggressive behavior, psychosis, paranoia, depression (behavioral signs), depression (physical signs), dependent personality disorder, avoidant disorder, and autism. There also are items designed to evaluate serious behavior problems: drug/alcohol abuse, self-injury, stealing, overactivity, sexual problems, and suicidal tendencies. The instrument provides cutoff scores that indicate a need for further assessment; these cutoff scores are available for the total scale, each subscale, and for the items assessing serious behavior problems. The instrument is administered by at least two trained raters who have regular contact with the client and know him/her well. The Diagnostic Assessment for the Severely Handicapped (DASH) Scale (Matson, Gardner, Coe, & Sovner, 1990) is appropriate for use with adolescents and adults with severe or profound mental retardation. The instrument consists of 13 subscales that are derived from the DSM-III-R classification system: anxiety, mood disorder±depression, mood disorder± mania, pervasive developmental disorder/autism, schizophrenia, stereotypies/tics, self-injurious behaviors, elimination disorders, eating disorders, sleep disorders, sexual disorders, organic syndromes, and impulse control and miscellaneous behavior problems. The instruments consists of two sections: a section seeking background information about the client; and a behavior-rating component designed to determine the frequency, duration, and severity of behavior problems or psychiatric symptoms. The instrument is administered by a mental health professional who conducts structured interviews with individuals who have regular contact with the clients and know them well. 9.01.6 TREATMENT 9.01.6.1 Behavioral Interventions The development of appropriate adaptive skills involves the acquisition and maintenance of appropriate social and personal behavior and the elimination of behavioral excesses. Learning of these skills occurs in an ecological context. This ecological context is a system in which the biology and behavior of the individual, the physical environment, the social environment, and the behavior of other people function as a

mutually interactive system in which each component influences the functioning of the entire system (Singh, 1997a). Understanding the rationale of effective behavioral interventions requires some discussion of the development of adaptive behavior in an ecological context for an individual, and how that development differs for persons with mental retardation. Initially, infants have very little direct control over the environment or the behavior of other people. As children develop biologically and interact with the social and physical environment, they begin to learn the relationship between their own behavior, the behavior of others, and reinforcing and aversive environmental consequences. As this process continues in a balanced ecological system, the individual learns to increase those socially adaptive functional behaviors that promote pleasant social interactions, and help meet basic needs in a socially acceptable manner. At the same time, inappropriate behavior that does not promote social interaction or meet basic needs begins to extinguish due to a lack of reinforcement or decreases in frequency and intensity as a result of aversive consequences. This process occurs most efficiently and will most likely enhance the person's quality of life, when the individual's health is adequate, when the physical environment is appropriately stimulating but not overwhelming, when other people are appropriately responsive, and when the social environment is inclusive; that is, when the ecological system is balanced. The process of acquiring adaptive skills is greatly enhanced by the development of language and cognitive capacity. The development of receptive and expressive language allows social learning to proceed more rapidly when contingencies can be represented symbolically, rather than through repetitive, direct experience. Increasing cognitive abilities allows the learner to be aware of contingencies that are remote in time or occur on infrequent schedules. Self-talk provides salient antecedents and immediate consequences not always available from the external environment. For many individuals, the biological environment of good health, and social and physical environment of a family, community, society, and educational system creates a balanced ecological system that is likely to lead to the learning of a set of relatively adaptive behaviors. The learner moves through the environment and encounters naturally occurring contingencies, and contingencies structured by caretakers and a community that shapes the appropriate adaptive skills. The more effective these learned social and adaptive skills are, the more positive

Treatment interactions the individual has with the social and physical environment, and the higher the quality of life. For persons with mental retardation, interaction in a system that promotes and strengthens adaptive behavior may be limited. The more severe the deficits, the less likely appropriate learning experiences will occur in the natural environment. Deficits in expressive and receptive language skills and cognitive capacity reduce functional interactions with caretakers and peers in the social environment and are severe impediments to efficient adaptive learning. When socially appropriate skills are not learned, other people in the community are less likely to interact with the individual, and opportunities for further learning is restricted. If the individual also has inappropriate behavioral excesses, further restrictions in the social and physical environment are likely to be imposed. In this ecologically unbalanced system, the individual's quality of life diminishes as restrictions in the social and physical environment increase. Thus, the limitations in cognitive functioning of the individual with mental retardation is only one part of the disordered system that promotes behavioral excesses, prevents development of adaptive behavior, and reduces the quality of life. Behavioral interventions that target only a narrowly defined behavior in a restricted environment are unlikely to promote more adaptive behavior. The ecology of the system in which the individual functions needs to be understood, and a plan for altering the system in ways that bring a better balance between the individual and the environment needs to be developed. An awareness of the role of the ecological context in determining the adaptive functioning and quality of life for individuals with mental retardation has entered the community consciousness as the principle of the least restrictive environment, the goal of deinstitutionalization and community placement, and increased sensitivity to the civil rights of institutionalized persons (Singh, 1995). An awareness of the role of ecological context also has influenced the nature of education and training. Interdisciplinary assessment, full inclusion in the least restrictive environment, due process, and the use of written individualized education plans or individualized family service plans have helped to improve the breadth of treatment planning so that it includes plans for altering the environment in ways that are more likely to support positive change and increase quality of life. Services required include the development of formal educational environments to enhance academic and adap-

9

tive skill development, treatment for behavioral excesses, skills training for behavioral deficits, psychiatric services for emotional disorders, and regular medical and dental services. Behavioral programs are based on the principles of learning. Thus, behavioral excesses that result from faulty or incomplete learning, and skill deficits that result from lack of opportunity to learn the skills are most amenable to behavioral programs. To be consistent with an approach that attempts to enhance the quality of life through greater ecological balance, behavioral interventions should target both behavior excesses to be reduced and skills to be enhanced. These interventions will be most effective if they take into account the context of the social, physical, and biological environment, and attempt to maximize the balance of the ecological system. The assessment and analysis of the ecological context of problem behavior, and the treatment of that behavior, involve a process that includes: (i) structural analysis of the problem behavior; (ii) descriptive analysis of the individual's behavior in its ecological context; (iii) hypothesis formation; (iv) functional analysis done informally in the natural environment, or formally in an analogue setting; (v) planning, implementing, and evaluating of treatment; and (vi) maintenance and generalization of treatment (Singh, 1997b). A structural analysis is designed to assess the impact of the physical, social, and biological environments on the problem behavior. Changes in these environments may lead to significant improvement in the individual's quality of life without the need for time-consuming and labor-intensive behavioral interventions. If the analysis indicates that the problem behavior is maintained by the individual's social (e.g., caretakers, peers) or physical (e.g., workplace structure) environment, one focus of treatment will be on the manipulation of these environments. If the analysis indicates that the problem is maintained by the individual's biological environment (e.g., earache, urinary tract infection, toothache), collaboration with a physician/dentist specializing in developmental disabilities will focus treatment on medical intervention and management (Feldman & Griffiths, 1997). A descriptive analysis provides as comprehensive a picture as possible of the problem behavior in its context. A detailed description of the target behavior and its antecedents and consequences can be determined through the

10

Mental Retardation

use of structured or unstructured observations in the natural setting, information from caretakers who know the individual and the situations in which the target behavior occurs, and systematic data collection using frequency or interval recording procedures. This descriptive analysis provides the information needed to form tentative hypotheses regarding the functional relationship between the target behavior and the environmental events that maintain it. Testing the tentative hypotheses can be done formally in an experimental analysis of the problem behavior. This is done by establishing a controlled environment with a limited number of contingencies as an analogue to the natural environment. Variables are manipulated one at a time to determine their effect on the behavior. This can be time consuming and labor intensive. It requires that the problem behavior be allowed to continue and even increase in order to determine the effective contingencies. For this reason, an informal functional analysis carried out in the environment in which the problem behavior usually occurs, and in which it will be treated, is usually preferable. In these situations where the informal analysis does not lead to successful treatment, a formal assessment can be conducted under analog conditions. The resulting treatment plan will have, as its primary goal, the enhancement of the quality of life of the individual. An effective treatment plan will focus on the creation of a balanced ecological system. The components of the plan will include guidelines for making changes in the biological, physical, and social environments, reducing excessive behavior, acquiring new skills, and improving interaction with the social and physical environment. Although no one of these components individually is an adequate plan, by systematically changing one or more components of the system, an effective treatment plan can be implemented.

9.01.6.2 Psychopharmacology Psychotropic medication is any medication prescribed to stabilize or improve mood, mental status, or behavior (Kalachnik et al., 1995). It is used as one part of a comprehensive treatment plan to address an individual's psychiatric symptoms or aberrant behavior. Ideally, the medication acts as a setting event for the occurrence of appropriate behavior when maladaptive behavior is reduced. Thus, psychotropic medication can allow the individual to function more fully or appropriately at school, work, or home. Psychotropic medication should be used to enhance the individual's quality of life rather than to strictly reduce

aberrant or undesirable behavior (Ellis, Singh, & Singh, 1997). Kalachnik et al. (1995), as part of the International Consensus Conference on Psychopharmacology, delineated guidelines for the use of psychotropic medication with persons with mental retardation and other developmental disabilities (see Table 2). The following sources were utilized in the formation of the guidelines: (i) regulatory (e.g., Health Care Financing Administration, 1992); (ii) accreditation (e.g., Joint Commission on Accreditation of Healthcare Organizations, 1995); (iii) professional (e.g., American Psychiatric Association Committee on Research on Psychiatric Treatments, 1992); (iv) litigation (e.g., Wyatt v. Stickney, 1972); (v) legislation (e.g., Civil Rights of Institutionalized Persons Act, 1981); and (vi) proclamations and declarations (e.g., Assembly of the United Nations, ªDeclaration on the Rights of Mentally Retarded Personsº; see Beyer, 1988; Kalachnik et al., 1995; Singh et al., 1992). The guidelines are endorsed by professionals in the field of mental retardation and serve as a model for appropriate use. Administration and monitoring of psychotropic medication should be conducted by a psychiatrist in cooperation with all individuals who interact with the client on a day-to-day basis (e.g., psychologist, teachers, caretakers). A multidisciplinary team approach enhances the reliable assessment as to whether the medication is successfully addressing the behaviors or psychiatric symptoms it was prescribed to address, and whether the medication is causing undesirable side effects (e.g., sedation, agitation) that interfere with the client's day-to-day activity. Medication monitoring processes are enhanced by the ongoing collection of systematic data that reflect the frequency, duration, and intensity of target behavior or psychiatric symptoms. This type of data is best collected by individuals who interact with the client for extended periods of time each day or night. These individuals can be trained to reliably assess and record the frequency, duration, and intensity of occurrence of aberrant behavior or psychiatric symptoms. A thorough psychotropic medication review should take place every 3±6 months unless more frequent reviews are indicated (e.g., change in medication or dose, increase in behavior or psychiatric symptoms). The process should include a review of the client's psychiatric/ behavioral history; a careful evaluation of the client's medical diagnoses and current medical status; behavioral changes since the last review (frequency, duration, intensity); observed medication side effects; a report of any environmental changes that may impact the client's

Future Directions for Research and Practice

11

Table 2 Guidelines for the use of psychotropic medication. 1.

Psychotropic medication definition. A psychotropic medication is any drug prescribed to stabilize or improve mood, mental status, or behavior.

2.

Inappropriate use. Psychotropic medication shall not be used excessively, as punishment, for staff convenience, as a substitute for meaningful psychosocial services, or in quantities that interfere with an individual's quality of life. Multidisciplinary care plan. Psychotropic medication must be used within a coordinated multidisciplinary care plan designed to improve the individual's quality of life. Diagnostic and functional assessment. The use of psychotropic medication must be based upon a psychiatric diagnosis or a specific behavioral-pharmacological hypothesis resulting from a full diagnostic and functional assessment. Informed consent. Written informed consent must be obtained from the individual, if competent, or the individual's guardian before the use of any psychotropic medication and must be periodically renewed. Index behaviors and empirical measurement. Specific index behaviors and quality of life outcomes must be objectively defined, quantified, and tracked using recognized empirical measurement methods in order to monitor psychotropic medication efficacy. Side effects monitoring. The individual must be monitored for side effects on a regular and systematic basis using an accepted methodology which includes a standardized assessment instrument. Tardive dyskinesia monitoring. If antipsychotic medication or other dopamine blocking drugs (e.g., amoxapine or metoclopramide) are prescribed, the individual must be monitored for tardive dyskinesia on a regular and systematic basis using a standardized assessment instrument. Regular and systematic review. Psychotropic medication must be reviewed on a regular and systematic basis. Clinical reviews must be conducted on a regular and systematic basis by the prescriber. Data reviews must be conducted on a regular and systematic basis by appropriate members of the multidisciplinary team. Lowest ªoptimal effective dose.º Psychotropic medication must be reviewed on a periodic and systematic basis to determine if it is still necessary or, if it is, if the lowest ªoptimal effective doseº is prescribed. Frequent changes. Frequent drug and dose changes should be avoided. Polypharmacy. Keep psychotropic medication regimens as simple as possible in order to enhance compliance and minimize side effects. Practices to minimize. Minimize the following practices to the degree possible: (i) long-term use of PRN (as needed) orders; (ii) long-term use of benzodiazepine antianxiety medications such as diazepam; (iii) use of long-acting sedative-hypnotic medications such as chloral hydrate; (iv) long-term use of shorter-acting sedative-hypnotics such as temazepam (Restoril); (v) anticholinergic use such as benztropine without signs of EPSE; (vi) long-term anticholinergic use; (vii) antipsychotic medication at high doses; (viii) use of phenytoin, phenobarbital, and primidone as psychotropic medication. Peer or external review. Establish a system of peer or external review of psychotropic medication prescribing which incorporates a system of flagging up cases of greatest concern.

3. 4. 5. 6. 7. 8. 9.

10. 11. 12. 13.

14.

Source: Bisconer, Sine, and Zhang (1996).

behavior or psychiatric symptoms; a progress report on skills training designed to decrease targeted behavior; and any changes to longterm plans for treatment and education (Bisconer, Zhang, & Sine, 1995). Medication side effects should be systematically monitored by the psychiatrist via appropriate laboratory tests and objective screening procedures (see Gadow & Poling, 1988 for a review of screening instruments). The psychiatrist can rely on trained care staff and other professionals to conduct periodic screenings for side effects. These results can then be reviewed and validated when the psychiatrist meets with the client. Table 3 provides psychotropic and antiepileptic medications by class, generic name, and recommended dosage by age for persons with

mental retardation. Table 4 provides the most common indications and side effects for different classes of medications. A comprehensive review of psychotropic medication use with persons with mental retardation can be found in the following sources (Aman & Singh, 1991; Ellis et al., 1996; Singh, Ellis, & Singh, 1994).

9.01.7 FUTURE DIRECTIONS FOR RESEARCH AND PRACTICE It is becoming increasingly common for persons with mental retardation to live and interact in inclusive community settings rather than in segregated settings (e.g., institutions, training centers, group homes, sheltered workshops). With this movement toward full com-

12

Mental Retardation Table 3 Recommended doses for the various classes of psychotropic drugs. Average daily dose

Drug A. Antipsychotics chlorpromazine (4 6 mos of age)a thioridazine (4 2 yrs of age)a trifluperazine (4 6 yrs of age)a thiothixene (4 12 yrs of age)a haloperidol (4 3 yrs of age)a reserpine clozapine (4 16 yrs of age)a loxapine (4 16 yrs of age)a B. Antidepressants amitriptyline (4 12 yrs of age)a bupropion (4 18 yrs of age)a clomipramine (4 10 yrs of age)a desipramine 10±150 mg (4 12 yrs of age)a fluoxetine (4 18 yrs of age)a imipramine (4 6 yrs of age)a nortriptyline (4 12 yrs of age)a phenelzine (4 16 yrs of age)a sertraline (not in children)a C. Antimatics lithium carbonateb (4 12 yrs of age)a D. Anxiolytics alprazolam (4 18 yrs of age)a chlordiazepoxide (4 6 yrs of age)a diazepam (4 6 mos of age)a lorazepam (4 12 yrs of age)a diphenhydramine

Children

Adolescents

Adults

30±200 mg (2.5±6 mg/kg/day) 75±200 mg (0.5±3 mg/kg/day) 1±15 mg

40±400 (3±6 mg/kg/day) 10±200+ mg 1±20 mg

100±800 mg (max 2000 mg/day) 150±800 mg (max 800 mg/day) 15±40 mg

2±10 mg

5±30 mg

20±60 mg

0.5±4 mg (0.05±0.15 mg/kg/day) 0.02±0.25 mg

2±16 mg

2±16+ mg

0.1±1.0 mg 50±200 mg (3±5 mg/kg/day) 20±100 mg

0.1±1.0 mg 300±450 mg (max 900 mg/day) 60±250 mg

50±100 mg (1±5 mg/kg/day) 75±300 mg (3±6 mg/kg/day) 50±150 mg (2±3 mg/kg/day)

75±300 mg

5±50 mg

30±100 mg (1±5 mg/kg/day) 25±150 mg 25±100 mg 50±150 mg (1±5 mg/kg/day) 5±20 mg 10±150 mg (1±5 mg/kg/day) 10±100 mg

25±100 mg

100±200 mg (1±5 mg/kg/day) 10±60 mg (0.5±1 mg/kg/day) 50±200 mg (1±5 mg/kg/day) 50±100 mg (1±3 mg/kg/day) 15±45 mg (0.5±1 mg/kg/day) 50±200 mg (1.5±3 mg/kg/day)

200±450 mg 100±250 mg

20±80 mg 75±200 mg 75±200 mg 45±90 mg 50±200 mg

300±900 mg

900±1200 mg (10±30 mg/kg/day)

900±1200 mg

0.25±2 mg

0.75±5 mg (0.02±0.06 mg/kg/day) 20±60 mg

1±8 mg

10±30 mg 1±10 mg 0.25±3 mg 25±200 mg

hydroxyzine

25±100 mg

buspirone (4 18 yrs of age)a

2.5±15 mg

2±20 mg (max 0.8 mg/kg) 0.05±6 mg (0.04±0.09 mg/kg/day) 50±300 mg (1±5 mg/kg/day) 40±150 mg (2 mg/kg/day) 5±30 mg (0.2±0.6 mg/kg/day)

20±100 mg 4±40 mg 1±10 mg 50±400 mg 75±400 mg 15±60 mg

13

Future Directions for Research and Practice Table 3 (continued). Average daily dose Drug

Children

Adolescents

Adults

E. Stimulants dextroamphetamine (4 3 yrs of age)a methylphenidate (4 6 yrs of age)a pemoline (46 yrs of age)a

2.5±15 mg (0.15±0.5 mg/kg/dose) 2.5±30 mg (0.3±1 mg/kg/dose) 18.75±75 mg (1±3 mg/kg/day)

5±40 mg (0.15±0.5 mg/kg/dose) 10±60 mg (0.3±1 mg/kg/dose) 37.5±112.5 mg (1±3 mg/kg/day)

10±40 mg (0.15±0.5 mg/kg/dose) 20±60 mg (0.3±1 mg/kg/dose) 37.5±112.5 mg (1±3 mg/kg/day)

F. Antiepileptics carbamazepineb (46 yrs of age)

200±800 mg (5±20 mg/kg/day)

600±1200 mg (max dose 1200 mg/ day) 750±1500 mg (max dose 1500 mg/ day) 150±250 mg

ethosuximideb

250±800 mg (20±30 mg/kg/day)

400±1000 mg (10±30 mg/kg/day; max dose 1000 mg/day) 500±1500 mg (20±40 mg/kg/day)

phenobarbitalb

primidone sodium valproate

5250 mg (4±8 mg/kg/day) 5300 mg (7.5±9 mg/kg/day) 150±750 mg 250±1000 mg

75±250 mg (1±3 mg/kg/day) 300±500 mg (6±7 mg/kg/day) 750±1500 mg 500±2000 mg

G. Others propranolol

2±80 mg

clonidine (not in children)a naltrexone (4 18 yrs of age)a

0.25±0.3 mg (3±6 mg/kg/day) 10±50 mg (0.5±1.5 mg/kg/day)

20±140 mg (max 2 mg/kg/day) 0.3±0.4 mg (3±6 mg/kg/day) 40±120 mg (1±2 mg/kg/day)

30±60 mg (4 12 yrs of age)a benzotropine (4 3 yrs of age)a

40±100 mg

phenytoinb

0.5±4 mg

60±120 mg (1±2 mg/kg/day) 0.5±6 mg (43±86 mg/kg/day)

300±400 mg 750±2000 mg 500±2500 mg (15±60 mg/kg/day) 80±480 mg 0.3±0.5 mg 50±150 mg (1.2 mg/kg/day) fenfluramine 2±6 mg

a Recommended FDA guidelines. bDosage titrated using serum levels. Source: Ellis et al. (1996); reprinted with permission from the authors.

munity inclusion comes the challenge of successfully integrating persons with mental retardation into neighborhoods, schools, employment settings, recreation and leisure settings, and retirement settings. Persons with mental retardation will continue to have a broad range of specialized needs, including a need for appropriate educational services and employment training, ongoing training in daily living and social skills, and oftentimes, long-term treatment for behavioral excesses and psychiatric disorders. Many persons with mental retardation have a life-long need for specialized medical care. Addressing the needs of persons with mental retardation typically requires the expertise of a variety of professionals working as part of a multidisciplinary team (e.g., physicians, dentists, nurses, psychologists, so-

cial workers, related services professionals, educators). Successful community inclusion also requires the ongoing support of the individual's family members and relatives, friends, neighbors, and peers with and without disabilities. Clinicians working with persons with mental retardation need specialized training in the assessment and diagnosis of mental retardation and coexisting psychiatric disorders, intervention and treatment methods, and experience in multidisciplinary team models. Clinicians often become a liaison with medical specialists including psychiatrists, neurologists, dentists, and others who have less specialized training with this population. They also provide ongoing training and assistance to family members and care providers in behavioral support strategies.

14

Mental Retardation Table 4 Psychiatric and behavioral indications and side effects of various classes of drugs.

A. Antipsychotic Indications:

Side effects:

B. Antidepressants Indications:

Side effects:

C. Antimanics Indications: Side effects:

D. Anxiolytics Indications:

Side effects:

E. Stimulants Indications:

Psychotic states; schizophrenia (exacerbations and maintenance); mania (in conjunction with lithium); behavior disorders with severe agitation, aggressivity and self-injury; and dyskinetic movement disorders (e.g., Tourette's disorder and juvenile Huntington's disease) Anticholinergic effects, including dry mouth, constipation, blurred vision, and urinary retention (most common with low potency phenothiazines); extrapyramidal reactions, including acute dystonia, akathesia, tremor (particularly with high potency phenothiazines); neuroleptic malignant syndrome; tardive dyskinesia (lower risk with clozapine); other central nervous system effects, including sedation, fatigue, cognitive blunting, psychotic symptoms, confusion, and excitement; orthostatic hypotension and cardiac conduction abnormalities; endocrine disturbances (e.g., menstrual irregularities and weight gain); gastrointestinal distress; skin photosensitivity; granulocytopenia and agranulocytosis (clozapine); and allergic reactions Enuresis; Attention-Deficit/Hyperactivity Disorder; Major Depressive Disorder; and anxiety disorders (including school phobia, separation anxiety disorder, panic disorder, and obsessive-compulsive disorder) Tricyclics: Anticholinergic effects, including dry mouth, constipation, blurred vision, and urinary retention; cardiac conduction slowing (treatment requires EKG monitoring), mild increases and/or irregularity in pulse rate and mild decreases or increases in blood pressure; confusion or the induction of psychosis; seizures; rash; and endocrine abnormalities Monoamine oxidase inhibitors: mild decreases or increases in blood pressure; drowsiness; weight gain; insomnia; hypertensive crisis with nonadherance to dietary restrictions (necessary to eliminate high tyramine foods from diet) or with certain drugs Selective serotonin reuptake inhibitors: irritability; gastrointestinal distress; headaches; insomnia Other antidepressants: irritability (bupropion, venlafaxine); insomnia (bupropion, venlafaxine); drug-induced seizures (bupropion, with high doses); changes in blood pressure (trazodone, venlafaxine); priapism (trazodone); sedation, sleepiness (trazodone, venlafaxine); gastrointestinal distress (venlafaxine); and headache (venlafaxine) Manic episodes of Bipolar Disorder; unipolar depression/adjunct treatment in Major Depressive Disorder; behavior disorders with extreme aggression Kidney abnormalities leading to increased urination and thirst; gastrointestinal distress; fine hand tremor; weakness and ataxia; possible thyroid abnormalities (with long-term use), weight gain, and electrolyte imbalances; sedation, confusion, slurred speech, irritability, headache, and subtle cogwheel rigidity; skin abnormalities; orthostatic hypotension and pulse rate irregularities; and allergic reactions Anxiety disorders; seizure control; night terrors; sleepwalking; insomnia and acute management of severe agitation; adjunct treatment of mania and refractory psychosis; Tourette's Disorder Headache, sedation, and decreased cognitive performance; behavioral disinhibition, including overexcitement, hyperactivity, increased aggressivity, and irritability; gastrointestinal distress, central nervous system disinhibition resulting in hallucinations, psychotic-like behavior, and depression; physical and psychological dependence (particularly with long-acting benzodiazepines); rebound or withdrawal reactions (particular with short-acting benzodiazepines); blood abnormalities; anticholinergic effects, including dry mouth, constipation, and blurred vision (antihistamines); and allergic reactions Attention-Deficit/Hyperactivity Disorder (including those with mental retardation, fragile X syndrome, Tourette's disorder, head trauma, pervasive developmental disorders, or other comorbid disorder); narcolepsy; adjunctive treatment in refractory depression

Future Directions for Research and Practice

15

Table 4 (continued). Side effects:

F. Antiepileptics Indications: Side effects:

Decreased appetite; weight loss; abdominal pain; headache, insomnia, irritability; sadness and depression; mild increases in pulse rate and blood pressure; possible temporary suppression of growth (with long-term use); choreoathetosis (pemoline) and rarely, tic disorders; and elevated liver function tests (pemoline) Seizure control; Bipolar Disorder; adjunct treatment in Major Depressive Disorder; severe behavior problems (e.g., aggression, self-injury) Sedation, weakness, dizziness, disturbances of coordination and vision, hallucinations, confusion, abnormal movements, nystagmus, slurred speech, and depression; blood abnormalities; gastrointestinal distress; skin rashes, alterations in pigmentation and photosensitivity reactions; increased or decreased blood pressure and congestive heart failure; abnormalities of liver functions (sodium valproate, carbamezapine±rate); genitourinary tract dysfunction; coarsening of facial features, enlargement of the lips, gingival hyperplasia, and excessive hair growth (phenytoin); and bone marrow suppression (carbamezapine, sodium valproate)

C. Others Propranolol Indications:

Behavior disorders with severe aggression, self-injury, or agitation; Tourette's disorder, akathesia

Side effects:

Decreased heart rate, peripheral circulation and blood pressure; fatigue, weakness, insomnia, nightmares, dizziness, hallucinations, and mild symptoms of depression; shortness of breath and wheezing (especially in patients with asthma); gastrointestinal distress; and rebound hypertension on abrupt withdrawal

Clonidine Indications:

Side effects: Guanfacine Indications: Side effects: Opioid antagonists Indications: Side effects: Fenfluramine Indications: Side effects:

Attention-Deficit/Hyperactivity Disorder; Tourette's Disorder; behavior disorders with severe aggression, self-injury, or agitation; adjunct treatment of schizophrenia and mania; possible use in anxiety disorders Sedation; decrease in blood pressure; rebound hypertension; dry mouth; confusion (with high doses); depression Attention-Deficit/Hyperactivity Disorder; Tourette's Disorder Sedation (less than with clonidine); decrease in blood pressure (less than with clonidine); rebound hypertension; dry mouth; confusion (with high doses); depression Reversal of narcotic depression; self-injury Drowsiness, dizziness, dry mouth, sweating, nausea, abdominal pain, and loss of energy Management of obesity; possible use in the control of some behavior problems in pervasive developmental disorders Anorexia, weight loss; drowsiness, dizziness, confusion, headache, incoordination; mood alterations, anxiety, insomnia, weakness, agitation, and slurred speech; gastrointestinal distress; increased or decreased blood pressure and palpitations; skin rashes; dry mouth; eye irritation; and muscle aches

Source: Ellis et al. (1996); reprinted with permission from the authors.

A practitioner-as-researcher approach is recommended for all clinicians working with persons with mental retardation. There is an ongoing need to identify: (i) successful clinical intervention and treatment models, (ii) valid and reliable assessment and diagnostic procedures for psychopathology, and (iii) appropriate psychotropic medication treatments for various psychiatric conditions and challenging

behaviors. Single-subject research designs can be integrated into a clinical practice and the outcomes of these studies provide a valuable source of information. Controlled, multisubject treatment-outcome designs are a more powerful study approach; they can validate the outcomes of single-subject research and increase generalizability (see Sulsky & Steiner, 1991 for a review of clinical research issues). Research conducted

16

Mental Retardation

in cooperation with a psychiatrist helps determine the impact of a given medication on a targeted behavior or psychiatric symptom. Research conducted in cooperation with family members or care providers helps determine the impact of a given behavioral intervention or skills training strategy on a targeted behavior or psychiatric symptom. A critical aspect of the research process includes the development and validation of assessment and data-gathering tools. Assessing treatment or drug effects on a targeted behavior or psychiatric symptom requires trained professionals administering valid and reliable psychological assessments or standardized tests, as well as trained observers using valid and reliable observational tools (e.g., checklists, rating scales). The ongoing and careful study of therapeutic treatments and outcomes will enhance the scholarly literature in mental retardation, and ultimately improve the quality of life of persons with mental retardation, their families, friends, and care providers. 9.01.8 REFERENCES Aman, M. G. (1991). Assessing psychopathology and behavior problems in persons with mental retardation: A review of available instruments. Rockville, MD: US Department of Health and Human Services. Aman, M. G., & Singh, N. N. (1986). Aberrant Behavior ChecklistÐResidential: Manual. East Aurora, NY: Slosson Educational Publications. Aman, M. G., & Singh, N. N. (1991). Pharmacological intervention. In J. L. Matson & J. A. Mulick (Eds.), Handbook of mental retardation (2nd ed., pp. 347±372). New York: Pergamon. Aman, M. G., & Singh, N. N. (1994). Aberrant Behavior ChecklistÐCommunity: Manual. East Aurora, NY: Slosson Educational Publications. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. American Psychiatric Association Committee on Research on Psychiatric Treatments (1992). Psychopharmacological screening criteria. Journal of Clinical Psychiatry, 52, 184±196. Anastasi, A. (1988). Psychological testing (6th ed.). New York: Macmillan. Anderson, D. J. (1989). Health care needs and residential settings: A national survey and policy perspectives. Australia and New Zealand Journal of Developmental Disabilities, 15, 289±300. Bayley, N. (1969). Bayley Scales of Infant Development. New York: Psychological Corporation. Beyer, H. A. (1988). Litigation and use of psychoactive drugs in developmental disabilities. In M. G. Aman & N. N. Singh (Eds.), Psychopharmacology and the developmental disabilities (pp. 29±57). New York: Springer. Bisconer, S. W., Sine, L. F., & Zhang, X. Q. (1996). Prevalence and patterns of psychotropic medication use by adults with mental retardation living in community settings. Journal of Developmental and Physical Disabilities, 8, 291±311. Bisconer, S. W., Zhang, X. Q., & Sine, L. F. (1995). Impact of a psychotropic medication and physical restraint review process on adults with mental retardation,

psychiatric diagnoses, and challenging behaviors. Journal of Developmental and Physical Disabilities, 7, 123±135. Cattell, P. (1950). The measurement of intelligence of infants and young children. New York: Psychological Corporation. Civil Rights of Institutionalized Persons Act, 42 U.S.C. x 1997 (1981). Dunn, L. M., & Dunn, L. M. (1981). Peabody Picture Vocabulary TestÐRevised. Circle Pines, MN: American Guidance Service. Ellis, C. R., Singh, Y. N., & Singh, N. N. (1997). Use of behavior modifying drugs. In N. N. Singh (Ed.), Prevention and treatment of severe behavior problems: Models and methods in developmental disabilities. Pacific Grove, CA: Brooks/Cole. Feldman, M. A., & Griffiths, D. (1997). Comprehensive assessment of severe behavior problems. In N. N. Singh (Ed.), Prevention and treatment of severe behavior problems: Models and methods in developmental disabilities (pp. 23±48). Pacific Grove, CA: Brooks/Cole. Gadow, K. D., & Poling, A. G. (1988). Pharmacotherapy and mental retardation. Boston, MA: College-Hill. Gesell, A. (1949). Gesell Developmental Schedules. New York: Psychological Corporation. Health Care Financing Administration (1992). Medicare and medicaid programs: Omnibus nursing home requirements. Proposed rule. Federal Register, 57, 4516±4534. Janicki, M. P., Dalton, A. J., Henderson, M., & Davidson, P. (1996). Mortality and morbidity demographics of a 10 year cohort of older adults with intellectual disability in New York. Paper presented at the 10th World Congress of International Association for the Scientific Study of Intellectual Disabilities, Helsinki, Finland. Joint Commission on Accreditation of Healthcare Organizations (1995). Accreditation manual for mental health, chemical dependency, and mental retardation developmental disabilities services. Oakbrook Terrace, IL: Author. Kalachnik, J. E., Leventhal, B. L., James, D. H., Sovner, R., Kastner, T. A., Walsh, K., & Klitzke, M. G. (1995). Guidelines for the use of psychotropic medication. Paper presented at the International Consensus Conference on Psychopharmacology, The Ohio State University, Columbus, OH. Kaplan, H. I., Sadock, B. J., & Grebb, J. A. (1994). Kaplan and Sadock's synopsis of psychiatry: Behavioral sciences, clinical psychiatry (7th ed.). Baltimore, MD: Williams & Wilkins. Kaufman, A. S., & Kaufman, N. L. (1983). Kaufman Assessment Battery for Children. Circle Pines, MN: American Guidance Service. Luckasson, R., Coulter, D. L., Polloway, E. A., Reiss, S., Schalock, R. S., Snell, M. E., Spitalnik, D. M., & Stark, J. A. (1992). Mental retardation: Definition, classification, and systems of support. Washington, DC: American Association on Mental Retardation. Matson, J. L., Gardner, W. I., Coe, D. A., & Sovner, R. (1990). Diagnostic Assessment for the Severely Handicapped (DASH) Scale (User manual). Unpublished manuscript, Louisiana State University, Baton Rouge, LA. Morgenstern, M., & Klass, E. (1991). Standard intelligence tests and related assessment techniques. In J. L. Matson & J. A. Mulick (Eds.), Handbook of mental retardation (2nd ed., pp. 195±210). New York: Pergamon. Nihira, K., Foster, R., Shellhaas, M., & Leland, H. (1975). AAMD Adaptive Behavior Scale Manual (Rev. ed.). Washington, DC: American Association on Mental Deficiency. Reiss, S. (1988). Test manual for the Reiss Screen for Maladaptive Behavior. Orland Park, IL: International Diagnostic Systems.

References Reschly, D. J. (1987). Adaptive behavior. Tallahassee, FL: Florida Department of Education. Reschly, D. J. (1990). Adaptive behavior. In A. Thomas & J. Grimes (Eds.), Best practices in school psychology (2nd ed., pp. 29±42). Washington, DC: National Association of School Psychologists. Scheerenberger, R. C. (1983). A history of mental retardation. Baltimore, MD: Brookes. Singh, N. N. (1995). Moving beyond institutional care for individuals with developmental disabilities. Journal of Child and Family Studies, 4, 129±145. Singh, N. N. (1997a). Prevention and treatment of severe behavior problems: Models and methods in developmental disabilities. Pacific Grove, CA: Brooks/Cole. Singh, N. N. (1997b). Enhancing quality of life through teaching and habilitation. In N. N. Singh (Ed.), Prevention and treatment of severe behavior problems: Models and methods in developmental disabilities (pp. 1±20). Pacific Grove, CA: Brooks/Cole. Singh, N. N., Ellis, C. R., & Singh, Y. N. (1994). Medication management. In E. Cipani & F. Spooner (Eds.), Curricular and instructional approaches for persons with severe handicaps (pp. 404±423). Boston, MA: Allyn & Bacon. Singh, N. N., Guernsey, T. F., & Ellis, C. R. (1992). Drug

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therapy for persons with developmental disabilities: Legislation and litigation. Clinical Psychology Review, 12, 665±679. Sparrow, S. S., Balla, D. A., & Cicchetti, D. V. (1984). The Vineland Adaptive Behavior Scales. Circle Pines, MN: American Guidance Service. Sulsky, L. M., & Steiner, D. D. (1991). Design, analysis, and measurement issues in mental retardation research: An integrated approach. In J. L. Matson & J. A. Mulick (Eds.), Handbook of mental retardation (2nd ed., pp. 541±551). New York: Pergamon. Thorndike, R. L., Hagen, E. P., & Sattler, J. M. (1986). Guide for administering and scoring the Stanford±Binet Intelligence Scale: 4th Edition. Chicago: Riverside Publishing. Wechsler, D. (1981). Manual for the Wechsler Adult Intelligence ScaleÐRevised. San Antonio, TX: The Psychological Corporation. Wechsler, D. (1989). Manual for the Wechsler Preschool and Primary Scale of IntelligenceÐRevised. San Antonio, TX: The Psychological Corporation. Wechsler, D. (1991). Manual for the Wechsler Intelligence Scale for ChildrenÐThird Edition. San Antonio, TX: The Psychological Corporation. Wyatt v. Stickney, 344 F. Supp. 380 (M. D. Ala. 1972).

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

9.02 Pervasive Developmental Disorders DONALD P. OSWALD Virginia Commonwealth University, Richmond, VA, USA 9.02.1 INTRODUCTION

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9.02.2 PHENOMENOLOGY 9.02.2.1 Autistic Disorder 9.02.2.2 Asperger's Disorder 9.02.2.3 Childhood Disintegrative Disorder 9.02.2.4 Rett's Disorder 9.02.2.5 Pervasive Developmental Disorder Not Otherwise Specified 9.02.2.6 Comorbid Conditions 9.02.2.6.1 Mental retardation 9.02.2.6.2 Seizure disorder 9.02.2.6.3 Obsessive-compulsive disorder 9.02.2.6.4 Schizophrenia 9.02.2.6.5 Other behavior problems 9.02.2.7 Adolescents and Adults with Pervasive Developmental Disorders 9.02.3 EPIDEMIOLOGY

20 21 21 22 22 23 23 23 23 23 24 24 24 25

9.02.4 ETIOLOGY 9.02.4.1 Genetic Influences 9.02.4.2 Prenatal/Perinatal Complications 9.02.4.3 Immunologic Factors 9.02.4.4 Microbial Infections 9.02.4.5 Neuropsychological Features 9.02.4.6 Neuroanatomic Features 9.02.4.7 Neurochemical Findings 9.02.5 ASSESSMENT AND DIAGNOSIS

25 25 25 26 26 26 26 26 26

9.02.6 TREATMENT 9.02.6.1 Structured Teaching and Behavior Modification Approaches 9.02.6.2 Social Intervention Strategies 9.02.6.3 Language Intervention Strategies 9.02.6.4 Other Behavioral Interventions 9.02.6.5 Psychopharmacology 9.02.6.5.1 Serotonergic drugs 9.02.6.5.2 Opiate antagonists 9.02.6.5.3 Dopaminergic drugs 9.02.6.5.4 Noradrenergic drugs 9.02.6.5.5 Stimulants 9.02.6.5.6 Nutritional supplements 9.02.7 SUMMARY

28 28 29 29 29 29 29 29 30 30 30 30 31

9.02.8 REFERENCES

31

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Pervasive Developmental Disorders

9.02.1 INTRODUCTION The pervasive developmental disorders (PDDs) are a class of neuropsychiatric syndromes that are typically identified in infancy or early childhood and persist throughout the lifespan. Characterized by marked developmental anomalies, particularly in the language and social domains, the PDDs represent a severe form of developmental psychopathology. Autism or Kanner's syndrome (Kanner, 1943) is generally considered the prototypical PDD and has received the lion's share of attention over the past five decades. Recent developments in the field, however, have led to the conceptualization of a continuum of PDDs, or autism spectrum disorders, with a set of common core features. Current diagnostic systems generally include Asperger's disorder, Rett's disorder, childhood disintegrative disorder, and PDD not otherwise specified, along with autistic disorder, in the PDD continuum (American Psychiatric Association [APA], 1994). A brief scan of the evolution of psychiatric nosology shows that, over the years, children with PDD have received a variety of diagnostic labels. Prior to Kanner's (1943) paper, the most commonly used terms were childhood psychosis, childhood schizophrenia, and borderline pathology of childhood. Children with characteristics that fit the PDD spectrum have also received a variety of other diagnoses, including infantile psychosis, infantile autism, symbiotic psychosis, autistic psychopathy, and schizoid and schizotypal personality disorders. 9.02.2 PHENOMENOLOGY The pathognomonic behavioral feature of the PDDs is a marked impairment in social interaction skills. The social impairment is generally understood to be qualitative in nature; that is, individuals with PDD are not merely delayed in their social development but they display social interaction characteristics that are different from those seen in typically-developing persons of any age (van Engeland, BoldnaÂr, & Bolhuis, 1985; Wenar, Ruttenberg, Kalish-Weiss, & Wolf, 1986). Persons in each of the subclasses of the PDD continuum manifest some form of social interaction abnormality, although the exact nature and extent of the impairment varies, in part, as a function of general intellectual ability. The social interaction impairment displayed by individuals with a PDD is generally characterized as a failure to develop social reciprocity (APA, 1994). Social reciprocity is the ability to regulate one's behavior in social interactions as a function of the perceived verbal and nonverbal

behavior and the attributed thoughts and feelings of the interaction partner. Deficits in social reciprocity have received considerable attention, particularly in persons with autism, and have sometimes been conceptualized as a failure of social cognitive development. One extensive line of related social cognition research has focused on the ability to perceive and interpret others' nonverbal expressions of emotion. Many studies have reported that persons with autism or other PDDs, even those whose general level of functioning is relatively high, show marked impairment in this ability, compared with nonautistic individuals with similar intellectual levels (e.g., Fein, Lucci, Braverman, & Waterhouse, 1992; Hobson, 1986; Macdonald et al., 1989). Other researchers have described the affected social cognitive skill as a deficit in role-taking or perspective-taking ability (Dawson & Fernald, 1987; Oswald & Ollendick, 1989). Role-taking ability is the capacity to accurately predict what others are likely to be thinking or feeling, even when those thoughts and feelings are different from one's own. In recent years, a similar line of research has focused on the ability to conceive of mental states in oneself or others, commonly referred to as ªa theory of mindº (Premack & Woodruff, 1978). Baron-Cohen and colleagues have produced a body of work that seeks to demonstrate the importance of theory of mind in understanding the social impairment of persons with autism. Persons with autism are said to display unique deficits in tasks that require a theory of mind, deficits that have been found to be associated with social interaction impairment (Baron-Cohen, Leslie, & Frith, 1985, 1986). The theory-of-mind studies have generated substantial discussion in the literature. The key question that remains unanswered is whether theory-of-mind deficits are important in themselves in determining the profile of social abnormalities present in autism, or whether they represent artifacts that are determined by more fundamental social or language problems. Some recent data support the latter conclusion in that individuals with autism have been found to display a typical developmental sequence in the performance of theory-of-mind tasks and progress along that sequence is associated with verbal ability (Sparrevohn & Howie, 1995). In addition, evidence of social abnormalities is commonly seen in children well before even the earliest precursors of a theory of mind would be expected in the normal developmental progression (Klin & Volkmar, 1992). Finally, children with Down's syndrome have been found to display theory-of-mind deficits similar to those seen in persons with autism, calling into question the specificity of the deficit (Zelazo, Burack, Benedetto, & Frye, 1996).

Phenomenology Virtually all persons with PDD also manifest some form of communication impairment. The impairment may range from an apparent lack of all receptive and expressive language abilities to subtle peculiarities in the use or understanding of language that are difficult to characterize. One PDD subtype, Asperger's disorder, includes a diagnostic criterion emphasizing more or less age-appropriate speech development, although the language of persons with Asperger's disorder is nearly always marked by some unusual features, particularly with regard to social communication. With the exception of Asperger's disorder, individuals with PDD also frequently present with intellectual functioning in the mentally retarded range (APA, 1994), and adaptive behavior deficits are even more common (Volkmar et al., 1987). Some authors have conluded that the empirical studies of adaptive behavior in persons with PDD support the presence of a specific pattern of adaptive skills that is common, if not unique. This pattern is characterized by relative deficits in adaptive skills in the socialization domain and relative strengths in the daily living skills domain (Carter, Gillham, Sparrow, & Volkmar, 1996). Such an adaptive skill pattern, however, may be primarily a reflection of the communication and social interaction problems inherent in the PDDs (Vig & Jedrysek, 1995). The age at which symptoms associated with PDD first appear varies somewhat by subcategory but most typically falls within the first 36 months of life (Rogers & DiLalla, 1990). Autistic disorder is generally thought to be present from very early in infancy, if not from birth, and in most cases these individuals will display a disability that comes to the attention of their parents in the first year of life (Volkmar, Klin, Marans, & McDougle, 1996). The profoundly debilitating behavioral features of Rett's syndrome generally appear between 6 and 48 months of age, after 6±18 months of apparently normal psychomotor development (Tsai, 1994). Symptoms of childhood disintegrative disorder appear after a longer period of normal development (usually two to three years), but are generally apparent by age four (Volkmar, 1994). Persons with Asperger's disorder are generally not diagnosed until after age two, frequently much later, although their symptoms can usually be traced to unusual behaviors in early childhood (Klin, 1994). Beyond the core feature of impaired social interaction, each of the PDDs manifests a slightly different presentation, although researchers and clinicians continue to debate the evidence regarding the distinctions among them. Nonetheless, the most widely accepted

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psychiatric taxonomies have converged on a set of four specific syndromes within the category (autistic disorder, Asperger's disorder, childhood disintegrative disorder, Rett's disorder) and one general designation for individuals who do not fit in any currently identified subcategory (pervasive developmental disorder not otherwise specified). 9.02.2.1 Autistic Disorder Autistic disorder (AD) is the PDD subgroup that most closely matches Kanner's (1943) original description of autism. The defining characteristic of AD is deviant social development which may take the form of a lack of interest in other people, preferential interest in nonsocial aspects of the environment, failure to display differential attachment, and failure to develop typical prelinguistic communicative behaviors (Volkmar & Cohen, 1994). Profound communication deficits are also an essential feature of AD, including failure to develop speech, echolalia, persistent pronoun reversal, extreme literalness, and unusual prosody (Paul, 1987). Even in those individuals with relatively intact intellectual function, language is a significant deficit area, particularly the understanding and use of social language. The third major group of symptoms of AD has been designated ªinsistence on samenessº (APA, 1994). This term includes a variety of behavioral features associated with autism ranging from stereotyped motor movements to difficulty with transitions and preferential (even obsessive) interest in particular topics of conversation. Kanner (1943) originally believed that most children with autism did not manifest mental retardation, a conclusion that was endorsed by others and led to the assertion that these individuals were merely unmotivated to engage in standardized intellectual assessment or that these instruments were somehow inappropriate for the population. Subsequent investigations, however, demonstrated that most individuals with AD also display general intellectual impairment (APA, 1994) and deficits in adaptive behavior (Schatz & Hamdan-Allen, 1995). 9.02.2.2 Asperger's Disorder Asperger's disorder was originally described by Hans Asperger in 1944 (Tantum, 1988) and over the next 50 years appeared infrequently in the literature under the designation Asperger's syndrome. Individuals in the contemporary category of Asperger's disorder have been described in the literature under other designations

22

Pervasive Developmental Disorders

as well, including mild autistic, high-functioning autistic, near-normal autistic, and schizotypal personality disorder. Recent work (Klin, Volkmar, Sparrow, Cicchetti, & Rourke, 1995) suggests substantial overlap between Asperger's disorder and two other diagnostic designations in contemporary literature: nonverbal learning disabilities syndrome (Rourke, 1989) and semantic-pragmatic disorder (Bishop, 1989). The key features of Asperger's disorder, as described in the Diagnostic and statistical manual of mental disorders (4th ed., DSM-IV, APA, 1994) are (i) a qualitative impairment in social interaction; and (ii) restricted repetitive and stereotyped patterns of behavior, interests, and activities. Significant speech deficits are not part of the presentation, and persons with Asperger's disorder are less likely to display deficits in nonverbal concept formation, auditory perception, articulation, vocabulary, and verbal output than are high-functioning persons with autism (Klin et al., 1995). However, several unusual features in the communication domain are common in individuals with Asperger's disorder, including poor prosody, tangential and circumstantial speech, and marked verbosity on specific topics of interest (Klin & Volkmar, 1995). In his original case descriptions, Asperger appears to have viewed clumsiness, or some other form of motor impairment, as a defining feature of the syndrome. Using high-functioning persons with autism as a comparison group, Asperger's disorder individuals have been reported to have greater difficulties with some motor tasks (Gillberg & Gillberg, 1989; Szatmari, Tuff, Finlayson, & Bartolucci, 1990). Reports of clumsiness in Asperger's disorder were sufficiently convincing that the feature was included among the diagnostic criteria for the syndrome in the International classification of diseases (10th ed., ICD-10), the most recent World Health Organization (1993) classification of diseases and health problems. Recent research findings differ on the question of whether motor skills deficits reliably distinguish individuals with Asperger's disorder from high-functioning individuals with autism (Klin et al., 1995; Manjivionna & Prior, 1995). Other studies of the distinction between highfunctioning autism and Asperger's disorder indicated that individuals with Asperger's disorder were more likely to engage in more prosocial behavior and less likely to use echolalic speech when young; their speech content was more likely to be repetitive and pedantic, without appropriate turn-taking; and they were likely to have collected facts about preferred subjects and to have asked questions or made statements on repetitive themes. Developmental

features which distinguished individuals with Asperger's disorder included a higher verbal mental age and a greater mean age at diagnosis; they were also less likely to have experienced delayed language onset (Eisenmajer et al., 1996). 9.02.2.3 Childhood Disintegrative Disorder The first description in the literature of the disorder currently designated as childhood disintegrative disorder (CDD) is commonly attributed to Heller, a Viennese special educator, who described six cases in 1908 (Volkmar, 1994). While there has been some variation in descriptions of CDD over the years, the condition is generally thought to be distinguished by several features including: (i) onset after at least two or three years of normal development, (ii) progressive deterioration in cognitive and behavioral functioning, and (iii) normal appearance and absence of signs of neurologic dysfunction (Volkmar, 1994). Some investigators have maintained that the criteria of at least two years of apparently normal development is not sufficiently documented in the literature on CDD (Perry, Cohen, & DeCarlo, 1995). Once the disorder is established, it is virtually indistinguishable from autism in terms of behavioral characteristics. Individuals with CDD typically manifest speech loss or deterioration, social impairment, stereotypies and resistance to change, overactivity, affective symptoms and anxiety, and deterioration in self-help skills. In most cases of CDD, no specific neuropathological conditions associated with the onset of the disorder can be identified. In individuals who have a particularly late onset of CDD, however, such conditions are more frequently identified (Volkmar, 1992). 9.02.2.4 Rett's Disorder The condition currently designated as Rett's disorder (RD) was first described by Rett in 1966 (Tsai, 1994). While aspects of the disorder are similar to autism (i.e., severe social and communication deficits), there are several key differences. RD has been reported only in females, while the other PDDs are substantially more common in males, and more individuals with RD fall into the severe range of mental retardation. Other key features of RD include: normal growth and development in the first months, followed by regression and decelerated head growth; loss of purposeful hand movement; and presence of characteristic stereotypies and gait abnormalities. There has been some controversy regarding whether RD should be considered one of the PDDs, but an emerging

Phenomenology consensus supports this position (Volkmar, Klin, Marans, & Cohen, 1996). The clinical course of individuals with RD has been described in detail by Hagberg and Witt-EngerstroÈm (1986). Four common stages of the development of the disorder include: (i) early-onset stagnation (6±18 months), (ii) rapid developmental regression beginning at 12±24 months, (iii) pseudostationary stage beginning at about three to four years, and (iv) late motor deterioration during the school-age years or adolescence. Autistic-like features are most common in the period of rapid regression and are reported to diminish during the pseudostationary stage. There are indications that some individuals with RD maintain social interest and may develop social interaction skills as they grow older.

9.02.2.5 Pervasive Developmental Disorder Not Otherwise Specified There has long been general acknowledgment that the PDDs represent a spectrum of conditions that include prototypical autism and several variations. DSM-III (APA, 1980) introduced the term ªatypical PDDº as a means of classifying those patients that shared some of the features of autism but did not meet all of the diagnostic criteria. In subsequent editions of the DSM, the term has evolved to pervasive developmental disorder not otherwise specified (PDD NOS), and the category has been understood to include a variety of individuals. For example, children whose primary disability is severe pragmatic language dysfunction have sometimes been seen as fitting into the PDD NOS category (Towbin, 1994). Diagnostic criteria for PDD NOS are relatively nonspecific, as is typical of the NOS disorders. One group of children in the PDD NOS category has been singled out for closer study in recent years. Designated as individuals with multiple complex developmental disorder (Cohen, Paul, & Volkmar, 1987), these children have been labeled with a variety of terms including childhood schizophrenia, childhood schizotypal disorder, schizotypal personality disorder, and borderline syndrome of childhood. The key features of multiple complex developmental disorder (MCDD) are defects in thinking, impaired social relatedness, and affect disregulation, all appearing by early childhood. Exploration of this proposed diagnostic category has yielded evidence supporting the view that the disorder is indeed best conceptualized as a developmental disorder, distinguishable from affective and disruptive behavior disorders of childhood (Towbin, Dykens, Pearson, &

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Cohen, 1993). The term is designed to avoid some of the semantic and conceptual problems raised by alternate labels such as ªchildhood schizophrenia.º 9.02.2.6 Comorbid Conditions 9.02.2.6.1 Mental retardation Samples of persons with autism typically show that about 80% have full-scale IQs in the mental retardation range (APA, 1994). Contrary to earlier notions that IQ was relatively meaningless in persons with autism, their scores on intelligence tests appear to be about as stable, reliable, and predictive as those for the general population (Volkmar, Klin, Marans, & McDougle, 1996). Mental retardation is an exclusionary criterion for persons with Asperger's disorder, according to the DSM-IV definition (APA, 1994). Some reports, however, have suggested that persons with Asperger's disorder may present with full-scale IQs in the mild range of mental retardation (Gillberg & Gillberg, 1989). Persons with RD and CDD generally function in the moderate to profound range of mental retardation. PDD NOS is a heterogeneous category with respect to intellectual function but includes many individuals whose measured IQ falls in the mental retardation range. 9.02.2.6.2 Seizure disorder Seizure disorders of all types are quite common in persons with a PDD. Seizures may develop during adolescence in up to 25% of individuals with AD, a pattern of onset that is somewhat unusual in the general population. The risk for seizures is increased for all PDD subgroups, but evidence suggests that individuals with prototypical autism are more likely to experience seizures than those with only some features of the disorder (Deykin & MacMahon, 1979). 9.02.2.6.3 Obsessive-compulsive disorder The presence of repetitive behaviors is a very common feature in persons with autism that has long been included in descriptions of their behavioral features (Simons, 1974). Rumsey, Rapoport, and Sceery (1985) reported that 86% of their adult male sample demonstrated some form of compulsive behavior, including hand washing, arranging objects, repetitive tapping, phonic tics, and stereotyped touching of clothing or other objects. Half of the sample was also characterized by chronic, generalized anxiety. Many younger, lower-functioning children with

24

Pervasive Developmental Disorders

autism display repetitive motor movements such as: rocking; toe-walking; arm, hand, or finger flapping; and whirling (Volkmar, Cohen, & Paul, 1986). These behaviors have a compulsive quality and may be associated with anxiety but their relationship to obsessive-compulsive disorder (OCD), if any, is unclear. Obsessional thinking is also common in persons in the PDD spectrum. Such thinking is most common, or at least most readily detected, in highly verbal individuals. The content of obsessional thinking in PDD is likely to be idiosyncratic, though it may be similar in other respects to that described for OCD. Obsessive thoughts and compulsive behaviors in adults with autism and OCD have been found to differ in some respects from those seen in OCD patients who are not autistic; individuals with autism and OCD were more likely to display hoarding, touching, tapping, rubbing, and selfdamaging behavior and were less likely to report repetitive thoughts involving aggression or symmetry or to engage in checking and counting (McDougle et al., 1995). Other anxiety symptoms are also frequently observed in individuals across the entire spectrum of PDDs; such symptoms include diffuse externalizing behavior problems in lower-functioning individuals, while persons with more typical intellectual skills may manifest obsessive worrying, psychomotor agitation, and excessive and rapid speech. 9.02.2.6.4 Schizophrenia While not common, a number of case reports document the late-childhood or adolescent onset of schizophrenia in individuals with a clear-cut diagnosis of autism in childhood (Petty, Ornitz, Michelman, & Zimmerman, 1984). Most adults with autism are distinguishable from adults with schizophrenia, however, by the absence of positive symptoms of thought disorder (e.g., derailment and illogicality) although they manifest similar affective flattening (Rumsey, Andreasen, & Rapoport, 1986). 9.02.2.6.5 Other behavior problems Hyperactivity is a commonly reported behavioral feature of children with PDD. Crosssectional studies suggest that hyperactivity tends to decline from middle childhood to adolescence, although other behavior problems may persist or increase (Ando & Yoshimura, 1979). Stereotypy, self-injury, and pica are common associated behavior problems, particularly in children with marked intellectual impairment. Many forms of behavior problems in persons with PDD have been hypothesized to serve communicative functions (Donnellan, Mirenda,

Mesaros, & Fassbender, 1984). From this perspective, describing the exact form of the maladaptive behavior is less important than determining the behavior's function. The resulting functional analytic approach has been productive in expanding the nature and range of specific intervention strategies for problem behaviors in persons with PDD.

9.02.2.7 Adolescents and Adults with Pervasive Developmental Disorders Some individuals with autism show improvement with the onset of puberty (Kanner, Rodriguez, & Ashenden, 1972), but adolescence is more commonly marked by increased difficulties (Gillberg, 1984). It is not uncommon for adolescents with no history of seizures to experience an onset of epilepsy during puberty, especially those with more severe intellectual impairment (Rutter, 1977). Problems with sexual behavior are quite common during adolescence, including public exposure and masturbation, and inappropriate sexual advances. Adolescents with autism, particularly those with higher IQs, may be vulnerable to depression as they become aware of the extent to which they differ from their peers. Behavioral problems may be exacerbated, especially in youth who experience marked physical changes as a result of puberty (Gillberg & Schumann, 1981). The social impairment of the PDDs persists throughout the life-span. Although those affected individuals without significant intellectual impairment are generally able to improve their social functioning through therapeutic support and the investment of considerable effort, difficulties in negotiating social interactions are unlikely to disappear entirely. A substantial majority of persons with PDD require significant supports throughout their lives. Adaptive functioning is generally quite impaired, even relative to IQ, and most adults with autism require support and supervision in their employment and living arrangements (Rumsey et al., 1985). Historically, adults with autism have been at considerable risk for long-term institutionalization. One state-wide survey suggested that nearly 60% of the identified adults with autism were living in an institutional setting (Janicki & Jacobson, 1983). In a description of adults with autism who had relatively good outcomes and were said to be ªcapable of functioning in society,º Kanner et al. (1972, p. 27) reported that these adults continued to be characterized by social awkwardness and an inability to form personal friendships. One common feature across these good outcome cases was that all were said to

Etiology

25

have become aware, during their teen years, that they were different from their peers and made a conscious effort to address these differences. Most reports agree that even high-functioning adults with autism engage in social improprieties, would be perceived as unusual by a layperson, are generally characterized as loners, and lack social competencies and, in some cases, social motivation (Rumsey et al., 1985). While long-range prediction of outcome for persons with PDD is an uncertain prospect, there are a few studies that offer some clues. The most powerful predictor of outcome appears to be measured IQ. Intellectual and language tests scores are quite stable in the population and are predictive of future educational placement (Freeman, Ritvo, Needleman, & Yokota, 1985). IQ has also been found to correlate with subsequent academic achievement and social behavior at home (Rutter & Bartak, 1973).

CDD is thought to be only about 0.11 in 10 000, and the male:female ratio of reported cases is about eight to one (Volkmar, 1996). In Kanner's (1943) original discussion of the case histories of his patients with autism, he described their families in terms that suggested they all enjoyed upper socioeconomic status. Although lacking any clear conceptual basis, reports of the association between autism and social class persisted in the literature for many years. Epidemiologic and clinical studies, however, have demonstrated that the relationship is illusory and have concluded that the early findings were likely the result of selection factors favoring the inclusion of the children of higher socioeconomic status families in published reports (Schopler, Andrews, & Strupp, 1979).

9.02.3 EPIDEMIOLOGY

Studies have shown that monozygotic twins show increased concordance for AD, compared with dizygotic twins, indicating that genetic factors play a role in the determination of the disorder. Concordance rates are not, however, 100% (Folstein & Rutter, 1977). Other relatives, particularly siblings, of persons with AD are also at increased risk for autism and other less severe developmental difficulties (Volkmar, Klin, Marans, & McDougle, 1996). The increased rate of occurrence of minor physical anomalies in persons with autism suggests a delay or disruption in early development that may contribute to the pathogenesis of the disorder; such a delay or disruption may result from a genetic predisposition, but no data exist at present to document such a pathway (Smalley & Collins, 1996). One genetic abnormality associated with PDD is the fragile-X syndrome (Brùndum-Neilsen, 1983). Estimates of the prevalence of fragile-X in males with autism have ranged from 5% to 20%, and some researchers have maintained that all fragile-X individuals show some autistic features (Levitas et al., 1983). Other features apparently associated with the combination of autism and fragile-X syndrome are epilepsy, brainstem abnormalities, and a variety of neuropsychiatric symptoms, including elaborate repetitive routines and an aversion to being touched (Gillberg, Persson, & WahlstroÈm, 1986).

AD occurs in approximately 5±10 cases per 10 000 children in the population (Bryson, 1996), and some researchers have indicated that prevalence of the disorder appears to be increasing (Volkmar, Klin, Marans, & McDougle, 1996) although this may be a function of increasingly sophisticated diagnostic procedures. Despite the vagaries of definition and diagnostic procedure, sex ratio figures of children with autism have remained remarkably stable over time: approximately four times as many males as females are diagnosed with autism (Wing, 1976). Evidence suggests, however, that females with autism are likely to have more severe intellectual impairment than males (Lord, Schopler, & Revicki, 1982). Prevalence of persons with Asperger's disorder has been estimated at between 10 and 26 per 10 000, counting only individuals with at least average intelligence (Gillberg & Gillberg, 1989). Available evidence suggests that few persons with IQs in the mentally retarded range display the features of Asperger's disorder and, in fact, current diagnostic criteria preclude mental retardation as a comorbid condition (APA, 1994). Persons with Asperger's disorder are more likely to be males, but epidemiological data on the gender ratio are not yet available. RD is observed in about one child out of 15 000. It is found in all races, and more than 1500 cases have been identified around the world. Generally considered to be a female-only disorder, there are a few cases in which RD was suspected in males. The disorder appears to be genetically determined, with spontaneous mutation the most likely cause (Hagberg & WittEngerstroÈm, 1986). The prevalence rate for

9.02.4 ETIOLOGY 9.02.4.1 Genetic Influences

9.02.4.2 Prenatal/Perinatal Complications Folstein and Rutter (1977) reported that in a discordant twin pair the twin with autism was likely to be the one at greater obstetrical risk. Obstetric complications that are found with increased frequency in the histories of persons with autism and other developmental disabil-

26

Pervasive Developmental Disorders

ities include prematurity, low birth weight, respiratory distress syndrome, rhesus incompatibility, emergency caesarean section, resuscitation, severe fetal/neonatal infection, hemolytic anemia, transfusion for anemia, gross physical abnormality in the fetus, and severe trauma during birth. Recent work, however, suggests that these complications probably represent epiphenomena of the condition or are the result of some shared risk factor, rather than playing a causal role (Bolton et al., 1997). 9.02.4.3 Immunologic Factors There is some evidence for the role of immune system dysfunction in autism (Rimland & Baker, 1996). T-cell abnormalities have been found in children with autism (Warren, Yonk, Burger, Odell, & Warren, 1995), and immune booster treatment has been reported to have benefitted some such children (Reap & Lawson, 1990). 9.02.4.4 Microbial Infections Anecdotal accounts of an onset of autisticlike features in infants following a course of high doses of antibiotics have led to speculation that PDDs may result from microbial infections. The antibiotics, by destroying the natural microorganisms in the intestinal tract, allow for the proliferation of harmful microbes such as Candida albicans. These organisms excrete neurotoxins that may cause symptoms like those seen in autism (Rimland & Baker, 1996). Empirical evidence for this etiological pathway to autism is, however, very limited. 9.02.4.5 Neuropsychological Features Neuropsychological studies have documented impaired function in persons with autism in virtually every domain of cognition, including general intelligence, attention, memory, language, and executive function. In each domain, however, except for executive function, there are also functions that do not appear to be universally affected in persons with autism. Examples of commonly spared functions include visuospatial organization, sustained attention, paired associate learning, and others. Proposed neural substrates for some of the early neuropsychological symptoms of autism include the amygdala, the hippocampus, the cerebellum, the frontal lobe, and the basal ganglia (Dawson, 1996). A study of nine, high-functioning autistic adult males indicated that, compared with normal controls, the autistic subjects showed significant weaknesses in conceptual problem-

solving involving deficiencies in conceptuallevel responding and a tendency to perseverate (Rumsey, 1985). A hypothesis focusing on weakness of frontal-subcortical functions is suggested by these data, but the wide variability in normative groups with demonstrable braindamage precludes unequivocal interpretation of the findings. 9.02.4.6 Neuroanatomic Features Morphological observations of the brains of persons with autism have revealed abnormalities in the brainstem and in the cerebellum (Hashimoto et al., 1995). Imaging studies have indicated enlargement of the parietal, temporal, and occipital lobes of the brains of individuals with autism (Piven, Arndt, Bailey, & Andreasen, 1996). Children with autism show frontal cortex abnormalities suggesting delayed frontal maturation (Zilbovicius et al., 1995). Abnormal limbic system and cerebellum findings have also been reported for Asperger's disorder, although the abnormality is less pronounced; lesions in these areas of abnormality have been associated with symptoms similar to those seen in autism (Bauman, 1996). Animal models indicate that early medial temporal lobe damage involving the amygdala and the hippocampus produces abnormal social behaviors and stereotypies analogous to those seen in autism (Bachevalier, 1966). RD appears to be associated with diffuse neuroanatomic abnormalities throughout the brain that are consistent with maturational failure (Bauman, 1996). A number of researchers have reported that macrocephaly is found in an unusually high proportion of persons with autism (e.g., Bailey, Luthert, Bolton, LeCouteur, & Rutter, 1993). However, this feature appears to be generally unrelated to most clinical characteristics (Lainhart et al., 1997). 9.02.4.7 Neurochemical Findings Investigation of the neurochemistry of autism is a relatively nascent field. One finding that has been replicated is an increased level of serotonin in the platelets of children with autism (e.g., Anderson et al., 1987). Other promising methods of neurochemical investigation are under development but have yielded little in the area of PDD as yet (Cook, 1996). 9.02.5 ASSESSMENT AND DIAGNOSIS Criteria for the diagnosis of autism have evolved over the past several decades, and this evolution has contributed to confusion and

Assessment and Diagnosis disagreement in the differential diagnosis of individuals with developmental disabilities. The use of latent class models in recent years, however, provides support for the assertion that diagnostic criteria have improved. PDD diagnostic criteria found in ICD-10 and in DSM-IV have shown the best agreement with a ªlatent standardº compared with the criteria found in other recent definitions (Szatmari, Volkmar, & Walter, 1995). The past four decades have seen the development of a wide range of diagnostic instruments and procedures that have contributed to improved diagnostic reliability. These tools include checklists, structured and semistructured interviews, and observation schedules. The Autism Behavior Checklist (ABC) is a diagnostic screening instrument designed to examine behavioral characteristics common in autism (Krug, Arick, & Almond, 1980). The 57item checklist was subsequently incorporated into the Autism screening instrument for educational planning (Krug, Arick, & Almond, 1993). Initial psychometric studies of the ABC were generally supportive and the instrument has received wide use, particularly in educational settings. A recent addition to the field, the Gilliam Autism Rating Scale (GARS; Gilliam, 1995), is a relatively brief, caregiver-report instrument designed to contribute to the diagnostic process for persons for whom autism is suspected. The GARS possesses reasonable psychometric properties and was normed on a sizeable sample (N = 1092) of individuals with autism. One of the more promising directions in diagnostic procedures is the development of semi-structured interviews for caregivers of children and adults for whom PDD is a suspected diagnosis. The Autism Diagnostic Interview-Revised (ADI-R; Le Couteur et al., 1989) takes about 90 minutes to administer and includes items related to communication, social development and play, repetitive and restricted behaviors, and general behavior problems. The diagnostic algorithm for the ADI-R is designed to match the clinical descriptions and diagnostic criteria found in DSM-IV and ICD-10 (APA, 1993; WHO, 1993). Reliability and validity data support the use of the ADI-R in distinguishing children with autism from nonautistic, mentally handicapped/language-impaired children (Lord, Rutter, & Le Couteur, 1994). Many clinicians interested in the diagnosis of PDDs are reluctant to rely solely on parent report checklists and interview data as their primary sources of data. As a result, structured observation protocols have emerged as a way of standardizing clinician±patient interaction and eliciting diagnostically relevant behaviors.

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Among the first of such instruments for autism was the Childhood Autism Rating Scale (CARS; Schopler, Reichler, DeVellis, & Daly, 1980). The CARS consists of clinician ratings on 15 scales based on observation of the child during a diagnostic interview session. Substantial research has supported the validity of the CARS, and it continues to be one of the most widely used instruments of its kind. Structured observation instruments have varied in terms of discriminant validity and typically performed best when distinguishing children with autism and severe mental retardation from normally developing or nonautistic children with mental retardation. The capacity of these instruments to identify higher-functioning persons with autism, however, has generally been found to be diminished. Observation of social and communicative features of children and adults with mild or no intellectual impairment was the express goal of a structured observation system designated the Autism Diagnostic Observation Schedule (ADOS; Lord et al., 1989). The procedure provides a standardized set of contexts within which the observer can assess social and communicative behavior. The ADOS consists of eight tasks requiring about 20±30 minutes to complete. The tasks are intended to provide opportunities for specific diagnostically-relevant target behaviors, including asking for help, symbolic play, and reciprocal play. A downward extension and revision of the ADOS format has also been developed to assess children under six years of age who are suspected of having autism (DiLavore, Lord, & Rutter, 1995). Even with the best diagnostic instruments and procedures, nothing can replace clinical experience with the population in producing an accurate, comprehensive evaluation. Further, an adequate assessment requires the knowledge and skills of parents, as well as professionals from a variety of disciplines, and an ability to coordinate those resources in a working team. In addition to the careful evaluation of diagnostic criteria, a comprehensive assessment of individuals with PDD will include at least three other major components: assessment of communication skills, psychological evaluation, and psychiatric assessment (Volkmar, Klin, Marans, & McDougle, 1996). The assessment of communication in persons with PDD should not only include the traditional areas of articulation, vocabulary, and syntax but also emphasize those aspects of communication that are particularly affected by the condition. Specifically, attention is given to nonverbal communication (e.g., gaze, gestures), pragmatic intent and pragmatics in speech, and the use of language in social contexts. In

28

Pervasive Developmental Disorders

individuals with more highly developed language, an evaluation of communication also incorporates assessment of subtle aspects of language such as the use of metaphors, humor, and irony and an understanding of ambiguity in communication (Klin & Shepard, 1994). Key components of a psychological evaluation of individuals with PDD include assessment of intelligence, adaptive behavior, and personality as well as neuropsychological assessment (Klin & Shepard, 1994). There is abundant evidence that the use of standard intellectual instruments with individuals with PDD yields meaningful estimates of general intellectual ability and information regarding specific cognitive strengths and weaknesses. The fact that mental retardation is common in the population, however, frequently limits the choice of instruments, and the marked deficits in language often render portions of intelligence tests inaccessible to persons with PDD. Nonverbal instruments such as the Leiter International Performance Scale (Leiter, 1948) and tests of early development such as the Bayley Scales of Infant Development (Bayley, 1993) have often been used to derive estimates of general intellectual functioning when other scales do not include an adequate range of skills on the lower end of the developmental continuum. Evaluation of adaptive behavior is less problematic, primarily because the most commonly used adaptive behavior assessment procedures rely on caretaker informants. The Vineland Adaptive Behavior Scale (Sparrow, Balla, & Cicchetti, 1984) and the AAMR Adaptive Behavior Scale (Lambert, Nihira, & Leland, 1993) are among the most commonly used instruments for the assessment of adaptive behavior in persons with PDD. The evaluation of social/emotional or personality functioning of individuals with PDD often requires some adaptation of typical procedure. Evaluation procedures that rely on language are frequently of limited value because of the communication deficits inherent to the disorders. However, informant ratings of problem behaviors can be supplemented by clinical observation and structured or unstructured play assessment. One of the more fruitful approaches to the assessment of problem behaviors in persons with PDD has been the functional analysis of behavior. Functional analysis is a conceptual framework for the assessment and treatment of challenging behaviors. The approach seeks to identify environmental stimuli and consequences that affect the frequency and intensity of such behaviors, with the goal of altering the environment or providing additional support to the individual. Functional analysis has a long

history in the field of applied behavior analysis and has served to stimulate and support efforts to provide treatment that is nonpunitive and nonrestrictive with a focus on supporting adaptive behavior rather than eliminating problem behaviors (Singh, 1997). The functional analytic approach has yielded a variety of intervention strategies focusing on the hypothesized function of the maladaptive behavior. These strategies include intensive instruction in basic communication, extinction through the elimination of specific naturally-occurring reinforcers in the environment, and providing noncontingent attention. 9.02.6 TREATMENT 9.02.6.1 Structured Teaching and Behavior Modification Approaches One of the most intensive and carefully studied approaches to structured teaching with children with autism was developed and originally described by Lovaas and colleagues (1980). The program was based on principles of operant reinforcement and involved intensive, highly structured instruction and behavior modification. Subjects, who were under four years of age at enrollment, were provided with one-on-one therapists for an average of 40 hours per week over a period of two or more years. Outcomes studies have documented clinically significant effects, including the finding that nearly half of the experimental group achieved normal intellectual and educational functioning at the post-treatment assessment (Lovaas, 1987). A long-term follow-up study of these children indicated that they had maintained their behavioral and intellectual progress, and continued to function much better than the original control group (McEachin, Smith, & Lovaas, 1993). A case report has also documented the success of an intervention based on Lovaas' work, with two children who showed significant deterioration similar to that seen in CDD (Perry et al., 1995). Structured teaching also constitutes the core of the treatment approach provided by division TEACCH, the statewide program of services to individuals with autism in North Carolina (Mesibov, 1997). Division TEACCH has pioneered a range of teaching methods, particularly in the area of communication strategies, and TEACCH-related programs have yielded extensive documentation of the efficacy of these methods (e.g., Ozonoff & Cathcart, in press; Schopler, Brehm, Kinsbourne, & Reichler, 1971; Short, 1984). A hallmark of TEACCH's work has been the active and fruitful involvement of parents in the treatment and education of

Treatment children with autism. TEACCH programs have demonstrated the importance and the impact of training parents in structured teaching methods; such parent training has been found to yield improved child behavior, parent±child interaction, and parental sense of control (Marcus, Lansing, Andrews, & Schopler, 1978). Outcome studies of TEACCH programs have documented their efficacy in terms of long-term placement in the community (Schopler, Mesibov, Devellis, & Short, 1981), vocational placement in supported employment (Mesibov, 1997), and parental satisfaction (Bristol & Schopler, 1983).

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9.02.6.4 Other Behavioral Interventions A variety of other types of interventions have emerged from the extensive use of behavior modification with persons with PDD. Behavioral interventions have shown promise in areas such as functional communication training (Carr & Durand, 1985), self-management in the treatment of social deficits and disruptive behavior (Koegel, Koegel, Hurley, & Frea, 1992), and the treatment of pica (Myles, Simpson, & Hirsch, 1997). 9.02.6.5 Psychopharmacology

9.02.6.2 Social Intervention Strategies Another approach to the treatment of children with autism has emphasized the importance of early social intervention, particularly with regard to peer influence in the development of interaction skills. Investigators at the Allegheny±Singer Research Institute have pursued a program of research that has served to clarify the type and level of support required for typically developing preschool-age children to elicit improved social interaction behaviors from peers with autism. Research in this area has explored differential responses to peer overtures (Kohler, Strain, & Shearer, 1992), the importance of group contingencies, and the role of specific instruction in corollary supportive peer behaviors (Kohler et al., 1995), and the role of teacher prompts (Odom & Strain, 1986). Some data suggest that a similar strategy can be applied in the home to increase positive interaction between young children with PDD and their siblings (Strain & Danko, 1995). 9.02.6.3 Language Intervention Strategies While communication problems have always been an important component of the syndrome of autism, the notion that these problems could be explained in terms of semantic and conceptual deficits has been replaced by an emphasis on the pragmatics of language (Tager-Flusberg, 1981). The communication problems of children and adults with PDD have led researchers to propose a variety of language-related intervention strategies. Examples of such strategies include visual cuing (Quill, 1995) and direct instruction in pragmatic skills (Ogletree, Fischer, & Sprouse, 1995). Other developments in the field of language intervention include investigation of methods to overcome the effects of motor limitations on speech and communication development and the effects of a loss of speech or speech regression common in the history of many children with PDD (Prizant, 1996).

Pharmacotherapy research related to PDDs has expanded dramatically in recent years. While it is unlikely that any drug will be equally effective for the entire PDD spectrum, researchers have begun to target key symptoms and subgroups for pharmacological intervention (McDougle, Price, & Volkmar, 1994). 9.02.6.5.1 Serotonergic drugs Medications that affect levels of the neurotransmitter serotonin have been explored for individuals with autism in response to a finding that up to one-half of this population has blood platelet levels of serotonin at the 95th percentile or above. An initial report of the effectiveness of fenfluramine in three young children with autism (Geller, Ritvo, Freeman, & Yuwiler, 1982) prompted a flurry of related research activity. Controlled studies, however, have failed to replicate positive changes in core symptoms of PDD and suggested that fenfluramine may have negative effects on discrimination learning (August, Raz, & Baird, 1987; Campbell et al., 1988). In general, the evidence suggests that drugs that release serotonin or block its reuptake at the neuronal level may be useful in reducing aggression and repetitive behavior that interferes with functioning and in improving social relatedness in persons with autism (McDougle et al., 1994). However, a recent study of clomipramine, a tricyclic antidepressant and serotonin reuptake inhibitor, found that the drug was not therapeutic and was associated with significant side effects (Sanchez et al., 1996). 9.02.6.5.2 Opiate antagonists In some persons with developmental disabilities who display self-injurious behavior, such behavior has been associated with elevated levels of endogenous opioids that are known to decrease pain sensitivity. This finding has led to trials of opiate antagonist drugs in the treatment

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Pervasive Developmental Disorders

of self-injury (Sandman et al., 1983). One such drug, naltrexone has been subjected to controlled studies which documented positive change in parent and teacher ratings of global improvement, restlessness, and impulsivity/ hyperactivity (Kolmen, Feldman, Handen, & Janosky, 1995) While opiate antagonists have shown promise in the treatment of self-injury in some persons with PDD, the findings are equivocal. Case reports have documented increases in self-injury when these medications are administered, the increases being commonly explained as extinction burst phenomena (e.g., Benjamin, Seek, Tresise, Price, & Gagnon, 1995). The extinction burst explanation is based on the conceptualization that when self-injurious behavior, previously reinforced by the natural secretion of endogenous opioids, is no longer reinforced, because of the suppression of opioid production, the behaviors may show the temporary increase in rate frequently associated with the removal of reinforcers. 9.02.6.5.3 Dopaminergic drugs Drugs that affect the neurotransmitter dopamine have been found to decrease stereotyped behavior in persons with autism (Mikkelsen, 1982). Dopamine antagonists (e.g., thioridazine) have also been investigated in the treatment of pica. A controlled study has indicated that such drugs can actually worsen pica in persons with mental retardation (Singh, Ellis, Crews, & Singh, 1994). Research on the effects of the dopaminergic drug risperidone in children and youth with PDD is encouraging, although the clinical trials are at a fairly early stage of development. An open-label trial of risperidone yielded clinicallysignificant global improvement and improvement in behavior symptoms (including repetitive behavior, aggression, and maladaptive behavior) in two-thirds of the subjects (McDougle et al., 1997). Other dopamine antagonist drugs have long been used to good effect in the treatment of children and adults with PDD. The medication most systematically investigated in the treatment of autism has been haloperidol. This drug has been shown to facilitate learning and to reduce core symptoms and associated behavior of autism in some children (Campbell, Schopler, Cueva, & Hallin, 1996). One of the key drawbacks to the use of neuroleptics such as haloperidol has always been the occurrence of tardive dyskinesia (TD) associated with longterm use. TD has been reported to occur in about one-third of patients with autism. Susceptibility to TD may be associated with female gender and

pre- and perinatal complications, and risk is increased by greater cumulative doses and longer exposure (Campbell et al., 1997). There is considerable evidence that dopamine antagonists are effective in reducing maladaptive behavior in many children with autism. However, the older drugs in this class frequently produce dyskinesias, rendering them relatively less desirable. Newer drugs that affect dopamine transmission have not been sufficiently tested but may offer similar benefits without the substantial side effects (McDougle et al., 1994). 9.02.6.5.4 Noradrenergic drugs Preliminary data indicate that clonidine, an alpha noradrenergic receptor agonist, may be useful in treating hyperactivity and irritability and that beta blockers may help control aggressive and self-injurious behaviors (Lewis, 1996). Few controlled studies have been conducted, however, and the existing data regarding the effects of this class of drugs on the core symptoms of autism are not particularly encouraging (McDougle et al., 1997). 9.02.6.5.5 Stimulants Early clinical trials of the use of stimulants with children with autism were generally discouraging, indicating increased irritability and stereotypic movements (Campbell et al., 1972). Criticism of this work, however, on the basis of a heterogeneous sample and possible interactions with neuroleptics, has prompted additional investigation in the area. More recent studies have supported the use of methylphenidate (Ritalin) in the treatment of hyperactivity in children with autism and have not found the untoward side effects previously reported (Birmaher, Quintana, & Greenhill, 1988; Quintana et al., 1995). 9.02.6.5.6 Nutritional supplements The most extensively investigated nutritionrelated treatment of autism is the use of supplements of vitamin B6 and magnesium. An early, double-blind crossover study (Rimland, Callaway, & Dreyfus, 1978) provided the impetus for considerable research in the area, leading to claims that more than 40% of the children with autism receiving this ªmegavitamin therapyº showed improvement (Rimland, 1988). In general, the efficacy of nutritional supplements in the treatment of core symptoms of PDD remains in question. While testimonials and anecdotal evidence abound, documented responses in controlled studies have been relatively scarce, suggesting that the

References improvement in some individuals within the PDD spectrum may be based on idiosyncratic factors rather than reliable response mechanisms inherently related to the disability. Nutritional supplements have been used to some effect in the treatment of specific symptoms common in autism. A serum zinc supplement and a general dietary supplement, for example, have been found to be effective in reducing pica in studies of individuals with mental retardation (Bugle & Rubin, 1993; Lofts, Schroeder, & Maier, 1990). 9.02.7 SUMMARY Investigation related to the diagnosis, assessment, and treatment of persons with PDDs has been a tremendously fruitful area since the 1960s. Diagnostic differentiation is becoming increasingly sophisticated, instruments that can contribute to a comprehensive assessment are more numerous and more appropriate to the population, and information regarding treatment alternatives with solid empirical support is slowly being developed and disseminated. Some promising emerging areas of research are in the burgeoning field of psychopharmacology and in the maturing study of ecological factors in the determination of behavior. The investigation of genetic, prenatal, and perinatal factors related to PDDs has also yielded many fruitful avenues for new research. Neuroanatomic studies continue to tantalize the field and represent a slow, steady accretion of knowledge that holds hope for tangible results. Finally, an increasing emphasis on early identification of persons in the PDD spectrum offers an opportunity for the development of more effective early intervention strategies. PDDs are among the most puzzling and rewarding challenges to contemporary clinical psychology. As the knowledge base expands, the prospects for accurate diagnosis, meaningful assessment, and effective intervention steadily improve and, with them, the possibility that individuals with PDDs will suffer less from the effects of their disabilities and will enjoy an improved quality of life. 9.02.8 REFERENCES American Psychiatric Association (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Anderson, G. M., Freedman, D. X., Cohen, D. J., Volkmar, F. R., Hoder, E. L., McPhedran, P., Minderaa, R. B., Hansen, C. R., & Young, J. R. (1987). Whole blood serotonin in autistic and normal subjects.

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Child Psychology, Psychiatry, and Allied Disciplines, 36, 249±263. Sparrow, S., Balla, D., & Cicchetti, D. (1984). Vineland Adaptive Behavior Scales Expanded Form. Circle Pines, MN: American Guidance Service. Strain, P. S., & Danko, C. D. (1995). Caregivers' encouragement of positive interaction between preschoolers with autism and their siblings. Journal of Emotional and Behavioral Disorders, 3, 2±12. Szatmari, P., Tuff, L., Finlayson, A. J., & Bartolucci, G. (1990). Asperger's syndrome and autism: Neurocognitive aspects. Journal of the American Academy of Child & Adolescent Psychiatry, 29, 130±136. Szatmari, P., Volkmar, F., & Walter, S. (1995). Evaluation of diagnostic criteria for autism using latent class models. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 216±222. Tager-Flusberg, H. (1981). On the nature of linguistic functioning in early infantile autism. Journal of Autism and Developmental Disorders, 11, 45±56. Tantum, D. (1988). Asperger's syndrome. Journal of Child Psychology, Psychiatry, and Allied Disciplines, 29, 245±255. Towbin, K. E. (1994). Pervasive developmental disorder not otherwise specified: A review and guidelines for clinical care. Child and Adolescent Psychiatric Clinics of North America, 3, 149±160. Towbin, K. E., Dykens, E. M., Pearson, G. S., & Cohen, D. J. (1993). Conceptualizing ªborderline syndrome of childhoodº and ªchildhood schizophreniaº as a developmental disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 775±782. Tsai, L. Y. (1994). Rett syndrome. Child and Adolescent Psychiatric Clinics of North America, 3, 105±118. van Engeland, H., BoldnaÁr, F. A., & Bolhuis, G. (1985). Some qualitative aspects of the social behaviour of autistic children: An ethological approach. Journal of Child Psychology and Psychiatry, 26, 879±893. Vig, S., & Jedrysek, E. (1995). Adaptive behavior of young urban children with developmental disabilities. Mental Retardation, 33, 90±98. Volkmar, F. R. (1992). Childhood disintegrative disorders: Issues for DSM-IV. Journal of Autism and Developmental Disorders, 22, 625±642. Volkmar, F. R. (1994). Childhood disintegrative disorder. Child and Adolescent Psychiatric Clinics of North America, 3, 119±129. Volkmar, F. R. (1996). The disintegrative disorders: Childhood disintegrative disorder and Rett's disorder. In F. R. Volkmar (Ed.), Psychoses and pervasive developmental disorders in childhood and adolescence (pp. 223±248). Washington, DC: American Psychiatric Press. Volkmar, F. R., & Cohen, D. J. (1994). Autism: Current concepts. Child and Adolescent Psychiatric Clinics of North America, 3, 43±52. Volkmar, F. R., Cohen, D. J., & Paul, R. (1986). An evaluation of DSM-III criteria for infantile autism. Journal of the American Academy of Child and Adolescent Psychiatry, 25, 190±197. Volkmar, F. R., Klin, A., Marans, W., & Cohen, D. J. (1996). The pervasive developmental disorders. Child and Adolescent Psychiatric Clinics of North America, 4, 963±977. Volkmar, F. R., Klin, A., Marans, W., & McDougle, C. J. (1996). Autistic disorder. In F. R. Volkmar (Ed.), Psychoses and pervasive developmental disorders in childhood and adolescence (pp. 129±190). Washington, DC: American Psychiatric Press. Volkmar, F. R., Sparrow, S. S., Goudreau, D., Cicchetti, D. V., Paul, R., & Cohen, D. J. (1987). Social deficits in autism: An operational approach using the Vineland Adaptive Behavior Scales. Journal of the American

References Academy of Child and Adolescent Psychiatry, 26, 156±161. Warren, R. P., Yonk, J., Burger, R. W., Odell, D., & Warren, W. L. (1995). DR-positive T-cells in autism: Association with decreased plasma levels of the complement C4B protein. Neuropsychobiology, 2, 53±57. Wenar, C., Ruttenberg, B. A., Kalish-Weiss, B., & Wolf, E. G. (1986). The development of normal and autistic children: A comparative study. Journal of Autism and Developmental Disorders, 16, 317±333. Wing, L. K. (1976). Early childhood autism. Oxford, UK: Pergamon.

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World Health Organization (1993). The ICD-10 classification of mental and behavioural disorders, Diagnostic criteria for research. Geneva, Switzerland: Author. Zelazo, P. D., Burack, J. A., Benedetto, E., & Frye, D. (1996). Theory of mind and rule use in individuals with Down's syndrome: A test of the uniqueness and specificity claims. Journal of Child Psychology, Psychiatry, and Allied Disciplines, 37, 479±484. Zilbovicius, M., Garreau, B., Samson, Y., Remy, P., BartheÂleÂmy, C., Syrota, A., & Lelord, G. (1995). Delayed maturation of the frontal cortex in childhood autism. American Journal of Psychiatry, 152, 248±252.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

9.03 Learning Disabilities IVAN L. BEALE University of Auckland, New Zealand 9.03.1 INTRODUCTION

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9.03.2 PHENOMENOLOGY

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9.03.2.1 General 9.03.2.2 A Typical Case of Learning Disabilities 9.03.2.3 Definition 9.03.2.4 Classification 9.03.2.4.1 Learning disabilities subtypes 9.03.2.4.2 Reading disability subtypes 9.03.2.4.3 Mathematics disability subtypes 9.03.2.5 Prognosis 9.03.2.6 Other Problems Associated with Learning Disabilities 9.03.3 EPIDEMIOLOGY

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9.03.3.1 Prevalence 9.03.3.2 Prevalence in Different Populations 9.03.4 ETIOLOGY 9.03.4.1 9.03.4.2 9.03.4.3 9.03.4.4

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Neurological Factors Psychological Factors Genetic Factors Environmental Factors

9.03.5 ASSESSMENT AND DIAGNOSIS

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9.03.5.1 The Behavioral Assessment Model 9.03.5.2 The Issue of Diagnosis 9.03.5.3 The Issue of Etiology 9.03.5.4 Classification 9.03.5.5 Goals of Assessment 9.03.5.5.1 Identification of the focus of treatment 9.03.5.5.2 Defining and measuring key behaviors 9.03.5.5.3 Functional assessment (functional analysis) 9.03.5.5.4 Selection of a treatment strategy 9.03.5.6 The Assessment Procedure 9.03.6 TREATMENT 9.03.6.1 9.03.6.2 9.03.6.3 9.03.6.4

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General Treatment Issues Treatment Programs Treatment Implementation Monitoring of Treatment

9.03.7 FUTURE DIRECTIONS FOR RESEARCH AND PRACTICE

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9.03.8 SUMMARY

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9.03.9 REFERENCES

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Learning Disabilities

9.03.1 INTRODUCTION Learning disabilities (LDs) are learning problems that specifically affect one or more skill areas, such as reading, writing, or social skills, in persons who appear to be otherwise normally skilled and educated. The best-known, and most common, type of LD is dyslexia, which is characterized by a singular inability to read in an otherwise competent person. Although learning disabilities may be acquired by adults or children as a result of brain trauma, they originate typically as a developmental disorder of childhood, where they are as common as they are seemingly intractable to treatment. There are many different psychological disorders that might afflict us at some time during our childhood. Some are known and feared by parents mainly because of the extensive media coverage they receive, featuring their dramatic nature, attendant family trauma, and poor prognosis. Examples include severe mental retardation, autism, fragile-X, and Tourette's and Rett's disorders. But many parents are less aware of the two psychological disorders of childhood that are by far the most likely to intrude into their lives. These are LD and Attention deficit hyperactivity disorder (ADHD). Each of these disorders affects about one child in every 20 and their combined prevalence is probably higher than that of all the other childhood psychological disorders (Pennington, 1991). Moreover, because LD and ADHD have a significant comorbidity and because each can lead to a secondary expression of some symptoms of the other, they are often confused with one another. This chapter primarily is concerned with learning disabilities of developmental origin, as expressed in school-aged children. However, some reference is made to life-span implications, comorbid conditions, and the effects of brain trauma. As is appropriate in a volume on clinical psychology, emphasis is placed on the main concerns of the clinician: identification, assessment, and treatment. As far as possible, in the interests of providing a consistent framework, these are placed in the context of a broad conceptualisation of the behavioral assessment model (Nelson & Hayes, 1986).

as whether learning disabilities even exist as identifiable disorders (Algozzine & Ysseldyke, 1983; Kavale & Forness, 1985; Radencich, 1984). For example, it is debated whether learning disabilities are reliably discriminable from cases of general learning backwardness or minor neurological damage, and it has long been argued whether medical, psychological, or educational expertise is most appropriate for dealing with the problem. At another level completely, there has been ongoing disagreement concerning the nature of some learning disabilities. For example, is dyslexia primarily a problem of visual processing, or does it result from a lack of phonological awareness (Hulme, 1988; Vellutino, 1979)? The extent and persistence of the debate has led to a range of negative consequences. An example of political fallout is seen in New Zealand, where an otherwise developed country with a serious child education program does not recognize a need to provide assessment and remedial services explicitly for LDs (Chapman, 1992). Another undesirable consequence of the lack of professional unity on LD has been the persistence of a variety of speculative theories and their related interventions which have no basis in science or any other systematic knowledge. Examples include special diets, inappropriate medication, tinted glasses, gross motor exercises, and cranial manipulation (Beale, 1995; Silver, 1987). Perhaps the most troubling consequence of the LDs controversy is that its existence has been used by administrators, educators, and other professionals as an excuse for sidelining the LDs problem in decision-making about funding and other resource priorities. Certainly the debate has importance within the framework of research and theory but, from a clinician's perspective, it is relevant mainly to the extent that it affects what is good practice in management of the clinical problems presented by the clients. Certainly, much of the controversy about etiology, definition, and classification can be regarded as only marginally relevant to the management of an individual case. This is because case presentation is primarily driven by concern about symptoms and the need for treatment rather than by the need for diagnosis, classification, and opinion regarding etiology.

9.03.2 PHENOMENOLOGY 9.03.2.2 A Typical Case of Learning Disabilities 9.03.2.1 General The study of learning disabilities has a long history of controversy. Topics in dispute include not only definition, etiology, classification, and treatment but also fundamental questions such

This point of view can best be illustrated by considering briefly an example of a child with learning disabilities. The point here is to show that the major clinical considerations in the individual case are independent of the major

Phenomenology issues under debate, including diagnosis, classification, and etiology. This case is revisited throughout this chapter to illustrate other issues. A typical case presenting in a clinical setting is Hank, a nine-year-old boy referred by his parents, who cite persistent failure to learn to read or spell at anything like the normal rate. In other respects he has always seemed capable and is actually good at computational aspects of mathematics. He has some difficulty, however, working out the computational requirements of problems that are presented verbally. The problem was noticed in Hank's first year of elementary school instruction and has continued since, with Hank falling progressively further behind his peers in his level of performance in reading and writing. Concurrently, his initial positive attitude to schoolwork has reversed to the point of general distress and negativism about most school-related activities, even in those areas in which he can perform at an age-appropriate level. He is now anxious about school and has generally low expectations about his academic achievements. In particular, Hank hates any activities involving reading and writing. He considers himself to be ªdumb,º largely because of his difficulties with written language and the reaction to this, over the years, by some teachers and other students. He has suffered ridicule and teasing, his self-esteem generally has been eroded, and this is reflected in the deterioration of his social behavior. Hank now has no friends among his peers and few activities that he seems to enjoy. Of late, he has been inattentive and surly in the classroom, and his teacher has suggested to his parents that they seek expert advice. Prior to this time, his teachers have not considered Hank's problem sufficiently severe to require expert intervention outside the remedial resources provided within the school. However, additional help provided in earlier years did not result in lasting gains in language skills. These remedial efforts consisted mainly of periods of one-to-one tutoring conducted by teacher aides who had no particular knowledge about learning disabilities nor insights into the nature of Hank's problem. The persistence of the reading problem in the face of remedial efforts has not been especially concerning to Hank's teachers, although it has been to Hank and his parents. His father recalls having reading problems at school and describes himself as still a ªreluctant reader and hopeless speller.º Hank's older brother had problems similar to Hank, although less severe. He seemed to get by after some remedial work was done with him. The impetus for the current expert assessment for Hank came not from

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concern about the reading problem but rather from the intrusive nature of the behavior problems that have emerged more recently. The clinical issues are clear enough. There are specific academic-skills deficits overlaid by secondary behavioral and attentional problems. In addition, socio-emotional and motivational problems have begun to develop. The assessment and treatment of these problems can proceed regardless of the uncertainties or debate around issues of definition or etiology. However, an awareness of these matters may be helpful in discussing the problem with Hank and his family, and in securing the cooperation of teachers and other professionals who might be involved. Funding of treatment may also be dependent on diagnosis and classification of the problem, so there may be formal requirements to be met which require the clinician to grasp the nettle of LD definition. 9.03.2.3 Definition The field of learning disabilities has a complex history. Kavale and Forness (1992) have traced the evolution of the definition of LD through the successive frameworks of brain injury (Strauss & Lehtinen, 1947), minimal brain dysfunction (Clements, 1966), and educational discrepancy (Kass & Myklebust, 1969) eventually to a series of consensual definitions required for legislative purposes (National Advisory Committee on Handicapped Children, 1968; National Joint Committee on Learning Disabilities, 1981). An example of a consensual definition of LD is that approved by the Interagency Committee on Learning Disabilities (ICLD) in 1988: Learning disabilities is a generic term that refers to a heterogeneous group of disorders manifested by significant difficulties in the acquisition and use of listening, speaking, reading, writing, reasoning or mathematical abilities, or of social skills. These disorders are intrinsic to the individual and presumed to be due to central nervous system dysfunction. Even though a learning disability may occur concomitantly with other handicapping conditions (e.g., sensory impairment, mental retardation, social and emotional disturbance), with socio-environmental influence (e.g., cultural differences, insufficient or inappropriate instruction, psychogenic factors), and especially with attention deficit disorder, all of which may cause learning problems, a learning disability is not the direct result of those conditions or influences. (Kavanagh & Truss, 1988, pp. 550±551)

Of course, such definitions are couched in broad descriptive terms that do not in themselves lead to a sure diagnosis. Concepts such as

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Learning Disabilities

ªsignificant difficultiesº are useful only in as far as they can be translated into actual assessment protocols and clear interpretative criteria. However, past attempts to produce generally acceptable operational definitions for these descriptive terms usually have not been considered to be successful (Chalfant & King, 1976; Schere, Richardson, & Bailer, 1980). In the meantime, the ICLD definition serves as a useful guideline for identification of LD, to be operationalized where necessary by the requirements of whatever local authority sets the rules for definition of LD for the purpose of controlling access to treatment resources. In the USA, requirements vary from state to state but are based on the federal requirement embodied in Public Law 101±476, the Individuals with Disabilities Education Act (1990). This includes a regulation stating that a student has a specific learning disability if: (i) The student does not achieve at the proper age and ability levels in one or more of several specific areas when provided with appropriate learning experiences, and; (ii) The student has a severe discrepancy between achievement and intellectual potential in one or more of these seven areas: oral expression, listening comprehension, written expression, basic reading skill, reading comprehension, mathematics calculation, and mathematics reasoning. Again, these criteria can serve only as a general guide to identification of LD. In particular, attempts to develop discrepancy criteria that are valid across a wide range of ages and symptomatology have not been successful (Siegel & Metsala, 1992). Clinicians also find difficulty with the exclusionary clause in the ICLD definition because factors such as inadequate educational experiences, emotional disturbance, and neurological dysfunction, may well contribute to or modify the expression of a child's learning disabilities, even when they are not the root cause of the LD symptoms (Silver & Hagan, 1990). The American Psychiatric Association's (1994) Diagnostic and Statistical Manual of Mental Disorders prefers the term ªLearning Disorders.º It identifies the categories of Reading Disorder, Mathematics Disorder, Disorder of Written Expression, and Learning Disorder Not Otherwise Specified. Subtypes are not specified within these disorders. 9.03.2.4 Classification 9.03.2.4.1 Learning disabilities subtypes Early in its evolution as a clinical entity, LD was often regarded as a unitary concept,

manifested in numerous research studies that contrasted ªlearning disabled vs. normal learnersº as a means of revealing the essential factor underlying LD. Since the 1960s, this has given way to a general acceptance that LD is a heterogeneous disorder both at the level of symptomatology and etiology. The problem has been to find classificatory systems that are both enlightening theoretically and helpful in the process of choosing an effective intervention. Useful approaches might be based on areas of academic skill deficits, some aspect of the presumed etiology (Silver & Hagin, 1990), patterns of academic performance (Siegel & Metsala; 1992), or statistically identified clustering of performance variables (Rourke, 1985). The skill areas of difficulty usually distinguished in the LD literature are: reading disability (oral reading and comprehension); oral language disability (listening and speaking); written language disability (spelling, handwriting, and written composition); mathematics disability (numerical concepts, computation); social disability (social skills); and motor disability (fine and gross movement, balance and kinaesthesis, orientation). Classification based on underlying processes generally makes reference to the following: memory (several categories); attention (several categories); phonological awareness; and cognitive and metacognitive strategies. There has been an extensive research effort to identify useful classification systems for LD problems, driven by the need to deal rationally with the apparent heterogeneity of the disorder. The empirical approach to subtyping is based on statistical procedures, such as Q-factor analysis, and cluster analysis of scores on performance batteries mainly comprised by academic attainment tests and neuropsychological tests. Studies of this type have identified three (Petrauskas & Rourke, 1979) to five subtypes (Satz & Morris, 1981). However, the limitations of this approach have been pointed out repeatedly (Kavale, 1990a; Siegel & Metsala, 1992), and there has yet to emerge a consensual classification scheme that could simplify rather than complicate the conceptualization of LD heterogeneity. 9.03.2.4.2 Reading disability subtypes Better understood are the predominant types within particular areas of academic skills deficit. The more specific category of reading disability, considered in less-enlightened times to be a unitary syndrome (Gaddes, 1985), has been classified into subgroups by several researchers (e.g., Doehring, Hoshko, & Bryans, 1979; Mattis, 1978). There is strong evidence that by far the most common type of reading

Phenomenology disability is characterized by an impairment in language skills, especially the phonological processing required to discriminate the sequence of sounds in spoken words. The spelling to dictation of children and adults with LD is difficult to decipher, because the sequence of letters often does not correspond to the sequence of sounds in the words; they do not write the word as it sounds. The least common is the visuo-spatial type of reading disability. Children in this category may have good phonological skills but poor visual memory. This is manifested in poor sight vocabulary in ªflashº tests. Their spelling of irregular words is often phonetically regular but visually incorrect. A third identified subtype is of intermediate prevalence relative to the other two types. The spelling problems in this group seem to be a mixture of the two other types. It has been suggested that this type of problem is characterized by difficulty with processing of sequential information (Mattis, 1978; Rourke, 1982). It should not be thought that these three groups form a complete typology that is well accepted. Some investigators (e.g., Bakker, 1992) have preferred two categories, based essentially on theories about inappropriate balance of control between the two hemispheres of the brain. In fact, many cases of reading disability do not readily fit these classification systems (e.g., Harness, Epstein, & Gordon, 1984), indicating that the degree of heterogeneity among reading disabled children may be incompatible with any simple system of typology. 9.03.2.4.3 Mathematics disability subtypes Mathematics disability has also attracted classificatory research. For example, Rourke and Strang (1983) and Rourke, Young, and Leenaars (1989) found useful subtypes based on patterns of children's performance on the reading, spelling, and arithmetic subtests of the Wide range achievement test (WRAT). Among those with mathematics problems, one type seemed primarily verbal (left hemisphere) and the other primarily visual-spatial (right hemisphere). This finding is partly supported by other studies (Share, Moffit, & Silva, 1988). 9.03.2.5 Prognosis Longitudinal studies have addressed the issue of which is the most appropriate model: deficit, lag, delay, or some amalgam of these. In a review of these studies, Reiff and Gerber (1992)

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concluded that although LDs may be best characterized by the deficit concept, favorable outcomes are nevertheless possible, depending on a number of factors such as effective interventions and favorable social ecologies. LDs are viewed as a persisting condition which is expressed differently at different life stages. In adulthood, the former focus on academic skills development is replaced by social and vocational issues. The problems of adults with LDs are unlikely to be confined to the stigma and inconvenience of illiteracy, although it is illiteracy that usually is the focus of whatever services are readily available for adults. Factors predicting poorer prognosis include greater severity of disability, lower intelligence (Minskoff, Hawks, Steidle, & Hoffman, 1989), failing to access intervention services (Bruck, 1987), and lack of family support (Reiff & Gerber, 1992). Notably, severity alone should not be equated with poor prognosis, given the many individuals with severe childhood disabilities who have led very successful adult lives. Much has been made of a possible link between learning disabilities and sociopathy in adolescence and adulthood, the so-called LD/JD (juvenile delinquency) connection. Several studies have shown that the prevalence of learning disabilities is unusually high among adjudicated delinquents (Brier, 1989; Broder, Dunivant, Smith, & Sutton, 1981) and that educational remediation can reduce recidivism significantly in LD delinquents (Brier, 1994). However, it is unclear what other factors may need to be present in a child with learning disabilities to precipitate the development of delinquency. A number of predisposing factors has been suggested by Reiff and Gerber (1992), including early conduct problems, association with a deviant peer group, and concurrent diagnosis of ADHD. The type of disorder may be an important predictor of adult outcomes. There is some evidence that a type of disorder with a nonverbal character may be associated with greater risk of depression and suicide (Rourke, Young, & Leenars, 1989).

9.03.2.6 Other Problems Associated with Learning Disabilities As already noted, LD and ADHD have substantial co-occurrence or comorbidity, although estimates of the extent of this (3±80%) vary considerably with alternative definitional criteria, especially for ADHD (Anderson, Williams, McGee, & Silva, 1987). Because LD often leads to secondary ADHD symptoms and vice versa, there is a need for comorbidity estimates to be based more than

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Learning Disabilities

usual on careful diagnosis. Studies indicate that similar heritable influences are in part responsible for both disorders (Narhi & Ahonen, 1995), and that comorbidity results from a different developmental pathway than that leading to LD or ADHD alone (Pennington, Grossier, & Welsh, 1993; Sanson, Prior, & Smart, 1996). Although clinical samples have generally indicated that left-handedness is associated with LDs, this is not found in epidemiological studies, suggesting that children with learning problems are simply more likely to be referred if they are left handed (Corballis & Beale, 1983). According to teacher ratings, problems that are more common in children than in those without LDs include: social maladjustment (Cullinan, Epstein, & Lloyd, 1981); self-consciousness, inferiority, withdrawal, tension, and anxiety (Stone & LaGreca, 1984). Parent ratings indicate lower levels of participation, social interaction, and social competence (McConaughy & Ritter, 1986). A meta-analysis of social skills deficits in LDs found that about 75% of students with LD problems had significantly marked social skills deficits (Kavale & Forness, 1996). Moreover, the data did not support the idea that social skills problems themselves represent a specific learning disability, but rather that they are simply associated with LD. Preschool or early-school characteristics that are predictive of LD diagnosis in later years include poorer ability to provide letter names and sounds or to perform rhyming tasks (Bryant & Bradley, 1985). In addition to such phonological skills, poor word attack and word identification skills have also been shown to predict later diagnosis of reading disability (Hurford, Schauf, Bunce, Blaich, & Moore, 1994). There are important implications for early intervention in these findings, at least to the extent that such skills are trainable in those children found to be deficient in them at the outset (Torgesen, Wagner, & Rashotte, 1994). 9.03.3 EPIDEMIOLOGY 9.03.3.1 Prevalence The uncertainties about definition have led to doubts about the prevalence of LDs because different studies have tended to use different criteria for identifying the presence of LD (Epps, Ysseldyke, & Algozzine, 1985). Moreover, methodologies used in surveys of prevalence are not uniform, including surveys of school policy (Silverman & Metz, 1973) and studies of normal population cohorts (Rutter, Graham, & Yule, 1970). Not surprisingly,

estimates of prevalence vary from 2 to 20%. A detailed analysis of prevalence studies is provided by Silver and Hagin (1990) and they reported that school administrators' estimates of the prevalence of LDs in US elementary schools ranged from 5 to 30%, the majority of estimates being between 10 and 15%. The US Department of Education (1991) reported that 3.6% of children between six and 21 years were classified as LD in 1990, compared to 1.2% in 1977. Presumably the increase in children classified as LD was a direct result of the first introduction in 1977 of legislation requiring identification and adequate resourcing of LD cases [Public Law 94±142: The Education for All Handicapped Children Act (1975)]. What this trend makes clear is the impossibility of using official figures on children served under the provisions of the Act as a basis for estimating the prevalence of LD. Kavale and Forness (1992) have observed that over a similar period (1977±1986), the number of children classified as mentally retarded for the purpose of resourcing under the Act apparently decreased by about 29%, suggesting that the change in LD numbers may have had more to do with changes in classification procedures than anything else. If only reading disability is considered, estimates again vary between studies. For example, epidemiological studies have reported ratios of about 2.5:1 (Berger, Yule, & Rutter, 1975) and about 1:1 (Shaywitz, Shaywitz, Fletcher, & Escobar, 1990). Studies of the familial incidence of reading disability show ratios of about 2:1 (deFries, 1989).

9.03.3.2 Prevalence in Different Populations Given the problems of definition discussed above, there seems to be no valid basis for comparing real prevalence rates in different countries. There is little doubt that LD occurs in many countries, cultures, and languages (Junkala & Paul, 1987) although it may well be expressed in different ways, especially where the form of the language is very different from English. For example, Rozin, Poritsky, and Sotsky (1971) reported that US children with reading disabilities in a phonetic-based language (English) were able to learn vocabulary in an idiographic language (Chinese) without difficulty. Another report (Motluk, 1996) described a boy raised by English-speaking parents in Japan who had reading disability in English but not in either Kanji or Kana, the written languages used in Japan. It is generally recognized that the prevalence of LD is higher among males than females, with estimates of the factor varying between 2:1

Assessment and Diagnosis (Nichols & Chen, 1981) and 2.5:1 (US General Accounting Office, 1981). Vogel (1990) has reported evidence that the symptoms expressed by boys and girls tend to be different, with boys having more problems of a visuo-spatial character. 9.03.4 ETIOLOGY 9.03.4.1 Neurological Factors In keeping with the origins of the LD concept in the framework of brain damage, theories of etiology primarily have had a neurological or neuropsychological character. These have dealt mainly with the predominant type of LD, reading disability, with relatively little attention being paid to other types of disability such as mathematics and social skills. Theories have been proposed at the level of basic neurological organization, basic psychological processes, and genetics. An early example of the first type, that has persisted in modified form even to the present day, is that proposed by the neurologist Orton (1937) who thought that reading disability was a phenomenon of visual memory and arose in individuals whose brains failed to develop the usual left-hemispheric dominance for language. The illogicality of some aspects of Orton's theory have been pointed out by Corballis and Beale (1983, 1993) who have proposed a modified version more in keeping with current knowledge of brain function, while retaining Orton's idea that lack of hemispheric asymmetry may be a critical factor. Other approaches to the understanding of the origins of reading disability at the level of brain anatomy or neurological organization have been presented by Geshwind and Galaburda (1987) and Hynd and Hynd (1984). The idea that reading disability has its origin in some aspect of lateralization of brain function also persists in theories that propose different rates of development of lateralization of function in reading disability (Satz & Sparrow, 1970; Witelson, 1977). 9.03.4.2 Psychological Factors Turning now to theories about anomalous psychological processes in reading disability, examples have featured different aspects of visual processing such as visual memory (Willows, Kruk, & Corcos, 1993), visual perception (Lovegrove, 1992), eye movements (Pirozzolo, 1979), and different aspects of auditory processing, such as auditory sequential perception (Tallal, 1988) or linguistic skills generally (Shankweiler, Liberman, Mark, Fowler, & Fisher, 1979; Vellutino, 1979).

43

Many studies have pointed to ineffective use of cognitive and metacognitive strategies by children with learning disabilities (Brown & Palincsar, 1982; Wong, 1979). While these clearly may play an important role in the maintenance of reading problems in older children, it is not clear that they are a primary cause of reading disability. In their review of neuropsychological theories of learning disabilities, Willis, Hooper, and Stone (1992) concluded that single-factor theories have not been successful in explaining the diversity of symptomatology in reading disability. The broader perspective of neuropsychological theories such as that of Rourke (1985) may have more promise as a guide to both research and clinical practice. 9.03.4.3 Genetic Factors The apparent tendency of reading disability to run in families has prompted research into possible genetic factors that might underlie the nervous-system anomalies associated with the problem. Pennington (1991) has noted that the evidence shows both familiarity (35±40% of first-degree relatives are affected) and heritability (50%). Reading disability is apparently heterogenous genetically, although this does not mean that the physiological or neurophysiological expression will also be heterogeneous (Pennington, 1991). 9.03.4.4 Environmental Factors It should be understood that environmental factors also have a role in the etiology of learning disabilities, although little is known about them. Badian (1984), for example, showed that reading problems are associated with large family size and low socioeconomic status. Of course, these factors also increase the risk of exposure to nervous-system toxins and poor nutrition that might affect brain development and learning directly or alternatively might interact in a negative way with a preexisting neurodevelopmental factor. In either case, the net effect still amounts to an ªintrinsic factorº within the standard definition of a learning disability. 9.03.5 ASSESSMENT AND DIAGNOSIS 9.03.5.1 The Behavioral Assessment Model Assessment of LDs takes many forms, corresponding to the many purposes to which it may be put (Salvia & Ysseldyke, 1991). This chapter uses the framework of a behavioral assessment model on the grounds that it is the most appropriate model for assessment of a

44

Learning Disabilities

problem that includes the intrinsic factors within the individual client, family, school, and other social factors, educational and other learning factors, and treatment considerations. Others making recommendations for the assessment of LDs have also proposed assessment approaches based on a behavioral assessment model. For example, Barkley (1981) advocated what he called a behavioral-neuropsychological assessment as being an approach that truly considers all of the aspects that might be relevant to the understanding and management of an LD problem. The behavioral assessment approach has a clear advantage over other, more traditional approaches to assessment in that it considers the referral problem within a broad environmental context in which that problem occurs and in which the treatment will also be implemented. As such, it does not attempt to isolate the problem either within the person central to it or within particular aspects or subsets of the person's environment (Nelson & Hayes, 1986). In particular, choosing and monitoring the treatment are considered a part of the assessment process, ensuring an assessment that is truly driven by treatment considerations. Thus, it is recognized that LD problems have multifactorial causes and require multifactorial solutions. This is a significant departure from a type of approach that has been more common in the LD field, that is, choosing a treatment on the basis of either theoretical preconceptions of the etiology of the LD problem (e.g., Delacato, 1966) or on the basis that only the deficient academic behaviors need to be considered (e.g., Treiber & Lahey, 1983). The assessment process essentially is one of gathering information to assist in reaching an understanding of the problem in order to design and test a suitable treatment. Texts on assessment of learning problems will often systematize formal aspects of the process of information gathering by organizing it on dimensions such as temporal (current vs. historical information) and methodological (direct observation, performance tests, rating scales, and checklists) (Salvia & Ysseldyke, 1991). There is heuristic value in this but, to be cost-effective, the information-gathering process needs to be driven by hypotheses about what sort of information is likely to be needed. Such hypotheses are derived from the general body of theory and knowledge about etiology, phenomenology, and treatment efficacy, as well as from the assessor's clinical experience or personal ªcase-lore.º Before proceeding to outline the formal structure of assessment, a return is made to Hank, the hypothetical boy with LD problems,

to consider how an assessment might proceed in the less-than-perfect light of the referral information and the information on the nature of learning disabilities already garnered from the literature. 9.03.5.2 The Issue of Diagnosis The funding of resources that may be needed to help Hank, including the cost of an assessment, are likely to be contingent on an LD diagnosis that is within the parameters specified by the local education administration. The information required is: (i) Are his symptoms consistent with the inclusionary criteria for skills deficits? Spelling and reading are described as below his age level. Tests will need to be given to show his current level of these skills. There may be a requirement to use approved tests. Either norm- or criterionreferenced tests would serve. (ii) Can an argument be made that central nervous system dysfunction is a contributing factor? No problem was apparent before he entered school, so evidence must be sought of some deficit in basic tests of psychological function. Such a deficit would not be definitive, but at least would be consistent with a hypothesis of central nervous system dysfunction. Norm-referenced tests would be required. The fact that his father and brother may have had similar problems indicates a familial and heritable disorder. This needs to be explored further by questionnaire or interview. (iii) The exclusionary factors will need to be addressed. On current evidence, inappropriate instruction is an improbable cause, because remedial efforts have been unsuccessful. Judging from referral information, mental retardation and sensory impairment are probably not present, but intellectual status can be obtained from a total IQ score, and evidence of subtle sensory impairment can be looked for during formal testing. The attentional and behavioral problems, as well as current emotional and social problems, are apparently secondary to LD, rather than causal, but further information is required from school and home. 9.03.5.3 The Issue of Etiology Although not necessarily helpful to the process of designing an effective treatment, etiology needs to be considered. Not only is it relevant to diagnosis but it can assist the family in coming to terms with the problem. Consideration of etiology also guides the assessment process in a way that may throw light on possible causal factors not indicated in the referral information. It cannot be assumed, on

Assessment and Diagnosis the basis of information about the possible occurrence of LD in other family members, that Hank's problem is totally developmental in origin. A medical history is required to check for the possibility of acquired neurological factors, such as head injury or meningitis, which may have contributed to a greater or lesser degree to the later emergence of the learning disability. Referral for neurological examination may need to be considered. 9.03.5.4 Classification Classification might be seen as helpful for several reasons: it may assist the choice of an effective treatment; it may indicate one or another prognosis; it may increase the usefulness of the case for research purposes; it may clarify the essential nature of the problem; or, it may assist interdisciplinary assessment. The extent to which classification serves these purposes depends very much on the type of classification that is envisaged. The simplest type of classification, based just on the type of skill deficit, serves at least the last two of these aims. Hank's problem would probably be classed as a case of reading and spelling disability, with an overlay of secondary attentional, social, and behavioral problems. This would identify the case sufficiently for some research purposes, at least, and would provide a clear handle on the case for the purpose of a fuller assessment. This initial classification would be subject to modification on the basis of further information, of course. In any case, it would need to be confirmed by formal testing or reading and spelling skills. Other types of classification, based on etiology or psychological processes, may contribute little in the immediate practical sense. They would assist prognosis and treatment choice only to the extent that the literature shows clear relationships between these variables and subtypes. But reviews of the research on subtypes are not hopeful in this respect (Forness, 1990; Siegel & Metsala, 1992). If there existed consensual guidelines on subtyping (e.g., Kavale, 1990a), these could at least be applied to a case to make it more accessible to retrospective research. Until that time, classification is likely to be driven by the theoretical framework in which the assessment is conducted, which may have more to do with the history of the assessor than with the nature of the problem being assessed. Nevertheless, the information gathered in the assessment process, particularly the formal psychometric tests that are used, will be determined jointly by the nature of the problem and the assessor's theoretical stance. Beyond the simple requirements of defining the

45

nature of the problem, then, there can be no overall recommendation regarding classification. However, the behavioral assessment model provides clear guidance that is based on other considerations. In proceeding with the assessment, there are two dimensions to consider that are simultaneously orthogonal and overlapping. The first is the goals of the assessment, including identification of the problem behaviors, identification of measurement methods, functional assessment (functional analysis) of the problem, and selection and monitoring of treatment (Nelson & Hayes; 1986). The second is the assessment procedure, including all aspects of data collection (interviewing, rating scales, tests, observation), data interpretation, and planning, implementation, and monitoring of treatment. The first dimension can be considered a guide to the second. 9.03.5.5 Goals of Assessment 9.03.5.5.1 Identification of the focus of treatment This phase requires a consideration of which behaviors need to be increased, and which reduced. The context for this includes both social comparison and subjective evaluation. First, the fact that an LD problem is the referral issue does not mean that this is the best context for dealing with the problem. Parent referrals, in particular, may be mistaken in supposing that there is a significant academic skills problem, their judgement influenced perhaps by the greater success of older children in the family. Information from the school is essential for checking skills status at the earliest opportunity. Behavior problems identified by parents also need to be considered in a wider social context than just their judgement about the child's behavior at home. In the case of both academic skills and other behavior, appropriate norms should be consulted in making a decision about the generality and severity of the problem. With regard to socio-emotional issues in LD, subjective evaluation is also important. What are the attitudes, feelings, and beliefs held by the client and others about the referral problem? The point here is that there are subjective as well as objective contexts that are important; there is no single ªcorrectº way of viewing the problem. In Hank's case, the identification of target behaviors probably would be based primarily on teacher opinions, performance records such as reading and spelling tests given in school, and parent and teacher rating scale evaluations of social and other problem behaviors. Initially, it would appear that reading and spelling skills need to be strengthened and inappropriate

46

Learning Disabilities

attitudes, attention, and social behaviors need to be reduced. Anxiety may be treated as a collateral issue rather than being targeted directly, on the assumption that it is secondary to other problems, but it may need to be directly addressed if it turns out that it impedes either the assessment or compliance with treatment. 9.03.5.5.2 Defining and measuring key behaviors When academic behaviors are targeted, this phase is achieved by the selection of formal tests, and care must be taken that the tests provide valid and reliable measurement of the behaviors at issue. The aim is to provide definitions that are objective, clear, and complete. What precisely are Hank's reading and spelling problems? This will not necessarily be obvious from the data available from school. Reading includes whole-text oral reading skills such as pronunciation, punctuation, and fluency. It also includes comprehension or material dictated or self-read. It includes single-word recognition skills, with or without the opportunity for word analysis. Spelling includes oral naming of letters in words, written spelling to dictation, and proof-reading. Words spelled may be phonetic or nonphonetic. Both for spelling and reading, specific tests will be required to delineate the areas of difficulty. The primary criteria to be considered in choosing these tests are validity and reliability. Assessment of the degree of deficit can be accomplished using either norm- or criterionreferenced tests, and a good case can be made for using both (Salvia & Ysseldyke, 1991). In Hank's case, attentional and behavioral problems are an issue. Regardless of whether it is intended to treat these directly or relegate them to the list of collateral behaviors, decisions are required about definition and measurement at the outset. This will be based, in the first instance, on rating scale and questionnaire information. Consideration might be given, however, to the possibility of a primary attentional problem, in which case tests will be required that differentiate between aspects such as sustained attention, focused attention, distractibility, and attention span (Lam & Beale, 1991). In Hank's case, anxiety and social skills scales might be considered both for the purposes of gauging the severity of such problems and for measuring changes accompanying treatment, although teacher and parent ratings would also be required to check their perceptions of functioning in these domains. Often it is advocated that systematic direct observation be included in the assessment process (Barkley, 1981), especially when referral

issues emphasize behaviors that are public and easily observable. An advantage is that direct observation can be carried out by an ªindependentº person without a stake in Hank's problems or their management. Thus, direct observation may be seen as less subject to the influences that are regarded as possibly biasing informal information-gathering or the global ratings of interested persons such as teachers or family members. On the other hand, direct observation is only as good as the observation system is valid and reliable in the hands of the particular observers using it. This can be difficult to achieve, because of factors such as reactivity of observation, observer drift, and nonrepresentative sampling (Mudford, Beale, & Singh, 1990), not to speak of the resources required to train observers and to carry out the observations. In the clinical context, as opposed to the research context, use of systematic direct observation protocols is unlikely to be considered cost-effective. However, consideration would be given to using it in instances where more convenient forms of measurement are likely to be unreliable. In Hank's case, social activity in the school playground might be difficult to measure reliably by any other method. Self-monitoring has been used extensively for the recording of semipublic or private behaviors, as well as providing a basis for the treatment of such behaviors (see Reid, 1996). For Hank, this method would be used to measure the proportion of time spent on-task in classroom instruction, both for the purpose of quantifying his initial level of distractibility and for treating this directly by reinforcing increases in time spent on-task. Variations of this method have been used for the measurement of accuracy (Marshall, Lloyd, & Hallahan, 1993) and productivity (Lloyd, Bateman, Landrum, & Hallahan, 1989) in classroom performance. 9.03.5.5.3 Functional assessment (functional analysis) This phase of the assessment process is at the core of interpretation of the problem, leading to the choice of a suitable treatment. It includes the assessment of: (i) variability in the target behaviors; (ii) the settings or other conditions in which the problems are better or worse; (iii) environmental consequences of the problem behaviors; and (iv) intrinsic or organismic factors that may be relevant. The first two of these, variability and settings, may be closely related. According to the behavioral assessment model, variability in a behavior is indicative of the joint control exercised over that behavior by setting events

Assessment and Diagnosis (discriminative stimuli) and consequences for that behavior in particular settings. LD problems may vary according to several variables, including who is the teacher, classroom dynamics, seating arrangements, time of day, day of the week, the general nature of the current classroom task, and especially, the specific subtask in which the child is engaged. A similar analysis is possible of behavior at home. Hank's reading, spelling, and attentional problems can be measured within this framework. A common strategy is to supply teachers with a checklist that requests global ratings on all academic skill areas as well as on general behavior and motivation. For each skill area, the teacher is also asked to respond to questions about subskills and about how they vary in the context of different conditions: before vs. after breaks; in group vs. alone; morning vs. afternoon, and so on. Analysis of such information may show that distractibility and wandering is worse on tasks of a particular type, or during subtasks in which accuracy is low, or just before a break. Afternoon performance may, in general, be worse than morning. Such observations not only indicate a causal relationship between academic skills problems and behavior and attentional problems, but they provide information about how the problems can be eased simply by environmental management. Examples are seating changes and rescheduling of academic lessons within the day or within the week. Some children have memory and organizational problems that can be circumvented greatly by changes of this sort. Variations in consequences for behaviors are of course related both to the probability of those behaviors and the occurrence of competing and collateral behaviors, including some that are private. Criticism or ridicule of a child's errors will affect not only the behavior specifically criticized but also the child's willingness to participate generally, and self-esteem. Conditioned anxiety may develop that impedes further learning. Different teachers have different styles in this regard, and it is important that the assessor discovers what they are and how typically they are deployed in relation to the areas of difficulty. Hank's anxiety may have originated in the reactions of previous teachers and peers, but it is nevertheless maintained by prevailing conditions, and these need to be understood so that they can be addressed as required by the treatment program. The next phase of the functional assessment involves consideration of intrinsic factors that might be relevant to the LD problem, including possible sensory impairment, neurological or neuropsychological problems, other physical and psychological conditions such as depression

47

or anxiety, and psychopharmacological factors. Past history of treatment may also be included here, because there presumably is some legacy of this in the client's present constitution. Notably, this phase is not included in the assessment model often advocated by those trained in the educational discipline, who prefer to view learning disabilities in the context of the simpler ABC (Antecedents, Behavior, Consequences) model (e.g., Treiber & Lahey, 1983). Sensory impairment can itself cause learning problems, or it can make worse problems that have a different cause. Visual and auditory perceptual problems clearly can have profound effects on the learning of academic skills. In most children referred to LD specialists, routine testing for hearing loss or for visual refractory errors will already have been conducted, but when this is not the case, such problems usually are apparent during psychological testing and a referral can be made for an expert assessment. More subtle problems, however, may have gone undetected. Rare individuals may have visual tracking problems that prevent fluent reading and are only identifiable on specialist optometric examination. Untreated chronic middleear infection is common in some countries, where it is a common cause of retardation of the development of language skills in preschool children. Visual perceptual factors such as scotopic sensitivity syndrome, and auditory problems such as central auditory processing deficit, have been regarded as causes of learning problems, and it is arguable whether they should be seen as simple sensory impairment for the purposes of exclusion under the standard definition of LD. The assessment of neuropsychological factors is central to many theoretical models of LD, even though the role of these factors in treatment selection remains contentious (Kavale, 1990b). The use of neuropsychological tests in the assessment of LDs is usually primarily driven by the assessor's belief that such tests will assist in characterization of the basic processing problem(s) underlying the LDs. Because there are several classificatory systems that are based on different conceptualizations of neuropsychological processes relevant to LDs, assessment practices vary considerably. LD assessments in the context of research programs commonly use the same battery of tests in all cases (e.g., Rourke, 1985), while clinically-oriented assessment services are more likely to select tests on the basis of hypotheses being tested about the individual cases (Sattler, 1992). A compromise approach that serves both purposes is to use a limited set of tests for all clients, supplemented by additional tests chosen to fit the individual case.

48

Learning Disabilities

An illustrative example is provided by the practice followed at the University of Auckland's Learning Assessment Centre. The core testing program includes the WISC-III, normreferenced tests of academic skills attainment (reading, spelling, and math) and tests encompassing basic neuropsychological domains of attention, memory and information processing (see Table 1). Additional tests are used to test hypotheses about weaknesses indicated by the initial tests, and these vary from case to case. Pharmacological factors are increasingly a concern in LD assessment (Aman & Rojahn, 1992). Many children referred for LD problems are currently on medication prescribed either for this or some related behavioral problem. This is especially the case for those with ADHD symptoms or diagnosis. In the USA, over 1% of schoolchildren are on stimulant medication, and the percentage has been as high as 10% in some states. Any psychoactive medication can be expected to influence the assessment process, including the judgement of severity and the choice of treatment. The issues are encapsulated in these questions: (i) Is the medication acceptable to the client and family? (ii) Is it perceived to be effective in controlling beha-

vioral or attentional problems? (iii) Will the medication mask aspects of the learning disabilities during assessment, potentially invalidating some assessment conclusions? (iv) Is it proposed to continue the medication concurrently with another recommended treatment? and (v) Have adverse effects of the medication been reported? The functional assessment concludes with an integrated synthesis of all the information collected to provide a coherent interpretation of the LD problem. This includes consideration of all probable contributing causal factors, intrinsic and environmental, an account of how these have been expressed in the development of the problem, and a description of the current problem that includes a discussion of the interactions between the LD problems and the current school and home environments. 9.03.5.5.4 Selection of a treatment strategy Selection, implementation, and monitoring of treatment normally are included as part of the behavioral assessment model but, in this chapter, they are considered under a separate heading.

Table 1 Instruments (tests and scales) suitable for the assessment of LD. Test

Scales

General intelligence

Weschler intelligence scale for children-III (WISC-III) Weschler preschool and primary scale of intelligence (WPPSI) Peabody picture vocabulary test-revised (PPVT-R) McCarthy scales of children's abilities Kaufman assessment battery for children (K-ABC) Peabody individual achievement test (PIAT) Detroit test of learning aptitude (DTLA-2) Lindamood auditory conceptualization test (LACT) Wide range achievement test-revised (WRAT-R) Progressive achievement test (PAT) Gray oral reading test-revised (GORT-R) The border test of reading-spelling patterns Neale analysis of reading ability-revised Gates-MacGinitie reading tests KeyMath diagnostic mathematics test-revised Woodcock-Johnson tests of achievement Proof-reading tests of spelling Conners teacher rating scale (CTRS) Swanson, Nolan, and Pelham rating scale (SNAP) Revised behavior problem checklist (RPBC) Visual retention test Learning efficiency test Wisconsin card sorting test Trail making test for children Symbol-digit modalities test Selective reminding task Rey±Osterreith complex figure

Abilities

Academic achievement

Behavior rating scales Neuropsychological tests

Treatment 9.03.5.6 The Assessment Procedure The second dimension of assessment is the actual physical process by which the assessment proceeds. Typically, referral is followed by a contract for services being sent to the client (in the case on a child with LD, the client is a parent or guardian). Usually this stipulates the nature and cost of the service being offered, and requests written approval for other agencies (e.g., schools) to be contacted for information. It may also include a request to use anonymous assessment data for research purposes. Receipt of approval may be followed by a mailing of questionnaires to parents and schools. Parents may be asked to complete medical and family history records, rating scales for their child's behavior problems, treatment acceptability scales, and so on. Teachers are asked to complete behavior rating scales and checklists relating to academic behaviors. When all the information has been returned, an appointment is made for the initial interview with the child and parents. The purpose of the initial interview is threefold: to impart information about the assessment process; to review the information already provided in questionnaires; and to talk to the parents and child about the LD problem. It is advisable that the interview be structured, at least on paper, so that everything gets covered. On the other hand, it is important to allow the clients to talk freely and offer information without excessive prompting. It is usually advisable to speak to the parents both with and without the child being present, as this provides valuable information about their interactions with the child around the LD problem. One to two hours is usually sufficient for the interview. Testing sessions should be conducted without a parent being present, but not if there is reason to expect a child to perform significantly worse with no parent present. Anxiety conditions, especially parent separation anxiety, can be exacerbated by the novel situation, and some children are untestable even with a parent close at hand in the waiting room. Recommended practice should be followed with regard to general factors such as rapport, sequence of tests, duration of test sessions, and so on (Sattler, 1992). School records, including reports and results of school administered tests, can be a valuable source of information, as can children's exercise books. This type of information gives a much wider sample of a child's current skills and their developmental history than can be obtained in the context of brief testing sessions. A useful

49

practice is to ask parents to gather this material and bring it to the initial interview. The assessment report is unquestionably an important part of the assessment process, and plays a critical role in whether an effective treatment will be implemented. Reports are most useful when they follow the recommendations given in good assessment texts (Kamphaus, 1993; Sattler, 1992). The sovereign principle is that they should be written for the consumer, usually parents, so as to maximize understanding of the nature of the problem, prognosis, and preferred course of remedial action. A report that is overly expansive on details of testing and interpretation may be set aside as patronizing, technical, jargonistic, and indecisive. In any case, the client should be debriefed on the report and its implications, at least by telephone, but preferably in a recorded follow-up interview where all interested parties are invited to attend. The assessor should be prepared to address any questions and to facilitate plans for implementation of the recommended treatment. 9.03.6 TREATMENT 9.03.6.1 General Treatment Issues Treatment issues can be divided into selection, implementation, and monitoring. Treatment selection follows logically from the functional assessment, which should provide an understanding of strengths and weaknesses in the client's repertoire of academic skills, social skills, and relevant psychological processes. It should also indicate the context, especially advantages and constraints, for possible alternative remedial approaches. A preferred initial treatment approach can then be chosen on the basis of the professional literature on treatment efficacy, together with local issues such as resources, treatment credibility, and acceptability. Reviews of alternative treatment strategies and specific treatment programs are provided elsewhere (Beale, 1995; Frostig & Horn, 1964; Hartlage & Telzrow, 1983; Kavale 1990b). It is emphasized here that treatment choice should not be based on theoretical preconceptions of the nature of LD, current fads, or anything other than functional assessment of the individual case. 9.03.6.2 Treatment Programs Treatment programs for LDs fall into two categories. One, sometimes called training the brain or psychological process training (Gaddes, 1985; Hammill & Larsen, 1978; Kavale, 1981, 1990b; Torgesen, 1979), directs treatment at

50

Learning Disabilities

processes, the supposed weakness of which are the underlying cause of the LD problem. It has been argued that processes cannot be trained directly, only skills that use those processes (Beale & Tippett, 1992), and that the validity of this approach is heavily dependent on unproven assumptions about generality of behavior change across skills. The literature on the effectiveness of process training for LD is mostly unfavorable (Hoehn & Baumeister, 1994). At the same time, it can be argued that evaluations of process-oriented treatments have relied primarily on between-groups research designs which are unsuitable for evaluating the effectiveness of treatments on individuals (Hersen & Barlow, 1976). Studies using single-case designs are needed to provide a basis for deciding whether there might be some cases for which this approach can be useful (Beale, 1995). The other category is referred to as direct remediation and consists of directly training the absent or poorly mastered academic or social skills, using established behavioral technology. There are abundant studies using good research designs which show that direct remediation programs can be applied effectively to a range of academic and social skills deficits in LD persons. Examples of useful programs and their areas of application are shown in Table 2. The choice of an appropriate program is determined by the areas of skill deficit. Where there is more than one area of deficit, as in the illustrative case of Hank, a decision is needed about prioritizing areas for remediation. Sometimes it is possible to proceed with an integrated program for the concurrent remediation of different skills. For example, Hank might receive a phonological skills training program that addresses his reading and spelling skills in the context of a self-monitoring program aimed at increasing his attention to task. Clinical experience indicates that such concurrent programing places a great burden on those responsible for its implementation, and it should probably be restricted to those cases where trained professionals are involved in the actual day-to-day administration of the program. Usually, programs are delivered sequentially and are prioritized on the basis that the more fundamental skills should be taught first. In Hank's case, attention to task is considered a prerequisite to effective participation in phonological-skills training, so it has first priority. Another useful principle for prioritization is the importance of securing client cooperation and motivation to continue with the treatment. Programs that produce desirable changes quickly will establish motivation and treatment credibility, so are well-placed at the front of the queue.

9.03.6.3 Treatment Implementation Implementation of a treatment is no less important than selection of the right treatment. Of the wide variety of treatment approaches described in the LD literature, there are a few approaches that are commonly considered among professionals to be effective, and not all of these will be effective in every case. The number of variables that influence the effectiveness of a particular treatment in a given case is much greater than there is space to describe here. It is recognized that treatment implementation is part science and part art (Talbott, Lloyd, & Tankersley, 1994). Having the right procedures is one thing but getting good results with a particular child in a particular setting is another thing altogether, about which very little is to be found in the formal literature on LD. The identification of weaknesses and strengths at the level of neuropsychological testing may be useful in formulating strategies for effective implementation of the chosen treatment program. The relevant remedial principles are called circumventive and capitalization of strengths (Chronbach & Snow, 1977; Hartlage & Telzrow, 1983). The program can be arranged to minimize the impact of weaknesses on the learning process. For example, distractibility problems can be minimized by initially removing stimuli that distract from the teaching setting, and only progressively reintroducing these when the trained skill has been learned. Problems of sustained attention are addressed by using short training sessions, especially during difficult tasks. Divided attention problems indicate a need to arrange teaching procedures so that tasks are attempted sequentially rather than simultaneously. Memory problems can be minimized in the same way. For example, if visual sequential memory is weak, the learning task can be designed to minimize the need for this type of processing. Capitalization of strengths essentially is the reverse of this strategy. The remediation program can take advantage of absolute or even relative strengths in say, visual memory by using visual representations of material or procedures to be remembered. The visual prompts can eventually be faded once the task has been mastered (Smeets, 1992). It is a sovereign principle that standard remedial programs will be most effective if they are modified to suit the requirements of the individual case. This is most obvious at the level of practicalities of program administration (who does what, where, and for how long) and in the designing of an appropriate incentive

Future Directions for Research and Practice

51

Table 2 Examples of remedial programs for LD. Methods

Comments

1. Reading and spelling A. Multisensory phonological training Reading and spelling made simplea

A detailed published package, including materials. General description of two alternative methods; includes rationale

B. Other systematic approaches SRA spelling (McGraw-Hill school division) Distar (McGraw-Hill school division) 2. Mathematics Behavioral approaches to skills trainingb Spatial skills trainingc 3. Attention Self-monitoringd Source:a Andrew (1994) and Bryant and Bradley (1985);

Mainstream published program, includes all materials Mainstream published program, includes materials Review of behavioral approaches to math remediation Method for remediating spatial skills problems in math Review of use of self-monitoring with LD students

b

Pereira and Winton (1991);

system. It is less obvious at the level of choice of incentives and choice of specific task materials and least obvious when it comes to incorporating the findings of neuropsychological assessment in the development of circumventive or capitalization-of-strengths strategies. 9.03.6.4 Monitoring of Treatment The need to monitor the behavior changes that accompany treatment implementation is predicated by the limited knowledge about treatment effectiveness in any individual case. The knowledge base and resources are always insufficient for a perfect assessment, so treatment is best seen as an experiment based on a best-guess as to what will work. Under these circumstances, there is a clear professional duty to monitor progress. Effective monitoring presupposes the prior selection of valid and reliable measures of change of target behaviors. If these are collected and graphed on a regular basis, say weekly, they can be reviewed by the treatment planner for evidence of satisfactory progress and also used to illustrate progress to the client. Thus, monitoring allows for dynamic assessment of the client's response to treatment, so providing a basis for identifying and changing an unsuccessful treatment. Further, it also reinforces treatment credibility to the extent that it shows desirable changes under treatment. Texts on applied behavior analysis generally recommend that treatment is monitored in the context of some single-subject research design capable of addressing the issue of internal

c

Lohman and Nichols (1990); d(1991).

validity, especially the ruling out of interpretations other than that the change in behavior was caused by the specific treatment being given (Hersen & Barlow, 1976; Kazdin, 1982). This is desirable if the case is intended to contribute to the research literature on treatment effectiveness. However, the requirements of a suitable research design are not readily achievable in the context of most clinical work. From the standpoint of clinical practice, it is not essential that a functional relationship between treatment and behavior change be demonstrated with every case in which a particular treatment is used, provided that the relationship has already been established in prior research. This is because the main aim of treatment in the clinical context is to produce change and not to show that a particular manipulation was responsible for the change. Nevertheless, singlesubject designs should be used when this is practicable, if only to increase the clinician's understanding of what is happening when the treatment is given. In particular, variations of the multiple-baseline designs are well-suited to the clinical context where they can be used to good effect for monitoring the generality of behavior change under treatment (Hayes, 1981). 9.03.7 FUTURE DIRECTIONS FOR RESEARCH AND PRACTICE The term ªlearning disabilitiesº was first coined in the mid-1990s in its present sense (Lloyd, 1992), and relevant phenomena were studied long before (Kavale & Forness, 1992).

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Learning Disabilities

Much of the ensuing time has been devoted to struggles over matters such as disciplinary ownership, appropriate theoretical models for etiology, and, of course, definition and classification. This period has also seen a staggering diversity of treatment approaches, almost always originating in some narrow (usually contentious) view of the cause of learning disabilities. From this welter of contradictions between different ideas and practices has arisen a theoretical framework that may just be broad enough to encompass most of the phenomena of learning disabilities. There have been some necessary casualties along the way. One is the concept that learning disabilities refer to a homogeneous population; happily, it is rare now to read a paper comparing an LD with a non-LD group on some psychological variable. Of course, the admission of heterogeneity has resulted in a small industry devoted to taxonomy but there is some hope now that this will eventually yield a classificatory strategy that both improves understanding of the individual LD problem and how best to treat it. Another casualty has been the idea that a medical, psychological, or an educational model alone might be sufficient for LD. There is a growing awareness that the field is truly interdisciplinary and that learning disabilities must be understood in a broad context that includes knowledge, ideas, and practices from neurology, neuropsychology, behavioral pharmacology, applied behavior analysis, cognitive psychology, education, social psychology, clinical psychology, and counseling. An important casualty has been the persistent belief that there is a one-size-fits-all treatment that will be at least partly effective in all cases. Outside the scientific community, of course, the fads and fallacies department continues to live on and be featured in the media on a regular basis. But few professionals can now be found who give credence to unvalidated therapies for LD. The now-sizable treatment literature seems to show that even the best theoretical pedigree does not ensure that a treatment will be effective even for an appropriately chosen problem. Kavale (1990b, p. 18) has concluded from meta-analysis of published intervention studies that ªLD interventions are more variable in their effects than they are beneficial.º By way of explanation, he points to evidence of the existence of many factors, outside those usually specified in intervention programs, that likely play an important role in whether or not an intervention succeeds. Researchers have got as far as recognizing that the effectiveness of LD interventions depends on the identification of variables that have not been considered routinely in theore-

tical accounts of LD assessment and remediation. These are variables relating to the individual client, the learning environment, and the treatment program itself. The view taken here is that the behavioral assessment model provides a framework that is sufficiently broad to encompass all the classes of variables that might be relevant in the assessment and treatment of learning disabilities. Moreover, the actual procedures specified in the model encourage the assessor to identify and define those variables in the context of the assessment. What is needed now is intervention research based on the behavioral assessment model, employing single-subject research designs that permit adequate control of threats to internal and external validity. Just as classificatory systems for learning disabilities can guide the selection of relevant variables for inclusion in the assessment process, LD research using the behavioral assessment model will provide validation for those classification variables that truly predict treatment outcome at the individual level.

9.03.8 SUMMARY Once referred to as the ªhidden handicapº because of the absence of distinctive diagnostic symptomatology, LD are now recognized widely both by professional and lay communities. Essentially, LD are learning problems that specifically affect one or more skill areas such as reading writing, or social skills in persons who appear to be otherwise normally skilled and educated. Despite continuing controversy about how they should best be defined and diagnosed, there has been little change to widely-accepted consensual definitions in the 1980s and 1990s. Alternative classificatory models have been proposed, based both on conceptual and statistical analyses of patterns of performance in persons with learning disabilities, but no consensual system has emerged. The prevalence of LD in school-aged children is estimated at about 2±20% in the few countries for which figures are available. The most common type, reading disability (developmental dyslexia), appears to have a prevalence of about 5%. Both neurological and environmental factors are implicated in the etiology of LD and, in the case of reading disability, a genetic factor has also been identified. Of the large variety of treatments that have been advocated for LD problems, few have been found to be reliably effective. On the basis of evidence regarding both the varied and complex nature of LD and the high variability in response to any particular treatment, the behavioral assessment

References model is suggested as being the most appropriate framework for the assessment and treatment of LD problems.

9.03.9 REFERENCES Algozzine, B., & Ysseldyke, J. (1983). Learning disabilities as a subset of school failure: The over sophistication of a concept. Exceptional Children, 50, 242±246. Aman, M. G., & Rojahn, J. (1992). Pharmacological intervention. In N. N. Singh & I. L. Beale (Eds.), Learning disabilities: Nature, theory and treatment (pp. 478±525). New York: Springer. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). New York: Author. Anderson, J. C., Williams, S., McGee, R., & Silva, P. A. (1987). DSM-III disorders in preadolescent children. Archives of General Psychiatry, 44, 69±76. Andrew, M. (1994). Reading and spelling made simple (4th ed.). Morrinsville, New Zealand: Gamlen Press. Badian, N. A. (1984). Reading disability in an epidemiological context: Incidence and environmental correlates. Journal of Learning Disabilities, 17, 129±136. Bakker, D. J. (1992). Neuropsychological classification and treatment of dyslexia. Journal of Learning Disabilities, 25, 102±109. Barkley, R. (1981). Learning disabilities. In E. J.Mash & L. G. Terdal (Eds.), Behavioural assessment of childhood disorders (pp. 441±482). Chichester, UK: Wiley. Beale, I. L. (1995). Learning disabilities: Current status and future prospects. Journal of Child and Family Studies, 4, 267±277. Beale, I. L., & Tippett, L. J. (1992). Remediation of psychological process deficits in learning disabilities. In N. N. Singh & I. L. Beale (Eds.), Learning disabilities: Nature, theory and treatment (pp. 526±568). New York: Springer. Berger, M., Yule, W., & Rutter, M. (1975). Attainment and adjustment in two geographical areas: The prevalence of specific reading retardation. British Journal of Psychiatry, 126, 510±519. Brier, N. (1989). The relationship between learning disability and delinquency: A review and reappraisal. Journal of Learning Disabilities, 22, 546±553. Brier, N. (1994). Targeted treatment for adjudicated youth with learning disabilities: Effects on recidivism. Journal of Learning Disabilities, 27, 215±222. Broder, P. K., Dunivant, N., Smith, E. C., & Sutton, L. P. (1981). Further observations on the link between learning disabilities and juvenile delinquency. Journal of Educational Psychology, 73, 838±850. Brown, A. L., & Palincsar, A. S. (1982). Inducing strategic learning from texts by means of informed, self-controlled training. Topics in Learning and Learning Disabilities, 2, 1±17. Bruck, M. (1987). The adult outcomes of children with learning disabilities. Annals of Dyslexia, 31, 252±263. Bryant, P., & Bradley, L. (1985). Children's reading problems. Oxford, UK: Blackwell. Chalfant, J. C., & King, F. S. (1976). An approach to operationalizing the definition of learning disabilities. Journal of Learning Disabilities, 9, 228±243. Chapman, J. W. (1992). Learning disabilities in New Zealand: Where kiwis and kids with LD can't fly. Journal of Learning Disabilities, 25, 362±370. Chronbach, L. J., & Snow, R. E. (1977). Aptitudes and instructional methods. New York: Irvington. Clements, S. D. (1966). Minimal brain dysfunction in children. Terminology and identification. NINDS Monograph No. 3, U.S. Public Health Service Publication No.

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1415. Washington, DC: US Department of Health, Education, and Welfare. Corballis, M. C., & Beale, I. L. (1983). The ambivalent mind: The neuropsychology of left and right. Chicago: Nelson-Hall. Corballis, M. C., & Beale, I. L. (1993). Orton revisited: Dyslexia, laterality and left-right confusion. In D. M. Willows, R. S. Kruk, & E. Corcos (Eds.), Visual processes in reading and reading disabilities (pp. 57±74). Hillsdale, NJ: Erlbaum. Cullinan, D., Epstein, M., & Lloyd, J. W. (1981). School behaviour problems of learning disabled and normal girls and boys. Learning Disability Quarterly, 4, 163±169. deFries, J. C. (1989). Gender ratios in reading-disabled children and their affected relatives. Journal of Learning Disabilities, 22, 544±555. Delacato, C. H. (1966). The treatment and prevention of reading problems. Springfield, IL: Charles C. Thomas. Doehring, D. G., Hoshko, I. M., & Bryans, B. N. (1979). Statistical classification of children with reading problems. Journal of Clinical Neuropsychology, 1, 5±16. Epps, S., Ysseldyke, J. E., & Algozzine, B. (1985). Impact of different definitions of learning disabilities on the number of students identified. Journal of Psychoeducational Assessment, 1, 341±352. Forness, S. R. (1990). Subtyping in learning disabilities: Introduction to the issues. In H. L. Swanson & B. Keogh (Eds.), Learning disabilities: Theoretical and research issues (pp. 195±200). Hillsdale, NJ: Erlbaum. Frostig, M., & Horne, D. (1964). The Frostig program for the development of visual perception. Chicago: Follett. Gaddes, W. H. (1985). Learning disabilities and brain function. New York: Springer. Geshwind, N., & Galaburda, A. M. (1987). Cerebral lateralization: Biological mechanisms, associations and pathology. Cambridge, MA: Bradford/MIT Press. Hammill, D. D., & Larsen, S. C. (1978). The effectiveness of psycholinguistic training: A reaffirmation of position. Exceptional Children, 44, 402±414. Harness, B. Z., Epstein, R., & Gordon, H. W. (1984). Cognitive profile of children referred to a clinic for reading disabilities. Journal of Learning Disabilities, 17, 346±351. Hartlage, L. C., & Telzrow, C. F. (1983). The neuropsychological basis of educational intervention. Journal of Learning Disabilities, 16, 521±528. Hayes, S. C. (1981). Single case experimental design and empirical clinical practice. Journal of Consulting and Clinical Psychology, 49, 193±211. Hersen, M., & Barlow, D. H. (1976). Single-case experimental designs: Strategies for studying behaviour change. New York: Pergamon. Hoehn, T. P., & Baumeister, A. A. (1994). A critique of the application of sensory integration therapy to children with learning disabilities. Journal of Learning Disabilities, 27, 338±351. Hulme, C. (1988). The implausibility of low-level visual deficits as a cause of children's reading difficulties. Cognitive Neuropsychology, 5, 369±374. Hurford, D. P., Schauf, J. D., Bunce, L., Blaich, T., & Moore, K. (1994). Early identification of children at risk for reading disabilities. Journal of Learning Disabilities, 27, 371±382. Hynd, G. W., & Hynd, C. R. (1984). Dyslexia: Neuroanatomical/neurolinguistic perspectives. Reading Research Quarterly, 19, 482±498. Individuals with Disabilities Act (1990). Public Law 101±476, Section 602(a)(19), October, 1990. Washington, DC: US Office of Education. Junkala, J., & Paul, J. (1987). Special monograph issue on international perspectives on learning disabilities. Paedoperisse: An International Journal on Comparative Special Education, 1, 1±107.

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Kamphaus, R. (1993). Clinical assessment of children's intelligence. Boston: Allyn and Bacon. Kass, C. E., & Myklebust, H. R. (1969). Learning disability: An educational definition. Journal of Learning Disabilities, 2, 377±379. Kavale, K. A. (1981). Functions of the Illinois Test of Psycholinguistic Abilities (ITPA): are they trainable? Exceptional Children, 47, 496±510. Kavale, K. A. (1990a). A critical appraisal of empirical subtyping research in learning disabilities. In H. L. Swanson & B. Keogh (Eds.), Learning disabilities: Theoretical and research issues (pp. 215±232). Hillsdale, NJ: Erlbaum. Kavale, K. A. (1990b). Variances and verities in learning disabilities interventions. In T. E. Scruggs & B. Y. L. Wong (Eds.), Intervention research in learning disabilities (pp. 3±33). New York: Springer. Kavale, K. A., & Forness, S. R. (1985). Learning disability and the history of science: Paradigm or paradox? RASE, 6, 12±23. Kavale, K. A., & Forness, S. R. (1992). History, definition, and diagnosis. In N. N. Singh & I. L. Beale (Eds.), Learning disabilities: Nature, theory, and treatment (pp. 3±43). New York: Springer. Kavale, K. A., & Forness, S. R. (1996). Social skills deficits and learning disabilities: A meta-analysis. Journal of Learning Disabilities, 29, 226±237. Kavanagh, J. F., & Truss, T. J. (1988). Revised definition of learning disabilities. In J. F. Kavanagh & T. J. Truss (Eds.), Learning disabilities: Proceedings of the national conference (pp. 549±551). Parkton, MD: York Press. Kazdin, A. (1982). Single-case research designs: Methods for clinical and applied settings. New York: Oxford University Press. Lam, C. M., & Beale, I. L. (1991). Relation between sustained attention, reading performance and teachers' ratings of behaviour problems. Remedial and Special Education, 12, 40±48. Lloyd, J. W. (1992). A commentary on learning disabilities. In N. N. Singh & I. L. Beale (Eds.), Learning disabilities: Nature, theory and treatment (pp. 569±586). New York: Springer. Lloyd, J. W., Bateman, D. F., Landrum, T. J., & Hallahan, D. P. (1989). Self-recording of attention versus productivity. Journal of Applied Behaviour Analysis, 22, 315±323. Lohman, D. F., & Nichols, P. D. (1990). Training spatial abilities: Effects of practice on rotation and synthesis tasks. Learning and Individual Differences, 2, 67±93. Lovegrove, W. (1992). The visual deficit hypothesis. In N. N. Singh and I. L. Beale (Eds.), Learning disabilities: Nature, theory and treatment (pp. 246±269). New York: Springer. Marshall, K. J., Lloyd, J. W., & Hallahan, D. P. (1993). The effects of training to increase self-monitoring accuracy on the attention-to-task of learning-disabled children. Journal of Behavioural Education, 3, 445±459. Mattis, S. (1978). Dyslexia syndromes: A working hypothesis that works. In A. L. Benton & D. Pearl (Eds.), Dyslexia: An appraisal of current knowledge (pp. 43±60). New York: Oxford University Press. McConaughy, S. H., & Ritter, D. R. (1986). Social competence and behavioural problems of learning disabled boys aged 6±11. Journal of Learning Disabilities, 19, 39±45. Minskoff, E. H., Hawks, R., Steidle, E. F., & Hoffman, F. J. (1989). A homogeneous group of persons with learning disabilities: Adults with severe learning disabilities in vocational rehabilitation. Journal of Learning Disabilities, 22, 521±528. Motluk, A. (1996). Why English is hard on the brain. New Scientist, 20 January, 14. Mudford, O. C., Beale, I. L., & Singh, N. N. (1990). The

representativeness of observational samples of different durations. Journal of Applied Behaviour Analysis, 23, 323±331. National Advisory Committee on Handicapped Children (1968). The first annual report: Special education for handicapped children. Washington, DC: US Office of Education, Department of Health, Education, and Welfare. National Joint Commission on Learning Disabilities (1981). Learning disabilities: Issues on definition. A position paper of the National Joint Committee on Learning Disabilities. Narhi, V., & Ahonen, T. (1995). Reading disability with or without attention deficit hyperactivity disorder: Do attentional problems make a difference? Developmental Neuropsychology, 11, 337±349. Nelson, R. O., & Hayes, S. C. (1986). Conceptual foundations of behavioral assessment. New York: Guilford. Nichols, P., & Chen, T. C. (1981). Minimal brain dysfunction: A prospective study. Hillsdale, NJ: Erlbaum. Orton, S. T. (1937). Reading, writing and speech problems in children. New York: Norton. Pennington, B. F. (1991). Diagnosing learning disorders. New York: Guilford. Pennington, B. F., Groisser, D., & Welsh, M. C. (1993). Contrasting cognitive deficits in attention deficit hyperactivity disorder versus reading disability. Developmental Psychology, 29, 511±523. Pereira, J. A., & Winton, A. S. W. (1991). Teaching and remediation of mathematics: A review of behavioral research. Journal of Behavioral Education, 1, 5±36. Petrauskas, R. J., & Rourke, B. P. (1979). Identification of subtypes of retarded readers: A neuropsychological, multivariate approach. Journal of Clinical Neuropsychology, 1, 17±37. Pirozzolo, F. J. (1979). The neuropsychology of developmental reading disorders. New York: Praeger. Public Law 94±142 (1975), 20 U.S.L. 1401 et seq. 1976. Radencich, M. C. (1984). The status of learning disabilities: The emergence of a paradigm or a paradigm shift? Learning Disabilities, 3, 79±89. Reid, R. (1996). Research in self-monitoring with students with learning disabilities: The present, the prospects, the pitfalls. Journal of Learning Disabilities, 29, 317±331. Reiff, H. B., & Gerber, P. J. (1992). Adults with learning disabilities. In N. N. Singh & I. L. Beale (Eds.), Learning disabilities: Nature, theory, and treatment (pp. 170±200). New York: Springer. Rourke, B. P. (1982). Central processing deficiencies in children: Towards a developmental neuropsychological model. Journal of Clinical Neuropsychology, 4, 1±18. Rourke, B. P. (1985). Neuropsychology of learning disabilities: Essentials of subtype analysis. New York: Guilford. Rourke, B. P., & Strang, J. D. (1983). Subtypes of reading and arithmetical disabilities: A neuropsychological analysis. In M. Rutter (Ed.), Developmental neuropsychiatry (pp. 473±488). New York: Guilford. Rourke, B. P., Young, G. C., & Leenaars, A. A. (1989). A childhood learning disability that predisposes those afflicted to adolescent and adult depression and suicide risk. Journal of Learning Disabilities, 22, 169±175. Rozin, P., Poritsky, S., & Sotsky, R. (1971). American children with reading problems can easily learn to read English represented by Chinese characters. Science, 171, 1264±1267. Rutter, M., Graham, P., & Yule, W. (1970). A neuropsychiatric study in childhood. London: Spastics International Publications. Salvia, J., & Ysseldyke, J. E. (1991). Assessment. Boston: Houghton Mifflin. Sanson, A., Prior, M., & Smart, D. (1996). Reading

References disabilities with and without behaviour problems at 7±8 years: Prediction from longitudinal data from infancy to 6 years. Journal of Child Psychology and Psychiatry, 37, 529±541. Sattler, J. M. (1992). Assessment of children. San Diego, CA: Sattler. Satz, P., & Morris, R. (1981). Learning disability subtypes: A review. In F. J. Pirozzolo & M. C. Wittrock (Eds.), Neuropsychological and cognitive processes in reading. New York: Academic Press. Satz, P., & Sparrow, S. S. (1970). Specific developmental dyslexia: A theoretical formulation. In D. J. Bakker & P. Satz (Eds.), Specific reading disability: Advances in theory and method (pp. 17±40). Rotterdam, The Netherlands: Rotterdam University Press. Schere, R. A., Richardson, E., & Bailer, I. (1980). Towards operationalizing a psychoeducational definition of learning disabilities. Journal of Abnormal Child Psychology, 8, 5±20. Shankweiler, D., Liberman, I., Mark, L., Fowler, C., & Fisher, F. (1979). The speech code and learning to read. Journal of Experimental Psychology: Human Learning and Memory, 5, 531±545. Share, D. L., Moffitt, T. E., & Silva, P. A. (1988). Factors associated with arithmetic-and-reading and specific arithmetic disability. Journal of Learning Disabilities, 21, 313±320. Shaywitz, S. E., Shaywitz, B. A., Fletcher, J. M., & Escobar, M. D. (1990). Prevalence of reading disabilities in boys and girls: Results of the Connecticut Longitudinal Study. Journal of the American Medical Association, 264, 998±1002. Siegel, L. S., & Metsala, J. (1992). An alternative to the food processor approach to subtypes of learning disabilities. In N. N. Singh & I. L. Beale (Eds.), Learning disabilities: Nature, theory, and treatment (pp. 44±60). New York: Springer. Silver, A. A., & Hagin, R. A. (1990). Disorders of learning in childhood. New York: Wiley. Silver, L. B. (1987). The ªmagic cureº: A review of the current controversial approaches for treating learning disabilities. Journal of Learning Disabilities, 20, 498±512. Silverman, L. A., & Metz, A. (1973). Numbers of pupils with specific learning disabilities in local public schools in the United States. Annals of the New York Academy of Sciences, 205, 146±157. Smeets, P. M. (1992). Prompt-aided instruction of mirrorimage discriminations: Abrupt prompt removal, time delay, and self-evaluation. Journal of Behavioural Education, 2, 87±104. Stone, W. L., & LaGreca, A. M. (1984). Comprehension of nonverbal communication: A reexamination of the social competencies of learning disabled children.

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Journal of Abnormal Child Psychology, 12, 205. Strauss, A. A., & Lehtinen, L. E. (1947). Psychopathology and education of the brain-injured child. New York: Grune & Stratton. Talbott, E., Lloyd, J. W., & Tankersley, M. (1994). Effects of reading comprehension interventions for students with learning disabilities. Learning Disability Quarterly, 17, 223±233. Tallal, P. (1988). Developmental language disorders. In J. F. Kavanagh & T. J. Truss (Eds.), Learning disabilities: Proceedings of the national conference (pp. 181±272). Parkton, MD: York Press. Torgesen, J. K. (1979). What shall we do with psychological processes? Journal of Learning Disabilities, 12, 16±23. Torgesen, J. K., Wagner, R. K., & Rashotte, C. A. (1994). Longitudinal studies of phonological processing and reading. Journal of Learning Disabilities, 27, 276±286. Treiber, F. A., & Lahey, B. B. (1983). Toward a behavioural model of academic remediation with learning disabled children. Journal of Learning Disabilities, 16, 111±116. US Department of Education (1991). To assure free appropriate public education of all children with disabilities. Thirteenth annual report to Congress on the implementation of the individuals with disabilities. Washington, DC: US Government Printing Office. US General Accounting Office (1981). Disparities still exist in who gets special education. Washington, DC: Comptroller General of the United States. Vellutino, F. R. (1979). The validity of perceptual deficit explanations of reading disability: A reply to Fletcher and Satz. Journal of Learning Disabilities, 12, 160±167. Vogel, S. (1990). Gender differences in intelligence, language, visual-motor abilities, and academic achievement in students with learning disabilities. Journal of Learning Disabilities, 23, 44±52. Willis, W. G., Hooper, S. R., & Stone, B. H. (1992). Neuropsychological theories of learning disabilities. In N. N. Singh & I. L. Beale (Eds.), Learning disabilities: Nature, theory and treatment (pp. 201±245). New York: Springer. Willows, D. M., Kruk, R., & Corcos, E. (1993). Are there differences between disabled and normal readers in their processing of visual information? In D. M. Willows, R. S. Kruk, & E. Corcos (Eds.), Visual processing in reading and reading disabilities (pp. 265±285). Hillsdale, NJ: Erlbaum. Witelson, S. (1977). Developmental dyslexia: Two right hemispheres and none left. Science, 195, 309±311. Wong, B. Y. L. (1979). Increasing retention of main ideas through questioning strategies. Learning Disability Quarterly, 2, 42±47.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

9.04 Visual Disabilities STEVEN J. LaGROW and STEVEN HUMPHRIES Massey University, Palmerston North, New Zealand 9.04.1 INTRODUCTION

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9.04.1.1 Type 9.04.1.2 Severity 9.04.1.3 Age of Onset 9.04.2 NATURE 9.04.2.1 9.04.2.2 9.04.2.3 9.04.2.4 9.04.2.5

59 59 59 60 60 61

Reaction to Loss Attitude Toward Disability Sudden and Traumatic Onset Age of Onset Other Health Issues

9.04.3 PREVALENCE

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9.04.3.1 Severe Visual Impairment 9.04.3.2 Legal and Total Blindness 9.04.3.3 Leading Causes 9.04.4 ASSESSMENT

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9.04.4.1 Psychometric Testing 9.04.4.2 Measures of Adjustment 9.04.4.3 Measures of Functional Ability 9.04.5 TREATMENT 9.04.5.1 9.04.5.2 9.04.5.3 9.04.5.4 9.04.5.5

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Skill Acquisition Counseling and Support Delivery Systems Other Services Services for Children

9.04.6 FUTURE DIRECTIONS FOR RESEARCH AND PRACTICE

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9.04.7 CONCLUSIONS

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9.04.8 REFERENCES

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health of the individual affected (L. M. Teitelbaum, Davidson, Gravetter, Taub, & C. S. Teitelbaum, 1994).

9.04.1 INTRODUCTION Visual disabilities result from a loss of function due to a visual impairment (Colenbrander, 1976). A visual disability may impose a number of limitations on the activities of an individual and restrict their level of independence. The number and degree of limitations experienced is dependent upon the type and severity of the disability, as well as the age and

9.04.1.1 Type Visual disabilities may be of the progressive or nonprogressive type and categorized according to location. The location refers to the field of 57

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view affected. Demonstrable field defects may or may not occur. When they do, they are defined as occurring in either the central or peripheral field of view (Faye, 1976). Persons with a central field defect have difficulty with reading and other close work but experience few problems with mobility, while just the opposite is true for those with a peripheral field defect. Those with no demonstrable field defect have difficulty performing most tasks since they experience a reduction of visual ability across the entire field of view (Faye, 1976). The degree of difficulty experienced with any of these types of disability is dependent on both its severity and age of onset. Both of these categories may be treated as being dichotomous. As a result, a visual disability is often seen as being either congenital (present at birth) or adventitious (not present at birth) and as producing either a total (blind) or partial loss of sight (low vision). A partial loss of sight is classified further by severity. 9.04.1.2 Severity The severity of a visual loss can range anywhere along a continuum from minimal involvement to total blindness. The severity of that loss may be measured in terms of both visual acuity and visual field. An acuity rating is a standard measure of visual reception, is reported as a ratio, and provides a direct comparison to normative sight. The standard acuity measure for normal vision is 20/20 when measured in feet or 6/6 when reported in meters. Generally, the greater the denominator (e.g., 20/ 200 vs. 20/20) the worse are visual functions (Jose, 1984). Persons with visual acuities of 20/70 or worse, for example, have difficulty reading regular newsprint and may be classified as being severely visually impaired for statistical purposes (Kirchner, 1985). Those with visual acuities of 20/200 or worse in the better eye after the best possible correction are considered to be legally blind. Persons may also be considered legally blind if their field of view does not exceed 20 degrees at its widest angle, regardless of their acuity ratings. To be considered totally blind one must have no usable or functional vision. 9.04.1.3 Age of Onset Age of onset also plays a major role in determining the effect the visual loss will have on functioning. The earlier a significant loss of sight occurs in a child's life, for example, the more likely it is that the developmental process

will be affected as well (Scholl, 1986). These children generally experience some delays or unevenness in their sensory perceptual, motor, concept, language, and social development (Ferrell, 1986; Scholl, 1986; Warren, 1984). These delays may result in deleterious effects in a number of areas of functioning including interpersonal and social skill development (Huebner, 1986). As a result, visually impaired children are thought to be at risk of social and emotional maladjustment (Ammerman, Van Hasselt, & Hersen, 1986; Van Hasselt, 1983). Infants often display deficits in those behaviors required for the development of secure mother± infant attachment (e.g., appropriate eye contact, responsive smiling, responsive motor responding) (Ammmerman, Van Hasselt, Hersen, & Moore, 1989). They also have difficulty modeling appropriate social behaviors and spontaneously and purposefully producing smiles and other facial expressions required in social interaction with their sighted peers (Ammerman et al., 1986; Van Hasselt, Hersen, Kazdin, Simon, & Mastantuono, 1985). Yet, results from research on the social and emotional adjustment of visually impaired children have generally been mixed, with a number of studies suggesting that these children have low self-concept, subnormal social functioning, poorer social experiences, poorer psychological and emotional adjustment, and a higher rate of social dysfunction within their family unit than their sighted peers (Beaty, 1991; Warren, 1984), while others have found no difference or even better adjustment in the visually impaired sample (Alexander, 1996; Ammerman et al., 1989; Beaty, 1994; Head, 1980; Van Hasselt et al., 1985). In general, it can be concluded that although there is a full range of social, emotional, and psychological adjustment exhibited among visually impaired children there is little evidence to suggest that there are any particular patterns of dysfunction among congenitally blind and visually impaired persons (Beaty, 1994; Warren, 1984). The only real exception to this conclusion is the relatively high incidence of stereotypic responding exhibited among visually impaired children especially those who are multiply disabled (Warren, 1984). However, these behaviors are not unique to visually impaired children nor are the interventions used in their treatment (Miner, 1991; LaGrow & Repp, 1984). Adventitiously blinded or visually impaired adults, on the other hand, tend to exhibit a pattern of maladjustment involving a high rate of depressive states and other social, emotional, and psychological problems (Branch, Horowitz, & Carr, 1989; Van Hasselt, 1983). Yet, these

Nature problems are not an inevitable consequence of reduced visual function (Teitelbaum et al., 1994). Rather, they appear to be more in response to the loss of function or role associated with the onset of visual impairment (Dale, 1992; Dodds, Bailey, Pearson, & Yates, 1991; Hudson, 1994; Van Zandt, Van Zandt, & Wang, 1994). This is specially evident immediately following the sudden onset of a visual impairment (Carroll, 1961; Dale, 1992; Dodds et al., 1991) and seems to be exacerbated by old age (Hersen et al., 1995; Robbins & McMurray, 1988) and poor health (Bernbaum, Albert, & Duckro, 1988; Zarit, 1992).

9.04.2 NATURE 9.04.2.1 Reaction to Loss The most common psychological responses exhibited following the onset of a significant visual impairment include feelings of shock, regression, denial, grief, depression, devaluation, and anxiety (Schulz, 1980). These responses are common reactions to any significant loss in life and not unique to the loss of sight. They are also not invariant, although most people will experience some of these reactions and some will experience all of them in response to a significant loss. The importance of the loss to the individual will have a bearing on the way the individual responds, as will its suddenness and completeness (Schulz, 1980). These responses may appear to be particularly common following the onset of a significant visual impairment because the loss of vision results in numerous other losses to the individual. These are generally thought to include a loss of visual function for social communication, written communication, and various independent living skills including mobility which variously results in a loss of personal independence, social and familial role, psychological and financial security, and ultimately self-esteem (Carroll, 1961; Hersen et al., 1995; Teitelbaum et al., 1994; Van Hasselt, 1983; Van Zandt et al., 1994). Carroll (1961) delineated no less than 20 separate losses which may be associated with the onset of a significant visual impairment. Some of these are temporary and occur immediately following a loss of sight but do not persist long after the individual has grown accustomed to the resulting change in function (e.g., the loss of reality contact with the environment, light security, and confidence in the remaining senses). Others are a direct result of the loss of sight and may persist a lifetime (e.g., the loss of physical integrity, visual background, the

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visual perception of the pleasurable, and the visual perception of the beautiful). A number are related to the functional limitations associated with the loss of sight and can often be overcome or minimized with appropriate intervention (e.g., the loss of mobility, the various techniques of daily living, written communication, spoken communication, recreational activities, and job). The remainder are associated with those disabilities and may change as the disabilities are minimized and skill in functioning is regained (e.g., the loss of personal independence, autonomy, social adequacy, selfesteem, meaningful interpersonal relationships, career, vocational goal, financial security, and various social and familial roles). The loss of functioning associated with the onset of a significant visual impairment (e.g., mobility, various daily living skills, communication skills, recreation activities, job, and ultimately personal independence, autonomy, social adequacy, career prospects, financial security, and myriad social roles) may be shattering to one's sense of self (e.g., selfconfidence, self-esteem, self-worth) (Delafield, 1976). Part of the depression so commonly seen in persons with recent sight loss may result from the shock to one's sense of self that comes from realizing that even the simplest tasks (e.g., dressing, eating, cooking, using a telephone, handling money, telling time, moving from room to room and place to place) may no longer be completed without considerable difficulty (Dodds et al., 1991).

9.04.2.2 Attitude Toward Disability The degree to which one's sense of self is affected by the onset of a disability is obviously associated with the severity of the disability (Delafield, 1976; Dodds et al., 1991). The permanence of that effect, however, often has more to do with one's perception of the abilities and capabilities of disabled people in general, and blind and visually impaired people in particular, than the severity of the disability itself (Harrell & Strauss, 1986; Hersen et al., 1995). Some persons, for example, may be so hampered by their prejudices that they cannot recognize the difference between real limitations and perceived losses. They truly believe that they cannot learn to adjust. They believe that blindness is the worst thing that can befall them. They believe that they are helpless and to be pitied. The usually temporary loss of selfesteem, self-confidence, and/or self-worth resulting from the onset of a disability may be prolonged by their perception of what it means to be blind.

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On the other hand, individuals who are not overwhelmed by a sense of helplessness, inadequacy, dependence, and self-pity will eventually become more comfortable, feel less inadequate, and begin to experience success in their ability to accommodate the change in their physical status (Dodds et al., 1991). As a result, the losses experienced in mobility, daily living skills, communication, recreation, job, career, and even financial security may be lessened or disappear. Thus, personal independence and/or autonomy may be re-established, as could the various social roles one fills, including those related to job and career. This success will build a more positive self-concept and a renewed feeling of social adequacy (Tuttle, 1984).

9.04.2.3 Sudden and Traumatic Onset The suddenness of the onset of the visual impairment will also affect one's response to it, with the more sudden and unexpected causes of visual impairment resulting in the greatest difficulties with adjustment (Delafield, 1976; Dodds et al., 1991). This is especially true in the case of traumatic blindness. Traumatic blindness is defined as a sudden loss of sight, either partial or total, resulting from an external or internal somatic event such as a head injury, anoxia, toxic ingestion, a stroke, a severe adverse drug reaction, chemical burns, or surgical failure (Dale, 1992). The traumatic event itself may be more shocking than the resultant vision loss. Thus, the event may dominate the individual's attention, at least during the early stages of adjustment. The process of adjustment may be delayed by a period of psychic numbness following the event. This may also have a negative effect on one's existing social support system because the normal and expected reactions to the trauma are not exhibited. Friends and families may find it difficult to relate to the individual who does not appear to be reacting normally. They may feel excluded, unwanted, useless, or even guilty. They may be traumatized by the event as well and, therefore, not be of much help to the affected individual. Family members may have to take on new roles or cope with other members whose roles are changed as a result of the event or the resultant visual impairment. The family's financial security may be jeopardized by the cost of the medical care, the loss of income, or both. As a result, the individual's social support network may also be in need of support. Problems with interactions caused by this will not aid the adjustment process for either the family or the visually impaired family member.

Post-traumatic stress syndrome may accompany or follow the event and, therefore, further complicate and prolong the process of adjustment (Dale, 1992). In addition, the cause of the impairment is usually known and clearly identifiable in cases of traumatic blindness. As a result, the individual may spend a great deal of time reliving the circumstances leading up to it. This may be especially true if the circumstances were avoidable and/or caused by one's own (e.g., suicide attempt, substance abuse, careless or drunken driving) or another's actions (e.g., accident, criminal assault, careless or drunken driving, medical misadventure). In this case, the individual's thoughts may be dominated by a sense of guilt, remorse, blame, or wish for revenge (Dale, 1992). Persons who blame others or themselves for events which affect their lives, or strongly hold to a sense of justice in the world, tend to have the greatest difficulty adjusting to the sudden and traumatic onset of visual impairment (Heinemann, Bulka, & Smetak, 1988; Malec, 1985; Rohe & Basford, 1989). Older persons also tend to have more difficulty adjusting to traumatic blindness than their younger peers (Dale, 1992).

9.04.2.4 Age of Onset The older the person is the more likely he or she is to have trouble adjusting to a significant visual impairment whether it is the result of trauma or a disease process (Teitelbaum et al., 1994). This appears to reflect a cumulative effect among the losses associated with both aging and the onset of a visual impairment (Branch et al., 1989; Hersen et al., 1995; Van Zandt et al., 1994). Older persons also tend to be less tolerant of stress and more likely to experience other symptoms of ill health than their younger peers (Fagerstrom, 1992; Zarit, 1992). Elderly persons who experience a loss in vision are often demoralized by this additional loss to their physical, social, and/or financial integrity (Branch et al., 1989; Vaughan & Hobson, 1990; Zarit, 1992). As a result, they tend to withdraw and become passive. They may complain a lot but do little to try to improve the situation they are in. They often refuse to try to learn to do new things or routine things in a new way. They also tend to reject the aids and devices which may be used to accommodate but not eliminate their vision loss. Often, their only goal is complete recovery. Anything less is dismissed as being unhelpful (Zarit, 1992). These behaviors may ultimately undermine their social support network and leave them isolated.

Prevalence As a result, older persons often lose their place in their existing social support system or volintarily withdraw due to a perception that they are no longer able to reciprocate in social situations (Hersen et al., 1995). This is especially common if persons in the network tend to be paternalistic or overprotective in relation to the individual concerned (Van Zandt et al., 1994). Unfortunately, severe depression is highly correlated with the loss of social support in this population (Vaughan & Hobson, 1990).

9.04.2.5 Other Health Issues Many of the conditions that result in visual impairment cause other physiological difficulties as well. The rate of chronic health conditions, such as hearing loss, arthritis, high blood pressure, diabetes, heart conditions, and orthopedic conditions is high among elderly blind persons (Kirchner & Peterson, 1988). When severe, these difficulties may compound the situation and intensify both the physical and emotional problems experienced in the adjustment process (Needham, Elridge, Harabedian, & Crawford, 1993; Rosenbloom, 1992). Persons who experience severe visual impairments as a result of diabetes, for example, generally experience numerous other health and functional problems, including neuropathy, nephropathy, hypertension, arteriosclerosis, and myocardial infarction (Berkow, 1982). They have also been found to have significant levels of depression, poor self-esteem, and decreased psychological well-being (Bernbaum, Albert, & Duckro, 1993). They experience very high divorce rates compared to both the general population and the population of diabetics who are not visually impaired (Drury, Danchick, & Harris, 1985). Disruptions to marriages and committed relationships appear to be directly related to the severity of the vision loss and occur relatively soon after its onset (i.e., within a year and a half) (Bernbaum et al., 1993). The stressors that cause divorce in this population are apparent across all groups of newly blinded persons. In fact, blindness in one person inevitably becomes a family affair (Jackson & Lawson, 1995). Roles of family members are invariably affected and financial security may be threatened due to lost wages, medical bills, or both. This is especially apparent when one's physical health is threatened, which is commonly the case among elderly, visually impaired persons who make up the bulk of the newly blinded population (Orr, 1992).

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9.04.3 PREVALENCE 9.04.3.1 Severe Visual Impairment Approximately 11 million people in the USA have some kind of visual impairment (Kirchner & Peterson, 1988). About three million of these are severely visually impaired (i.e., have difficulty reading newsprint). Nearly 70% of those with severe visual impairments are age 65 and over (Davis, Lovie-Kitchen, & Thompson, 1995). About 25% of the visually impaired population are 18±65 years of age and only about 5% are under 18 (Rosenbloom, 1992). 9.04.3.2 Legal and Total Blindness Just over 20% of the severely visually impaired population are legally blind and 10±15% of that population are totally blind (Rosenbloom, 1992). Only about 6% of all cases of legal blindness are due to trauma (National Society for the Prevention of Blindness, 1988). Most are due to progressive disease and are often associated with conditions which cause other health or physical/sensory problems as well (Needham et al., 1993). Although rare among children, adolescents, and young adults, the rate of severe visual impairment increases dramatically with age (Yeadon, 1984). In primary school age children, for example, the rate is around 0.5 per 100 and in all persons under 24 years it is just over 0.5 per 1000. However, it increases nearly 100-fold for those who are aged 65 to 74 to a rate of 47 per 1000. For those aged 75 to 84, it is 99 per 1000; and beyond 85, it jumps to 250 per 1000, or 1 in 4 (Van Zandt et al., 1994). 9.04.3.3 Leading Causes As would be expected all the leading causes of visual impairment are age related. The most common of these are macular degeneration, cataracts, glaucoma, and diabetic retinopathy (Davis et al., 1995; Orr, 1992; Rosenbloom, 1992). All are adventitious, progressive, and usually result in a partial loss of sight, although both glaucoma and diabetic retinopathy may result in total blindness. In addition, a person may become totally blind due to senile cataracts. Yet, partial vision can usually be regained through surgery. Macular degeneration, by far the most common cause of new blindness (i.e., legal blindness), results in a central field loss but only rarely progresses to total blindness. Glaucoma results in a peripheral field loss, while cataracts and diabetic retinopathy generally result in an overall or, as Faye (1976) describes it, no demonstrable field loss.

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9.04.4 ASSESSMENT A thorough assessment is necessary before it can be assumed that the person to be served is known or understood (Vander Kolk, 1981). In the case of visually impaired persons, this would usually include ophthalmological, optometric, and functional evaluations as well as more general medical and psychological assessments. Both ophthalmological and general medical examinations are required to establish the extent and nature of the visual disability as well as any secondary disabilities or health problems which may affect the individual's functional ability and physical well-being. Optometric assessments identify the individual's acuity, refractive error, and field of view. Functional assessments may be used to determine the way the individual functions on any number of daily living tasks. Psychological assessments may be conducted to identify the individual's aptitudes, interests, and abilities as well as their acceptance of and adjustment to vision loss. As a result, a number of instruments and a variety of methods including clinical examination, psychometric testing, behavioral observations, and self-report may be used.

9.04.4.1 Psychometric Testing Psychometric assessment is widely used with visually impaired individuals (Swallow, 1981). However, there are only a limited number and range of tests designed specifically for use with this population (Johnson, 1989). Those which are available generally concentrate on either cognitive factors (i.e., IQ tests) or on aptitudes and abilities (e.g., tests of body and spatial concepts) (Dodds, Craig, & Flannigan, 1996). The latter are of limited applicability, designed for use with children, and used for planning specific educational interventions. Most tests used with visually impaired persons have been designed for use with normally sighted persons and therefore must be modified in some way for use with this population. This is usually done in terms of content and/or administrative style (Needham & Eldridge, 1990). Administration of the test may be modified by reading the test aloud to the individual or into a tape recorder, reproducing the test in enlarged print or Braille, and/or allowing the individual to respond orally or by typing (Fuchs, Fuchs, Benowitz, & Barringer, 1987; Johnson, 1989). The content of tests is often modified by dropping items seen to be inappropriate for visually impaired persons. The entire performance sections of some tests (e.g., Stanford Binet and WISC-R) are

dropped, while individual items considered to be visually loaded may be omitted from others (Ammerman et al, 1986; Jan, Freeman, & Scott, 1977). Any modification from the original format, however, may alter the results of the test or otherwise disadvantage those for whom the modifications are made (Ammerman et al., 1989; Johnson, 1989). The use of Braille, for example, can be problematic for some because only a small percentage of the blind population are proficient with its use while emphasis and intonation accompanying an oral presentation of a written question may change its meaning (Johnson, 1989). Furthermore, modifications in presentation and response format often greatly increase the time and energy required to complete the test (Barker, Wright, Meyerson, & Gonick, 1953). This last factor has especially strong implications for the administration of timed tests to people with visual impairments. There are a number of problems associated with dropping ªinvalidº test items. First, it is not always easy to detect which test items are visually loaded (Jan et al., 1977). Indeed, attempts to develop items whose solution is not dependent on sight, and that could be solved equally well by blind and sighted subjects, is extremely difficult to do (Brambring & Troster, 1994). Second, dropping items causes the reliability and the scope of a test to be reduced due to the shortened test length. Such truncated tests can give only a partial measurement of functioning when compared with the original instrument. For example, the information and vocabulary subscales of WISC correlate with the full-scale WISC-R at 0.71 and 0.74, respectively. That is, only half of the variance in the full-scale test can be accounted for by these two subscale measures. Other problems may occur when using tests designed for one population with another. For example, care must be taken in assuming that any given item has the same interpretative significance for a person with a visual impairment as it does for sighted peers (Barker et al., 1953). One aspect of this is the need to distinguish a normal reaction to a disability from dysfunction (Ammerman et al., 1986). For example, some items on the MMPI that ostensibly measure hysteria may evoke positive responses in people with a disability, purely on the basis of the physical symptoms associated with their disability (Vash, 1981). Furthermore, many of the tests commonly used with subjects with visual impairment are norm-referenced tests based on sighted populations (Adrian, Miller, & De l'Aune, 1982; Scholl & Schnur, 1976). These tests include the Stanford Binet

Treatment

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and WISC measures of intellectual functioning, the Benreuter Personality Inventory and California Personality Inventory, and the Maxfield± Buchholz Social Maturity Scale that is derived from the Vineland Social Maturity Scale (Ammerman et al., 1986; Greenberg & Jordan, 1957; Maxfield & Buchholz, 1957; Petrucci, 1953). The use of a norm-referenced test on a subgroup that it was not standardized on makes test interpretation questionable at best (Anastasi, 1988), and it may easily discriminate against that subgroup (Fuchs et al., 1987). Some tests have been standardized on visually impaired populations (e.g., the Perkins Binet; the Anxiety Scale for the Blind; the Nottingham Ajustment Scale) (Jan et al., 1977). Yet, even these tests must be used and interpreted with caution because the existing norms do not adequately account for the heterogeneity of the visually impaired population (Ammerman et al., 1986). There is, for example, a notable lack of norms for very young and very old visually impaired people (Hersen et al., 1995), and little reason to believe that a test standardized on a congenitally visually impaired population would have validity for an adventitiously blinded person or vice versa.

9.04.4.3 Measures of Functional Ability

9.04.4.2 Measures of Adjustment

9.04.5 TREATMENT

Following the loss of sight, a period of adjustment is usually necessary in order for the individuals to prepare themselves mentally for the task ahead (Dodds et al., 1991). Assessments are often conducted to determine if the individual is ready to begin the rehabilitation process and if other treatment or support services may be needed to aid in this process. Adjustment is a complex process which may be best reflected in multidimensional assessments. The Reactions to Disability and Impairment Inventory (RIDI) is one example of a scale that attempts to measure reaction to the onset of disability in terms of a multidimensional assessment, using eight different psychosocial scales (Antonak & Livneh, 1991). The Nottingham Adjustment Scale (NAS) is another scale designed specifically for use with and standardized on visually impaired persons (Dodds et al., 1996). The NAS consists of seven subsections that measure emotional and cognitive states, including anxiety, depression, selfesteem, acceptance of blindness, attitudes toward blind people, self-efficacy, locus of control, and attributional style. These seven factors are seen as constituting adjustment. As such, a low score on any one of the seven subsections is thought to be indicative of poor adjustment.

Adjustment to the onset of a significant visual impairment generally involves both the acquisition of new skills and the restoration of psychosocial health (Elliott & Kuyk, 1994). Adjustment may be characterized by low levels of anxiety, an absence of depression, and high self-esteem (Dodds et al., 1991). The latter requires a high sense of self-efficacy and positive acceptance of one's visual state (Dodds et al.).

Functional capacity is the product of a great many factors, including: the extent, etiology, and nature of vision loss; personality and cognitive factors; and environmental influences such as support networks and the attitudes of significant others (Van Hasselt, Hersen, & Kazdin, 1985). Self-report and direct observation may be used to gain a richness of information not possible with standard psychometric and clinical testing (Smith, De l'Aune, & Geruschat, 1992). While self-reports may not always be accurate (Wylie, 1961), they can provide good prediction of functioning, and high levels of agreement have been found between self-report and other measures of functional capacity, such as behavioral observation (Elliot & Kuyk, 1994; Szlyk, Arditi, Coffey Bucci, & Laderman, 1990). Behavioral observation tends to have good internal and ecological validity and has proven useful for determining a person's current level of functioning on a variety of tasks and evaluating the overall effectiveness of treatment programs, as well as the relative effectiveness of various treatment options (LaGrow & Murray, 1992; Van Hasselt & Hersen, 1981).

9.04.5.1 Skill Acquisition Rehabilitation program for visually impaired persons are designed to provide the individual with the skills necessary to regain independence in functioning following a significant loss of sight. The re-establishment of functional capacity is a prerequisite for vocational rehabilitation for working age persons. Functional capacity has also been shown to be one of the most important factors involved in satisfaction ratings of a person's quality of life among older severely disabled persons (Osberg, 1987). In fact, restoration of the opportunity to participate in meaningful and enjoyable activities may be the best antidote for the sadness caused by the losses associated with aging and ill health (Zarit, 1992). As such, it is often the goal

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of rehabilitation for older visually impaired persons, while the restoration of independence, both personal and financial, to the level previously enjoyed is aimed for with younger persons. In order to achieve these goals, individualized instructional programs are provided in the areas of orientation and mobility, adaptive communication skills for both reading and writing, leisure time activities, and the techniques of daily living. The latter includes: eating etiquette, food preparation, grooming, house cleaning and maintenance, money identification and management, personal hygiene, shopping, sewing, telephone use, time-telling, and most other daily needs including those required to manage particular health or medical conditions (e.g., self-monitoring of glucose levels and self-administration of insulin by diabetics) (Huebner, 1986). Vocational rehabilitation may follow if appropriate. The instructional system used is success based and relies upon both a multisensory approach and a logical sequence for the presentation of the skills and subskills to be mastered (LaGrow, 1992). These programs are designed as much to promote the restoration of a sense of selfefficacy and self-esteem through the development of skill and a history of success, as they are to establish the skills necessary to regain independence in functioning (Elliott & Kuyk, 1994). However, one's psychological state may mediate the amount of success experienced in these programs (Davis et al., 1995). Therefore, specific interventions to promote psychological adjustment may also be needed.

9.04.5.2 Counseling and Support Psychological intervention may be required to alleviate extreme anxiety, emotional stress, and other depressive states (Dodds et al., 1991). Promotion of the use of positive coping strategies and mature defense mechanisms for dealing with the losses associated with the onset of significant visual impairment is often the focus of such intervention (Fagerstrom, 1992; Zarit, 1992). Both professional counseling and participation in specifically constructed support groups have proven beneficial for these purposes (Teitelbaum et al., 1994). Because ªan individual's adjustment to sight loss is closely related to the attitudes, perceptions, and behaviors of his or her familyº (Dumas & Sadowsky, 1984, p. 473), counseling services are often recommended for the family as well (Dumas & Sadowsky, 1984; Moore, 1984; Ponchillia, 1984). The strategies and therapies (e.g., traditional psychotherapy, relaxation training, biofeed-

back, counseling, hypnosis, systematic desensitization, cognitive therapy for irrational thinking) developed for use with sighted persons can benefit visually impaired persons as they come to to terms with their loss (Needham et al., 1993). These interventions need no particular modification for use with visually impaired persons, yet their focus may vary according to the needs and experiences of the affected individual. The objectives of therapeutic intervention following traumatic blindness, for example, are to help these individuals understand what has happened to them and to facilitate a sense of self-acceptance and forgiveness for themselves and for those who may be responsible for the event leading to their blindness (Dale, 1992). It is important to help those who are demoralized by the onset of a significant vision impairment verbalize their beliefs (i.e., those related to a sense of helplessness) and identify ways in which their lives can continue to be meaningful and full. Working age persons often require vocational or guidance counseling in addition to personal counseling (Needham et al., 1993). More severely depressed persons may need psychiatric treatment, including the use of antidepressant medications and psychotherapy (Zarit, 1992). Developing a thorough understanding of one's visual condition and an acceptance of the disabilities associated with it appears to be a requisite to adjustment for all persons with a vision impairment (Dale, 1992; Dodds et al., 1991; Teitelbaum et al., 1994; Zarit, 1992). Although individual counseling is often provided as a means of crisis intervention, ongoing attention is generally provided in the context of a group. Group counseling procedures allow people to resolve their feelings about the loss of sight, vent their emotions to others, and discover that their feelings, attitudes, and experiences may not be completely unique (Schulz, 1980). Group counseling sessions may also provide the basis for the development of peer support. Peer support may come naturally from interaction with others experiencing similar situations or through formal groups formed to provide support. These groups may prove to be especially beneficial for older persons with visual impairments who often find themselves being overprotected or treated paternalistically by those who do not understand vision impairment and/or aging. Peer support groups tend to balance such counterproductive support and therefore serve to reduce their membersº feelings of isolation and the sense that their problems and experiences are unique (Van Zandt et al., 1994). As a result, peer support

Future Directions for Research and Practice proves to be beneficial to spouses and other members of the affected person's family as well (Jackson & Lawson, 1995). 9.04.5.3 Delivery Systems Counselling and support services may be provided by either general or specialist agencies, while the instructional programs provided for adapting to visual loss are generally only available from agencies specifically serving individuals who are blind or visually impaired (Hilton, Ellis, Genwright, Miller, & Stern, 1992). These services are traditionally delivered in the person's place of residence by an itinerant teacher, or at a rehabilitation center from a multidisciplinary team of specialists (Ponchillia & Kaarlela, 1986). Center-based programming may be either day or residential. Residential rehabilitation programs provide the most therapeutic environment of the options available and have proven to be effective even for those who have had a history of psychological illness. In fact, those illnesses have been seen to become much less evident upon entry to such a program where structure, support and the promise of increased personal adequacy is available (Needham, Acton, & Eldridge, 1992). Residential rehabilitation programs have been shown to result in significant improvement in independent function, self-image, self-esteem (Elliott & Kuyk, 1994), and a significant decrease in irrational thinking about visual impairment (Needham, Ehmer, De l'Aune, & Carr, 1984). One of the greatest advantages of residential rehabilitation over home-based and even day programs is the opportunity for interaction with the other persons in attendance (Hilton et al., 1992). 9.04.5.4 Other Services Rehabilitation services are not always the most appropriate treatment option for visually impaired persons. Such services assume that the loss of vision is the root cause of the problems the individual is facing. This is certainly not always the case among visually impaired persons. Congenitally blind persons may, in fact, experience no loss in visual function associated with their visual disability. Others, who have experienced the onset of a significant visual impairment later in life but have adapted for it and adjusted to it, may have other problems which require professional counseling or support which are not related directly to their loss in visual function. These problems may best be provided by those who specialize in the problem area (e.g., marriage or family counsel-

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ing, alcohol and drug counseling, vocational or guidance counseling) rather than those who specialize in the adjustment process per se. However, referral and consultation with someone who has experience working with visually impaired persons may be helpful at times. 9.04.5.5 Services for Children This chapter has concentrated on the needs of adventitiously visually impaired adults. The goal of treatment with this population is to restore the level of functioning to that obtained prior to the loss of sight. This goal and the strategies used to obtain it are not necessarily appropriate to meet the needs of visually impaired children. Their needs are much more general than those of adults who experienced a loss in function. In fact, many of these children experience no loss at all, and indeed have no previous level of function to return to. Visually impaired children, like all other children, need to grow and develop in order to meet their potential as adults; receive an education which prepares them to participate fully in life; become acculturated in the norms, values, and mores of the society in which they live; and be prepared for their future as a productive member of that society. These children will need some special attention to aid them in meeting these goals (LaGrow, 1992). This assistance is generally available through the provision of special education and related services and is prescribed in an individualized education or development plan (Ward, 1986). 9.04.6 FUTURE DIRECTIONS FOR RESEARCH AND PRACTICE The number of elderly persons in the population is expected to increase dramatically in the future (e.g., in the USA the number of persons over 65 is expected to double from 1990 to 2030). As a result, both the number and proportion of persons in the population experiencing a significant visual impairment will also increase (Orr, 1992). Thus, we will need to know more about the effects of the onset of visual impairment on the elderly population and the most effective means of treatment. This research needs to be more theoretically driven than it is at present. Therefore, testable models of adjustment to adventitious blindness need to be developed that provide an explanation for the effects of the onset of a disability, a rationale for intervention, and predictions to guide future research. The loss model in use in the 1990s has been criticized as being merely descriptive and defies testing (Dodds et al., 1991).

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New models of services delivery need to be developed and tested as well. The majority of older persons receive home-based rehabilitation programs without the benefit of comprehensive counseling services or ready access to formal or informal peer groups (Hilton et al., 1992). Yet, it appears that this population is most at risk of depression, devaluation, and demoralization from the onset of a visual impairment and the most likely to benefit from both counseling and peer support. Thus, the best way to provide services to this population and alternative ways to provide peer support need to be investigated. More specific assessment devices need be developed for this population which are standardized on this population (Hersen et al., 1995). Finally, a clear distinction between congenital and adventitious, and early and late onset, need to be made in future research. More needs to be known about the effect of adventitious onset of visual impairment on children and the most effective means of treatment (Dale, 1992). Clear distinctions need to be made between rehabilitation and habilitation in this population, and the effects of each.

9.04.7 CONCLUSIONS The psychological and emotional distress accompanying severe visual impairment and blindness has been well documented. This distress appears to be primarily a reaction to the loss of sight and related losses in functional adequacy and social role (Hudson, 1994). The more suddenly this occurs and the more severe the impairment, the more likely it is that the person will have significant problems with adjustment (Dale, 1992; Dodds et al., 1991). These problems often manifest themselves in terms of anxiety, devaluation, demoralization, and depression (Schulz, 1980). Older persons and those in ill health tend to find it harder to adjust to the changes associated with the onset of a significant visual impairment than their younger and healthier peers (Bernbaum et al., 1988; Hersen et al., 1995: Robbins & McMurray, 1988; Teitelbaum et al., 1994; Zarit, 1992). Rehabilitation services are designed to help with the adjustment process by restoring a person's functional ability through instruction and the use of adaptive equipment. This, in turn, should lead to a restoration of role, self-esteem, and security (LaGrow, 1992). Counseling and other psychological interventions may be most useful in helping this process unfold (Dodds et al., 1991). Peer support, either formal or informal, appears to be a critical factor for success in rehabilitation, especially for those who are older (Teitelbaum et al., 1994).

Rehabilitation may be provided either at home by one or more itinerant instructors or in a center by a multidisciplinary team of specialists. Center-based programs may be either day or residential. Residential programs appear to offer the most therapeutic environment, the most intensive instructional programing, and the greatest opportunity for peer support. The latter may, in fact, prove to be the greatest single advantage of this particular service delivery system (Hilton et al., 1992). The therapeutic and treatment programs available in residential rehabilitation tend to promote both the learning and overall adjustment of people with various degrees of psychological health, despite the anxiety involved in living away from home and learning new skills (Needham et al., 1992). Unfortunately, such programs are more commonly provided for younger, working-age people than for the older population. These people are usually served by home-based programs (Hilton et al., 1992). As a result, they often have limited access to specialized counseling services and little opportunity for peer support, as well as less intensive instructional programs than those attending residential rehabilitation programs (Ponchillia & Kaarlela, 1986). It is assumed, however, that this population, who tend to have greater difficulty in their adjustment to the onset of a visual impairment than their younger and healthier peers, would need more of all of these things. Thus, if these services are not provided through specialized blindness services, they may have to be gained through other providers in the community. Services for visually impaired children are primarily provided through the schools. Most of these children are congenitally visually impaired and tend to be about as well adjusted as their sighted peers (Beaty, 1994). Special services for adjustment to blindness are generally only needed if they experience the onset of a visual impairment and thus experience a loss in function. 9.04.8 REFERENCES Adrian, R. J., Miller, L. R., De l'Aune, W. R. (1982). Personality assessment of early visually impaired persons using the CPI and MMPI. Journal of Visual Impairment and Blindness, 76, 172±178. Alexander, F. E. (1996). Self-concepts of children with visual impairments. RE: View, 28(1), 35±43. Ammerman, R. T., Van Hasselt, V. B., & Hersen, M. (1986). Psychological adjustment of visually handicapped children and youth. Clinical Psychology Review, 6, 67±85. Ammerman, R. T., Van Hasselt, V. B., Hersen, M., & Moore, L. E. (1989). Assessment of social skills in visually impaired adolescents and their parents. Behavioral Assessment, 11, 327±351.

References Anastasi, A. (1988). Psychological testing (6th. ed.). New York: Macmillan. Antonak, R. F., & Livneh, H. (1991). A hierarchy of reactions to disability. International Journal of Rehabilitation Research, 14, 13±24. Barker, R. G., Wright, B. A., Meyerson, L., & Gonick, M. R. (1953). Adjustment to physical handicap and illness: A survey of the social psychology of physique and disability. New York: Social Science Research Council. Baumeister, A. A., & Forehand, R. (1973). Stereotyped acts. In N. R. Ellis (Ed.), International review of research in mental retardation (Vol. 6). New York: Academic Press. Beaty, L. A. (1991). The effects of visual impairment on adolescentsº self-concept. Journal of Visual Impairment and Blindness, 85, 129±132. Beaty, L. A. (1994). Psychological factors and academic success of visually impaired college students. RE: View, 26, 131±139. Berkow, R. (1982). The Merck Manual: Diagnosis and Therapy. Rahway, NJ: Merck & Co, Ltd. Bernbaum, M., Albert, S. G., & Duckro, P. N. (1988). Psycho-social profiles in patients with visual impairment due to diabetic retinopathy. Diabetes Care, 11, 551±557. Bernbaum, M., Albert, S. G., & Duckro, P. N. (1993). Personal and family stress in individuals with diabetes and vision loss. Journal of Clinical Psychology, 49, 670±677. Brambring, M., & Troster, H. (1994). The assessment of cognitive development in blind infants and preschoolers. Journal of Visual Impairment and Blindness, 88, 9±18. Branch, L. G., Horowitz, A., & Carr, C. (1989). The implications for everyday life of self-reported visual decline among people over age 65 living in the community. The Gerontologist, 29, 359±365. Carroll, T. J. (1961). Blindness: What it is, what it does, and how to live with it. Boston: Little, Brown & Co. Colenbrander, A. (1976). Low vision: Definition and classification. In E. E. Faye (Ed.), Clinical low vision (pp. 3±6). Boston: Little, Brown & Co. Dale, B. (1992). Issues in traumatic blindness. Journal of Visual Impairment and Blindness, 86, 140±143. Davis, C., Lovie-Kitchen, J., & Thompson, B. (1995). Psychosocial adjustment to age-related macular degeneration. Journal of Visual Impairment and Blindness, 89, 16±27. Delafield, G. L. (1976). Adjustment to blindness. New Outlook for the Blind, 70, 64±68. Dodds, A. G., Bailey, P., Pearson, A., & Yates, L. (1991). Psychological factors in acquired visual impairment: The development of a scale of adjustment. Journal of Visual Impairment and Blindness, 85, 306±310. Dodds, A. G., Craig, D., & Flannigan, H. (1996). The Nottingham Adjustment Scale: An estimation of response bias. Journal of Visual Impairment and Blindness, 90, 51±57. Drury, T. F., Danchik, K. M., & Harris, M. I. (1985). Socio-demographic characteristics of adult diabetes. In Diabetes in America. National Diabetes Data Group, NIH Publication No. 85±1468 VII, 15±17. Washington, DC: Department of Health and Human Services. Dumas, A., & Sadowsky, A. (1984). A family training program for adventitiously blinded and low vision veterans. Journal of Visual Impairment and Blindness, 78, 473±478. Elliott, J. L., & Kuyk, T. K. (1994). Self-reported functional and psychosocial outcomes of blind rehabilitation. Journal of Visual Impairment and Blindness, 88, 206±212. Fagerstrom, R. (1992). Defense mechanisms of elderly persons before and after a cataract operation. Journal of Visual Impairment and Blindness, 86, 361±363.

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Faye, E. E. (1976). Clinical low vision. Boston: Little, Brown & Co. Ferrell, K. (1986). Infancy and early childhood. In G. T. Scholl (Ed.), Foundations of education for blind and visually handicapped children and youth: Theory and practice (pp. 119±136). New York: American Foundation for the Blind. Fuchs, D., Fuchs, L. S., Benowitz, S., & Barringer, K. (1987). Norm-referenced tests: Are they valid for use with handicapped students? Exceptional Children, 54, 263±271. Greenberg, H. M., & Jordan, S. (1957). Differential effects of total blindness and partial sight. Exceptional Children, 24, 123±124. Harrell, R. L., & Strauss, F. A. (1986). Approaches to increasing assertive behavior and communication skills in blind and visually impaired persons. Journal of Visual Impairment and Blindness, 80, 794±798. Head, D. N. (1980). The stability of self-concept scores in visually impaired adolescents. Education of the Visually Handicapped, 12, 66±74. Heinemann, A., Bulka, M., & Smetak, S. (1988). Attribution and disability acceptance following traumatic injury. Rehabilitation Psychology, 33, 195±206. Hersen, M., Kabacoff, R. I., Van Hasselt, V. B., Null, J. A., Ryan, C. F., Melton, M. A., & Segal, D. L. (1995). Assertiveness, depression and social support in older visually impaired adults. Journal of Visual Impairment and Blindness, 89, 524±530. Hilton, J., Ellis, F. J., Genwright, R., Miller, L. R., & Stern, H. (1992). The state of the blindness system today: Report of system of service delivery work group B. Journal of Visual Impairment and Blindness, 86, 323±330. Hudson, D. (1994). Causes of emotional and psychological reactions to adventitious blindness. Journal of Visual Impairment and Blindness, 88, 498±503. Huebner, K. (1986). Social skills. In G. T. Scholl (Ed.), Foundations of education for blind and visually handicapped children and youth: Theory and practice (pp. 341±362). New York: American Foundation for the Blind. Jackson, R., & Lawson, G. (1995). Family environment and psychological distress in persons who are visually impaired. Journal of Visual Impairment & Blindness, 89, 157±160. Jan, J. E., Freeman, R. D., & Scott, E. P. (1977). Visual impairment in children and adolescents. New York: Grune & Stratton. Johnson, D. G. (1989). An unassisted method of psychological testing of visually impaired individuals. Journal of Visual Impairment and Blindness, 83, 114±118. Jose, R. (1984). Understanding low vision. New York: American Foundation for the Blind. Kirchner, C. (1985). Data on blindness and visual impairment in the US: A resource manual on characteristics, education employment, and service delivery. New York: American Foundation for the Blind. Kirchner, C., & Peterson, R. (1988). Data on visual disability from NCHS, 1977. In C. Kirchner (Ed.), Data on blindness and visual impairment in the US (2nd ed., pp. 19±24). New York: American Foundation for the Blind. LaGrow, S. (1992). The rehabilitation of visually impaired people. Auckland, New Zealand: Royal New Zealand Foundation for the Blind. LaGrow, S., & Murray, S. (1992). Use of alternating treatment design to evaluate intervention in low vision rehabilitation. Journal of Visual Impairment and Blindness, 86, 435±439. LaGrow, S., & Repp, A. (1984). Stereotypic responding. A review of intervention research. American Journal of Mental Deficiency, 88, 595±609. Malec, D. (1985). Personality factors associated with severe

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traumatic disability. Rehabilitation Psychology, 30, 165±172. Maxfield, K. E., & Buchholz, S. (1957). A social maturity scale for blind preschool children: A guide to its use. New York: American Foundation of the Blind. Miner, D. (1991). Using nonaversive techniques to reduce self-stimulatory hand-mouthing in a visually impaired and severely retarded student. RE: View, 22, 185±194. Moore, J. (1984). Impact of family attitudes toward blindness/visual impairment on the rehabilitation process. Journal of Visual Impairment and Blindness, 78, 100±105. National Society for the Prevention of Blindness. (1988). Vision loss in the United States. Washington, DC: Author. Needham, W. E., Acton, J. J., & Eldridge, L. S. (1992). Psychological disorders of blind persons and success in residential rehabilitation. Journal of Visual Impairment and Blindness, 86, 144±147. Needham, W. E., Ehmer, M. N., De l'Aune, W. R., & Carr, R. B. (1984, August). Irrational thinking, adjustment and change in the blind during rehabilitation. Paper presented at the annual meeting of the American Psychological Association, Toronto, Canada. Needham, W. E., & Eldridge, L. S. (1990). Performance of blind vocational rehabilitation clients on the Minnesota Rate of Manipulation Tests. Journal of Visual Impairment and Blindness, 84, 182±185. Needham, W. E., Eldridge, L. S., Harabedian, B., & Crawford, D. G. (1993). Blindness, diabetes, amputations: Alleviation of depression and pain through thermal biofeedback therapy. Journal of Visual Impairment and Blindness, 87, 368±371. Orr, A. L. (1992). Aging and blindness: Toward a systems approach to service delivery. In A. L. Orr (Ed.), Vision and aging: Crossroads for service delivery (pp. 3±31). New York: American Foundation for the Blind. Osberg, J. S. (1987). Life satisfaction and quality of life among disabled elderly adults. Journal of Gerontology, 42, 228±230. Petrucci, D. (1953). The blind child and his outlook. New Outlook for the Blind, 47, 240±246. Ponchillia, P. (1984). Family services: Role of the centerbased teaching professional. Journal of Visual Impairment and Blindness, 78, 97±100. Ponchillia, P., & Kaarlela, R. (1986). Post-rehabilitative use of adaptive skills. Journal of Visual Impairment and Blindness, 80, 665±669. Robbins, H. G., & McMurray, N. (1988). Psychosocial and visual factors in low vision rehabilitation of patients with age-related maculopathy. Journal of Vision Rehabilitation, 2, 11±21. Rohe, D., & Basford, B. (1989). Traumatic spinal cord injury, alcohol and the MMPL. Rehabilitation Psychology, 34, 25±32. Rosenbloom, A. A. (1992). Physiological and functional aspects of aging, vision, and visual impairment. In A. L. Orr (Ed.), Vision and aging: Crossroads for service delivery (pp. 47±68). New York: American Foundation for the Blind. Scholl, G. T. (1986). Growth and development. In G. T. Scholl (Ed.), Foundation of education for blind and visually handicapped children and youth: Theory and practice (pp. 65±81). New York: American Foundation for the Blind. Scholl, G., & Schnur, R. (1976). Measures of psychological,

vocational and educational functioning in the visually handicapped. New York: American Foundation for the Blind. Schulz, P. J. (1980). How does it feel to be blind: The psychodynamics of visual impairment. Los Angeles: Muse-Ed. Smith, A. J., De l'Aune, W., & Geruschat, D. R. (1992). Low vision and mobility problems: Perceptions of O&M specialists and persons with low vision. Journal of Visual Impairment and Blindness, 86, 58±62. Swallow, R. (1981). Fifty assessment instruments commonly used with blind and partially seeing individuals. Journal of Visual Impairment and Blindness, 75, 65±72. Szlyk, J., Arditi, A., Coffey Bucci, P., & Laderman, D. (1990). Self-report in functional assessment of low vision. Journal of Visual Impairment and Blindness, 84, 61±66. Teitelbaum, L. M., Davidson, P. W., Gravetter, F. J., Taub, H. A., & Teitelbaum, C. S. (1994). The relation of vision loss to depression in older veterans. Journal of Visual Impairment and Blindness, 88, 253±257. Tuttle, D. W. (1984). Self-esteem and adjusting with blindness. Springfield, IL: Charles C. Thomas. Van Hasselt, V. B. (1983). Visual impairment. In M. Hersen, V. B. Van Hasselt, & J. L. Matson (Eds.), Behavior therapy for the developmentally and physically disabled (pp. 109±128). New York: Academic Press. Van Hasselt, V. B., & Hersen, M. (1981). Applications of single-case designs to research with visually impaired individuals. Journal of Visual Impairment and Blindness, 75, 359±362. Van Hasselt, V. B., Hersen, M., & Kazdin, A. E. (1985). Assessment of social skills in visually handicapped adolescents. Behavior Research and Therapy, 25, 53±63. Van Hasselt, V. B., Hersen, M., Kazdin, A. E., Simon, J., & Mastantuono, A. K. (1985). A behavioral-analytic model for assessing social skills in blind adolescents. Behavior Research and Therapy, 23, 395±405. Van Zandt, P. L., Van Zandt, S. L., & Wang, A. (1994). The role of support groups in adjusting to visual impairment in old age. Journal of Visual Impairment and Blindness, 88, 244±252. Vander Kolk, C. (1982). Rehabilitation and visual impairment: A human system. Journal of Visual Impairment and Blindness, 76, 346±350. Vash, C. L. (1981). The psychology of disability. New York: Springer. Vaughan, C. E., & Hobson, S. (1990). Reducing late-life dependence resulting from declining visual acuity. Journal of Visual Impairment and Blindness, 84, 370±372. Ward, M. E. (1986). Planning the individualized education program. In G. T. Scholl (Ed.), Foundations of education for blind and visually handicapped children and youth: Theory and practice (pp. 215±238). New York: American Foundation for the Blind. Warren, D. (1984). Blindness and early childhood development (2nd ed.). New York: American Foundation for the Blind. Wylie, R. C. (1961). The self-concept. Lincoln, NE: University of Nebraska Press. Yeadon, A. (1984). The informal care group: Problem or potential. Journal of Visual Impairment and Blindness, 78, 149±154. Zarit, S. H. (1992). Psychosocial aspects of aging and visual impairment. In A. L. Orr (Ed.), Vision and aging: Crossroads for service delivery (pp. 93±117). New York: American Foundation for the Blind.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

9.05 Hearing Disabilities LAURENCE McKENNA Guy's Hospital and the Royal National Throat, Nose and Ear Hospital, London, UK and GERHARD ANDERSSON Uppsala University, Sweden 9.05.1 INTRODUCTION

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9.05.2 PREVALENCE

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9.05.3 NATURE

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9.05.3.1 Detection 9.05.3.2 Problems Experienced 9.05.3.3 Psychological Factors and Theoretical Views 9.05.4 ASSESSMENT

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9.05.4.1 Audiological Assessments 9.05.4.2 Self-report Measures 9.05.4.3 Psychological Assessments 9.05.5 TREATMENT

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9.05.5.1 Hearing Aids and Other Prosthetic Devices 9.05.5.2 Counseling and Self-help Approaches 9.05.5.3 Psychological Treatments for Hearing Loss and Tinnitus

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9.05.6 FUTURE DIRECTIONS FOR RESEARCH AND PRACTICE

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9.05.7 SUMMARY

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9.05.8 REFERENCES

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prevalent among elderly people. All people experience problems with listening (Noble, 1983), especially in demanding auditory situations, and many people have experienced tinnitus after being exposed to loud sound. To review the physiological underpinnings of hearing loss and tinnitus is beyond the scope of this chapter and the reader is referred to textbooks on audiology (Katz, 1994). Here it suffices to say that hearing disorders can occur as a result of damage to or interference with any part of the auditory pathway from the outer ear to the brain.

9.05.1 INTRODUCTION The application of clinical psychology within the fields of audiological medicine and its associated science otolaryngology is comparatively new. Most of the clinical psychology and research efforts have taken place since the early 1980s. This chapter focuses on psychological issues relating to hearing loss and tinnitus, both of which are disorders of the ear. Sensory restrictions are an almost universal part of human existence and are particularly 69

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Hearing disorders may arise from a wide range of etiologies. A basic distinction may be made between hearing loss that is present at birth or prelingually and that which is acquired postlingually. This chapter is concerned with only the latter type. Distinctions can also be made between conductive hearing loss and sensori-neural hearing loss. When the structures of the outer or middle ear are dysfunctional, the hearing loss is described as conductive in nature. Sensori-neural hearing loss arises as a result of cochlear (inner ear) dysfunction. The majority of hearing loss of 25 dB hearing level (HL) or greater is sensori-neural in nature. The causes of acquired hearing loss range from common influenza type infections to cerebral tumors and to iatrogenic causes. Most commonly, hearing loss is attributed to exposure to loud noises, generally over a period of years, or to the process of aging (Katz, 1994). The term presbyacusis was coined to describe the almost ubiquitous presence of hearing loss in elderly people (Katz, 1994). It is most likely that hearing loss in elderly people involves changes in central auditory processes as well as the loss of sensory hair cells in the cochlea (Katz, 1994). Central presbyacusis is the component related to the aging central auditory nervous system. It is used to describe changes in speech understanding, especially in noise, that many older people experience. Although sometimes observed, functional or nonorganic hearing difficulties should not be classified as hearing loss, but rather should be regarded a sign of psychological disturbance or abuse (Reidner & Efros, 1995). Malingering and faked hearing loss may also be found in the clinic, especially when monetary compensation is involved, but these are easily detected during testing. Tinnitus is the perception of noise in the absence of any external stimulation to produce that noise (Hazell & Jastreboff, 1990). It is not a disease but a symptom that can be produced by an enormous variety of change in the auditory pathway. Tinnitus has for long been regarded as the result of cochlear dysfunction. Since the early 1990s, however, an emphasis has been placed on the central processing of cochlear pathology in the perception of tinnitus(Jastreboff & Hazell, 1993). Tinnitus is almost always a phantom auditory perception, perceived only by the patient. It is widely experienced in the general population and more particularly by people with hearing loss, although hearing loss and tinnitus can occur independently of one another. For many people seen in audiology clinics, tinnitus is the primary complaint. Again, like hearing loss, the symptom can have many and diverse etiologies. In a clinical

setting, the causes of many cases of tinnitus may go undiscovered. In seeking to account for tinnitus it is common clinical practice to tell the patient that ªwhatever caused your hearing loss also caused your tinnitus.º Tinnitus can be distressing, and for the majority of people there are no practical medical or surgical solutions to the symptom (Stouffer, Tyler, Kileny, & Dalzell, 1991). In some rare cases ªobjective tinnitusº has been documented where an outside observer can hear the tinnitus (Norton, Schmidt, & Stover, 1990). In such cases, the noises are somato sounds resulting from factors such as the patient's pulse or muscle twitches. Technically such noises should be not be included in the same classification as subjective tinnitus. The idea that temporomandibular dysfunction can be a cause of tinnitus has been debated and the evidence is not overwhelming (Chan & Reade, 1994). Popular images of people with hearing impairment and of those with tinnitus are not flattering. Hearing disorders are associated with old age and as a consequence with frailty of body and mind. In word association the word ªdeafº is very likely to be followed by ªdumbº and to have the connotation of stupidity. It has been suggested that most physical disorders cut people off from ªthings,º but hearing loss cuts the sufferer off from people. There are not only communication problems to overcome but also prejudice. For example, hearing-impaired people are commonly regarded as suffering from psychological disturbances such as depression and paranoia. A ªhearing aid effectº has also been observed, that is, hearing aid users are rated less favorably than controls without a hearing aid (Danhauer, Johnson, Kasten, & Brimacombe, 1985). The popular view of the tinnitus patient is of a neurotic, complaining individual whom many physicians and surgeons would wish to avoid. Again, in the popular mind there is a link between tinnitus and psychiatric disorder including suicidal behavior. This is reflected in patients' views of tinnitus, and, although cases of tinnitus-related suicide have been reported, it is not associated with a greater increased risk than say unemployment (Lewis, Stephens, & McKenna, 1994).

9.05.2 PREVALENCE Hearing loss and tinnitus affect large numbers of people. In the UK the National Study of Hearing conducted by the MRC Institute of Hearing Research (Davis, 1989) estimated that 16.1% of the adult population (aged 18±80 years) report a hearing disorder of 25 dB HL or greater. This means that there are about 7.7

Nature million people in the UK with a hearing loss. As the severity of hearing impairment increases, the prevalence decreases. The prevalence of very profound hearing loss (95 dB HL or greater) is 0.2% of the population. The prevalence of hearing impairment at all levels of severity is very dependent on age. Below the age of 45 years even mild hearing loss is relatively rare (55% of the population), but close to 50% of people aged 70±74 years have a hearing loss of 25 dB HL or more. Some 30% of the population experience some degree of tinnitus, although usually very minor in nature. About 10% of the population report persistent spontaneous tinnitus, that is, not just after exposure to noise, and nearly 7% of the population have consulted a doctor about tinnitus (Davis, 1993). Tinnitus causes severe annoyance in 1% of the population and brings about a severely reduced ability to live a normal life in 0.5%. Davis (1993) noted that tinnitus correlates highly with the individual's hearing impairment and that the best predictor of tinnitus is the severity of hearing impairment. Axelsson and Ringdahl (1989) studied 3600 randomly selected adults in Gothenburg, Sweden and reported that 14.2% of them suffered from tinnitus ªoftenº or ªalwaysº and that 2.4% described tinnitus as ªplaguing me all day.º 9.05.3 NATURE 9.05.3.1 Detection There are differences between tinnitus and hearing impairment regarding how and when they are noticed. Hearing loss may be more noticeable in noisy surroundings, whereas tinnitus may be more intrusive in a quiet environment. Tinnitus is, however, a complex phenomenon; in some cases it is aggravated by noise, sometimes the task in hand may distract a person from the tinnitus, while at other times tinnitus may be the distracter. There is no inevitability about when it will be detected. Both tinnitus and hearing loss can come on gradually and may also be exacerbated at times of high stress such as when changes in lifestyle occur, for example, retirement. It is also possible for both symptoms to go unnoticed or at least unreported. It is well recognized that many older people never seek assistance for their hearing impairment. According to Brooks (1989), older people tolerate a greater degree of impairment before taking action than younger people, and they might also think that a hearing aid alone may be of little use. Commonly, it is a close relative that encourages the person to seek audiological help. Reasons for seeking help have been investigated. Swan

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and Gatehouse (1990) compared persons seeking help for hearing loss with those who did not. The results showed that help-seekers had more asymmetrical hearing, greater disability, and were more handicapped. There is little work specifically investigating the process of tinnitus detection and the reasons for seeking help. Attias et al. (1995) did report that help-seekers displayed more psychiatric symptoms than nonhelp-seekers. Nonetheless, the tinnitus patients who did not seek help had more psychological problems than a control group without tinnitus. Curiously, the perceived loudness of tinnitus was significantly lower in the help-seeking group. Differences between tinnitus complainers and noncomplainers have, however, been found in terms of psychological differences (Hallberg & Erlandsson, 1993; Kirsch, Blanchard, & Parnes, 1989). To our knowledge, there are no prospective studies of the onset of tinnitus, although retrospective estimates of psychological changes exist (Stouffer & Tyler, 1992).

9.05.3.2 Problems Experienced Hearing loss and tinnitus are associated with different kinds of problems. Tinnitus is more of a private, and hearing loss more of a communicative handicap. Since the comorbidity between the two is high (Lindberg, Lyttkens, Melin, & Scott, 1984), many patients are likely to experience both sets of problems. Negative consequences of hearing loss as described by patients and in the literature include communication problems, noise sensitivity, technical problems with the hearing aid or assistive device, occupational difficulties, reduced performance on cognitive tests, and poor uptake of rehabilitation services. Moreover, there is an extensive literature on the negative consequences of hearing loss (e.g., Jakes, 1988; McKenna, 1993). Emotional problems such as depression, neurotic symptoms, paranoia, social stress, insecurity, loneliness, social isolation, and cognitive deficits have all been reported. Attempts have been made to record the psychological impact of simulated hearing loss (Zimbardo, Andersen, & Kabat, 1981). While some negative emotional consequences have been described, the results are inconclusive; these studies have been restricted by the difficulty of achieving meaningful levels of hearing loss and by their temporary and artificial nature. Improvements in psychological functioning after partial restoration of hearing have been documented (Mulrow et al., 1990); more recently this has been studied after cochlear implantation (McKenna, 1991).

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In terms of emotional consequences, the empirical picture is mixed with some studies showing an association between hearing impairment and psychiatric complications (Singerman, Riedner, & Folstein, 1980), whereas others have found less or conflicting support for these findings (Eastwood, Corbin, Reed, Nobbs, & Kedward, 1985). When other health problems are controlled, the correlations between hearing loss and anxiety and depression are found to be weaker (Jones, Victor, & Vetter, 1984). Andersson, Melin, Lindberg, and Scott 1995b), in studying older people with hearing impairment, found that health factors, hearing problems, and psychological factors clustered together, again pointing to the importance of other health problems. A lack of a clear relationship between the extent of hearing loss and the extent of psychological disturbance has thus been a frequent observation. However, Thomas and Gilholme-Herbst (1980) did identify psychological disturbance in a greater number of a subsample of subjects with more severe hearing loss and poor speech discrimination. Obviously, for some patients hearing impairment is accompanied by psychological problems (McKenna, Hallam, & Hinchcliffe, 1991). There is only a small number of studies (Clark, Hirsch, Smith, Furman, & Jacob, 1994) that have examined the prevalence of emotional disturbances in the hearing-impaired population using DSM-IV (American Psychological Association, 1994) criteria and structured clinical interviews. McKenna (1993) reported that anxiety problems were common in his clinical practice. This observation is in line with a study by Eriksson-Mangold and Carlsson (1991) and with a study by Andersson and Green (1995) that showed a correlation between self-reported hearing handicap and anxiety. In other studies, the subjective experience of hearing impairment has been linked with depression (Knutson & Lansing, 1990), but the link between audiological measures and depression is less clear (Gilhome-Herbst & Humphrey, 1980). The cognitive status of elderly hearingimpaired people has been a focus for study. Ohta, Carlin, and Harmon (1981) concluded that cognitive abilities of elderly persons can be underestimated because of their reduced sensory acuity. Hearing impairment has been associated with dementia (Uhlmann, Larson, Rees, Koepsell, & Duckert, 1989), but conflicting results have been reported (Gilhome-Herbst & Humphrey, 1980). The social consequences of hearing impairment have been investigated. Meadow-Orlans (1985) cited research showing that elderly hearing-impaired people are less willing to guess, less flexible, and more cautious in social settings

than younger hearing-impaired individuals. Weinstein and Ventry (1982) reported significant correlations between subjective and objective measures of isolation and hearing loss in a group of elderly people. In a population survey, Stephens, Lewis, Charny, Farrow, and Francis (1990) found that the most common problems associated with hearing impairment was trouble hearing television, radio, and general conversation. Other studies have also documented adverse effects on social interaction and communication (Tyler, Baker, & Armstrong-Bednall, 1983). The role of the spouse in the adjustment to hearing impairment has been investigated and has been found to be important in the sense that the spouse influences acceptance of the loss (Hallberg & BarrenaÈs, 1993). There are numerous descriptions of the negative consequences of tinnitus (Hallam, Rachman, & Hinchcliffe, 1984; Tyler & Baker, 1983). Among the consequences described by patients and in the literature are sleep disturbances, concentration difficulties, muscular tension, noise sensitivity, and emotional consequences (Hallam, 1989; Hallam, Jakes, & Hinchcliffe, 1988). It is important to note that there are large individual differences in the extent to which patients experience these problems. The link between tinnitus and emotional distress has been investigated in several studies (Collet, Moussu, Disant, Ahami, & Morgon, 1990; Halford & Anderson, 1991). Most studies on the emotional consequences of tinnitus have been conducted on highly selected samples of patients with severe tinnitus distress (Briner, Risey, Guth, & Noris, 1990). Some studies have found relatively low (but significant) correlations between tinnitus distress and psychological complaints (Halford & Anderson, 1991; Hiller, Goebel, & Rief, 1994). McKenna et al. (1991), however, reported that 45% of those whose main complaint was tinnitus showed signs of significant psychological disturbance. Simpson, Nedzelski, Barber, and Thomas, (1988) found that 63% of tinnitus sufferers could be classified as psychiatrically disturbed and 46% had mood disorder as assessed by the structured interview for the DSM-III-R (SCID). Russo, Katon, Sullivan, Clark, and Buchwald (1994) used the DSM-IV to estimate the prevalence of psychiatric disorder among tinnitus patients. A number of studies have used the Beck depression inventory (BDI); (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) in the assessment of tinnitus patients. Kirsch et al. (1989) reported that the mean BDI score for a group of tinnitus patients was within the normal range. Wilson, Henry, Bowen, and Haralambous (1991) reported mean scores within the range of mild mood disturbance. In a recent review by

Nature Hinchcliffe and King (1992), depression was found to be the principal distinguishing feature between tinnitus complainers and noncomplainers. As with hearing impairment, psychoacoustic measures (e.g., matching of tinnitus loudness) have not been found to be good predictors of tinnitus discomfort (Hinchcliffe & King, 1992). Compared with the literature on chronic pain (Weiss & Kerns, 1995), little work has been done on the interpersonal aspects of tinnitus. One exception is a study by Sullivan, Katon, Russo, Dobie, and Sakai (1994) where role dysfunction in marital interaction was found to be associated with appraisal of tinnitus as salient. Punishing responses to illness behavior were associated with tinnitus-related dysfunction. 9.05.3.3 Psychological Factors and Theoretical Views Psychological factors are involved in the illness behavior of hearing-impaired people and may disrupt the communication strategies such as lip-reading used by hearing-impaired people. A link between personality and vulnerability to noise-induced hearing loss has been postulated (Jakes, 1988). Although links between Type A personality and noise-induced peripheral vasoconstriction, and between temporary threshold shift and vasoconstriction, have been demonstrated, no clear link has been established between personality and causes of hearing loss. It seems unlikely that there is a psychological cause for most hearing loss. A number of studies have examined the role of personality in coping with hearing impairment (Andersson, 1995). Stephens (1980) used the Eysenck personality inventory and found elevated levels of neuroticism and introversion. Coren and Harland (1995) found that reduced hearing acuity was associated with increased neuroticism. The personality of the tinnitus patient has also been the subject of some interest (Gerber, Nehemkis, Charter, & Jones, 1985). For example, Collet et al. (1990) used the Minnesota multiphasic personality inventory (MMPI) and found normal scores overall, with the exception of elevated depression scores in men. Dispositional optimism, as assessed by the life orientation scale (LOT); (Scheier & Carver, 1985), has been found to be positively related to coping with hearing impairment (Scott, Lindberg, Melin, & Lyttkens, 1994), and negatively related with tinnitus complaints (Andersson, 1996). Personal control was found to be an important aspect of hearing-impaired peoples' communication success in a study by Scott et al.

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(1994). It is also an important predictor of tinnitus discomfort and adaptation (Scott, Lindberg, Melin, & Lyttkens, 1990). Budd and Pugh (1995) found significant relationships between locus of control, tinnitus severity, and emotional distress in tinnitus sufferers. Kyle, Jones, and Wood (1985) described the notion that individuals usually attempt to control the access features of the information they receive by personal and social adjustment and that hearing loss disturbs the control the individual exerts. According to Kyle et al. (1985), there are at least three solutions available: (i) increase the level of control at all costs, (ii) accept or expect a reduced level of control and flow of information, and (iii) reject or avoid situations in which the level of control is threatened. A different view of hearing originates from the work of Gibson (1986) who emphasized that our perceptions are rich and elaborate because the stimuli in our environment are rich with information rather than because our thought processes or experiences provide the richness. This is an ecological model. In the field of audiology, Noble (1983) has presented an ecological model that views hearing in relation to the audible features and characteristics of the real, day-to-day world. Noble especially pointed to the active role of the perceiver. In other words, hearing is more than just perceiving sounds, it also has to do with how a person acts in an environment. Noble and HeÂtu (1994) further described an ecological approach to hearing impairment which takes special notice of the interactions between people, environments, and their interfaces. The ecological approach has been important in diverting attention away from technological and towards psychological and environmental factors involved in rehabilitation. To our knowledge no research has yet dealt with an ecological approach to tinnitus. The ideas of Skinner (1957) allow another view of hearing. One appealing aspect of Skinner's work was a focus on communication. According to this view, hearing could be viewed as an operant, that is, as a behavior classified on the basis of its effects and also being under the influence of contingencies of reinforcement. During his later years, Skinner extended his theories into the field of aging in the book Enjoy old age (Skinner & Vaughan, 1983), with some behavioral advice on how to handle hearing loss. Skinner advocates an assertive approach while still acknowledging when it is impossible to hear: ªYou do best to stop trying to hear things when you are having trouble. You are probably not enjoying what is said in a television program if you are straining to hear itº (Skinner & Vaughan, 1983, p. 44).

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A related perspective is the functional approach. Applied to hearing impairment and communication difficulties, this can be viewed as an interaction between the capabilities of the individual and the particular task demand at hand in the communication situation (Andersson & Melin, 1993). Functional analysis deals with the identification of important, causal, and ideally controllable variables that are applicable to a specified set of target behaviors for the patient in question (Haynes & O'Brien, 1990). Emphasis is placed on viewing each patient as unique and finding strengths as well as needs. In the field of tinnitus theory, recent neurophysiological approaches hold that tinnitus is better conceptualized as a problem in which central processes are involved (Jastreboff, Hazell, & Graham, 1994). This is in contrast to earlier models which emphasized the acoustic characteristics and peripheral causes of tinnitus. According to Jastreboff et al. (1994) and Jastreboff (1990), tinnitus is a phantom auditory sensation and they have developed an animal model to test the implications of their theory. Advances in neuroscience research, for example, by Flor et al. (1995), on phantom-limb pain and cortical reorganization, may improve the understanding of tinnitus from a neuropsychological point of view. Interestingly, a case study by Salah, DeQuardo, Jibson, Carli, and Tandon (1995) showed that tinnitus was alleviated by electroconvulsive therapy in a depressed patient. Although promising, research on evoked potentials in tinnitus patients (Attias, Urbach, Gold, & Sheemesh, 1993; Colding-Jorgensen, Lauritzen, Johnsen, Mikkelsen, & Saermark, 1992) has not yet given consistent results overall; a similar picture has emerged from work on auditory brainstem responses (Rosenhall & Axelsson, 1995). The ideas of Jastreboff and co-workers about tinnitus are in keeping with a psychological habituation model for tinnitus annoyance described by Hallam et al. (1984) in which they theorized that the natural reaction to tinnitus is to habituate. This original model has been challenged (Carlsson & Erlandsson, 1991), but little research has been done. Dishabituation may be another way to describe the process of developing tinnitus-related distress, or that the emotional coloring of the tinnitus sound is interpreted as a warning signal that shortcircuits the habituation process. 9.05.4 ASSESSMENT 9.05.4.1 Audiological Assessments Hearing impairment can be identified from observations by the patient or by their family

and friends, by questionnaires, and by audiometric evaluations (Brooks, 1989). After being referred by the general practitioner, the patient is screened by audiometric tests that serve as a guideline for further rehabilitation. The procedures used vary, but most include pure-tone air and bone-conduction threshold determination. All of these are based on the patient's self-report of detecting or not detecting the stimuli presented. Speech audiometry is also commonly used; this involves the presentation of speech material to the patient through earphones, again requesting their evaluation of hearing. The presentation of subjective methods may vary, and masking procedures are often needed to determine mono-aural functioning. Sometimes, more objective methods such as otoscopy, impedance audiometry, stapedius reflex thresholds, brainstem audiometry, and a number of other specialized tests are needed (Katz, 1994). Tinnitus cannot be measured without the subject's active participation. The audiological assessment of tinnitus, that is, tinnitus matching, usually consists of obtaining an estimate of loudness, pitch, maskability, and sometimes residual inhibition (short period of absence of tinnitus after exposure to a loud tone) (Tyler & Stouffer, 1989). Tinnitus matchings have a weak correlation with measures of annoyance and also a doubtful prognostic value. The reliability and validity studies of tinnitus matchings show large intra individual variations (Penner & Bilger, 1992). Recent thoughts hold that tinnitus maskability could be used as an outcome measure, and that reduced levels of masking required to mask the tinnitus could be regarded as a sign of treatment success (Jastreboff et al., 1994). 9.05.4.2 Self-report Measures Self-assessment scales for the hearing impaired have been used in audiological research and practice (Schow & Gatehouse, 1990). Audiological measures are insufficient as descriptors of the problems experienced. Selfassessments help clarify issues concerning the experience of hearing loss, hearing handicap, rehabilitation effectiveness, and communication strategies used by the hearing-impaired patient. This is reflected in the number of scales available (Andersson, Melin, Lindberg, & Scott, 1995a; Schow & Gatehouse, 1990). Although Pearson correlations between actual hearing impairment and experienced disability/handicap approaching r=0.60 have been found (Brainerd & Frankel, 1985; Lutman, Brown, & Coles, 1987), self-reported hearing problems and audiometric tests generally show relatively low correspondence. Daily assessments of

Treatment hearing aid use and hearing problems are relatively rare, but have been applied (Andersson, Palmkvist, Melin, & Arlinger, 1996). Similarly, a number of self-report scales for the assessment of tinnitus-related distress have been developed (Hallam et al., 1988; Kuk, Tyler, Russell & Jordan, 1990; Wilson et al., 1991). Most of these scales have adequate psychometric properties. Further, daily measures of tinnitus distress and loudness on visual analogue scales have been applied (Andersson & HaÈgnebo, 1996), even though the use of repeated measures is relatively rare. Self-report measures such as like the BDI (Beck et al., 1961), the Beck anxiety inventory (Beck, Epstein, Brown, & Steer, 1988), and other measures of psychological problems, personality, and coping, may well be used in audiological populations, given some consideration of the group being assessed. Self-report is becoming an important tool in audiological research and rehabilitation. It has a potential value for research on rehabilitation effectiveness and in the treatment itself. Daily measures have not been widely used. 9.05.4.3 Psychological Assessments Little has been written on the psychological assessment of hearing-impaired adults. Functional and behavioral analysis have been applied as mentioned earlier. Cognitive behavioral assessment methods are well suited, as long as the communication is secured and the client can understand what is being said (Kirk, 1989). As the therapist/clinical psychologist may serve as a model later on, it is important that they are familiar with communicating with hearing-impaired people. For the assessment of tinnitus patients, a structured interview has been developed in Uppsala, Sweden. In this interview, cognitivebehavioral assessment methods are used. All patients referred to the psychologist for tinnitus treatment are assessed in this interview. The interview consists of questions about the following: tinnitus characteristics (including a metaphor for tinnitus): attention given to tinnitus (what time during the day, in which situations, and so on); variations in annoyance and loudness; coping ability, avoidance, ability to influence the tinnitus; psychological consequences and prior psychiatric history (e.g., depression, anxiety, irritation, concentration difficulties); sleep problems; influence of environmental sounds (masking), influence of tiredness and stress; influence of medication (if there is any), caffeine, alcohol, and tobacco. A positive response to any of the questions leads to further questioning.

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A grading of tinnitus severity is also made. The availability of social support for the patient is investigated. Information is also gathered about changes in tinnitus since it first appeared, habituation, and the patient's beliefs about the cause of tinnitus. The use of other treatments for tinnitus and any other conditions are enquired about. The patient is asked about hearing problems, hearing rehabilitation, the effect of the hearing aid on tinnitus, noise sensitivity, headaches, dizziness, muscle tension, and jaw problems. Finally, a cognitive-behavioral model of how tinnitus becomes annoying is described. The patient's acceptance of a psychological model can influence the outcome of therapy for somatic complaints (Salkovskis, 1989) and it is therefore important to determine the tinnitus patient's beliefs in this respect. 9.05.5 TREATMENT When possible, medical intervention seeks to treat the underlying cause of hearing loss. Surgical techniques are available for conditions that give rise to conductive hearing loss. Surgery is also possible for some causes of sensoryneural hearing loss such as acoustic neuroma. Cochlear implantation offers some restoration of hearing for some profoundly deafened people. It is important to note that for the majority of hearing losses (e.g., presbyacusis), no curative medical or surgical treatment exists. Many medical treatments for tinnitus have been investigated, including pharmacological (Murai, Tyler, Harker, & Stouffer, 1992), electrical stimulation with cochlear implants (Hazell, 1991), transcutaneous nerve stimulation (Kaada, Hognestad, & Havstad, 1989), ultrasound (Carrick, Davies, Fielder, & Bihari, 1986), dental procedures (stomatognatic); (Erlandsson, Rubenstein, & Carlsson, 1991), and surgery (Hazell, 1990). A range of alternative therapies have also been attempted such as Ginkgo biloba (Holgers, Axelsson, & Pringle, 1994) and acupuncture (Andersson & Lyttkens, 1996). In other words, practically everything has been tried in the treatment of tinnitus. To sum up a large body of literature, the results of these attempts to alleviate tinnitus have been modest or unsuccessful. The exception may be treatment with antidepressants (Sullivan, Katon, Russo, Dobie, & Sakai, 1993), but in our experience it is not likely that this will become the treatment of choice for all tinnitus patients. 9.05.5.1 Hearing Aids and Other Prosthetic Devices Since there exists no curative treatment for most cases of hearing loss (especially among the

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elderly), the hearing aid is the treatment of first choice for many individuals seeking audiological assistance. There are few controlled studies showing the benefits of hearing-aid fitting. One exception was a study by Mulrow et al. (1990) who randomly assigned elderly subjects to hearing-aid fitting or to a waiting-list control. Results showed significant improvements for social and emotional function, communication function, cognitive function, and depression. The authors concluded that hearing impairment is associated with adverse effects and that these are reversible with hearing aids. The amount of use of hearing aids has been the subject of several studies (for a review see Andersson, 1995). The amount of use varies between those studies, but it is well recognized that many hearing aids remain in the file-drawer (Brooks, 1989). In the hearing-aid field, the theoretical framework is basically a technical approach. It could be argued that this focuses primarily on the provision of hearing aids and devotes little attention to the psychological aspects of adjustment to the hearing aid. Consequently, it is mostly the technical causes that are used to explain the limited hearing aid benefit often observed. There are many possible reasons why people may obtain limited benefit from hearing aids. A proper assessment of the issue must go beyond the technical considerations and include attitudes towards the hearing aid and other social and psychological factors (Andersson, 1995; Brooks, 1989; Tyler et al., 1983). Hearing aids have been proposed as a treatment of tinnitus (Surr, Montgomery, & Mueller, 1985). The notion is that environmental sounds amplified by the hearing aid mask tinnitus. Although a controlled study by Melin, Scott, Lindberg, and Lyttkens (1987) failed to find any evidence of this, some patients report benefit from using a hearing aid. Much hope and research effort has been invested in the fitting of tinnitus maskers and combined hearing aid/tinnitus maskers (Hazell et al., 1985). The purpose of tinnitus maskers is to obscure the tinnitus with a sound that is supposed to be more tolerable. Although early experience with maskers was positive, controlled studies and later experiences have been less encouraging (Erlandsson, Ringdahl, Hutchins, & Carlsson, 1987). Jastreboff et al. (1994) have suggested that masking should not involve totally obscuring the tinnitus. Instead, the tinnitus should be audible and be a part of the background sound. This is accomplished by a so-called white-noise generator. A cochlear implant can be of assistance to people with profound hearing impairment. Parts of this device are surgically implanted into the

ear. The cochlear implant receives sound, converts this into an electrical signal that is then carried past the damaged parts of the ear and used to stimulate the preserved parts of the cochlea or the auditory nerve directly (Clark, Tong, & Patrick, 1990). Cochlear implants therefore straddle the surgical and prosthetic approaches. They have been at the leading edge of bionic technology since the early 1980s. It has received some interest from a psychological point of view (McKenna, 1993). McKenna and Denman (1993) found that implant users reported larger perceived improvements in psychological well-being than might be expected from relatively modest acoustical benefits. Knutson et al. (1991) reported psychological improvements that were uncorrelated with acoustical abilities. The use of cochlear implants for the treatment of tinnitus is restricted to profoundly hearing-impaired people where tinnitus is a main primary complaint (Hazell, 1991). Hearing aids can be very helpful in the rehabilitation of hearing handicap. There are, however, a number of problems relating to hearing-aid use yet to be resolved. Among the most important ones are motivating people to seek help and then to use the aid in appropriate settings. Tinnitus maskers have not been as helpful as expected, but the more recent approach of noise generators may be more effective.

9.05.5.2 Counseling and Self-help Approaches The importance of counseling in the management of hearing loss, especially when fitting hearing aids, was pointed out by Brooks (1989). There is some empirical support for counseling programs for improving hearing-aid benefit (Brooks, 1989), but others have found less evidence of benefit (Parving & Sibelle, 1995). It is difficult to differentiate counseling from general clinical management. The time spent on each individual patient may be one distinction; counseling programs usually devote more time to each patient. A program described by Brooks (1989) includes home visits. The need for counseling tinnitus patients has also been pointed out (Stouffer et al., 1991), but with more emphasis on formal psychological treatment. Auditory training is a technique that involves taking advantage of acoustic cues still available for the hearing-impaired person. Some support for auditory training exists (Tye-Murray, 1991), but there are conflicting results (Tye-Murray, 1992). Hearing tactics were defined by van der Lieth (1973) as ªthose methods used by someone suffering from a hearing impairment to solve the problems of his daily lifeÐthe

Treatment practical, technical, and psychological problems caused by the handicapº (p. 209). Hearing tactics often deal with different ways of facilitating communication, such as optimizing signals and using conversational strategies. The use of hearing tactics involves a broader set of techniques than auditory training. In clinical practice, these techniques are usually taught by audiological scientists or hearing therapists; however, it is useful for clinical psychologists to be aware of these ideas. Few empirical investigations of the benefits of hearing tactics exist (Andersson, 1995). Self-help approaches have been suggested and applied for both hearing loss and tinnitus (Hallam, 1989; Shimon, 1992; Slater, 1987), but only a few empirical investigations exist (Axelsson, Nilsson, & Coles, 1995; Loumidis, Hallam, & Cadge, 1991). These approaches usually amounts to patient education, which can sometimes be sufficient, although giving the patient adequate information should be normal practice.

9.05.5.3 Psychological Treatments for Hearing Loss and Tinnitus A functional approach involving goal-setting activities in audiological rehabilitation has been proposed by McKenna (1987) and its use described in the care of an individual patient. A cognitive-behavioral adaptation of hearing tactics has been developed. The group treatment package includes applied relaxation, video self-modeling, exposure, information, and teaching of hearing tactics. Treatment is based on a cognitive-behavioral analysis of each patient. Increasing hearing ability in the acoustic sense has not been a goal, except for the benefits of behavioral adjustments when listening. Instead, the aim is to develop coping strategies for handling the consequences of hearing impairment. Lindberg, Scott, Andersson, and Melin (1993) did a controlled study with elderly patients randomly allocated to treatment or to a control condition. The treatment group received a general information session before the actual treatment. Cognitive±behavioral treatment began according to the individualized functional analyses in which the subjectsº strengths, needs, and treatment goals were established. This was followed by three sessions in which hearing tactics and coping strategies were taught and practised. The choice of these was based on the result of the functional analysis. Treatment was given in three onehour sessions over three consecutive weeks, in either an individual, a group, or a combined

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format. The overall aim was to supply the subjects with a sense of control and an ability to control their hearing problems. The role of their spouses/relatives and cognitive aspects was highlighted during treatment. The results of self-report questionnaires showed some effects suggesting that treatment had improved subjects' ability to cope with their hearing loss. In a 15-month follow-up study, the effects were sustained and even more in favor of the treatment group (Andersson, Melin, Scott, & Lindberg, 1994). In another controlled study, the effects of a comprehensive group behavioral treatment program were evaluated (Andersson, Melin, Scott, & Lindberg, 1995b). This consisted of four two-hour sessions after an individual behavioral analysis. The first treatment session provided general information about the importance of behavior in coping with hearing impairment, and individualized treatment goals were determined for each subject. The session also included a short version of applied relaxation (OÈst, 1987). Relaxation skills were associated with difficult hearing situations that became the targets for homework assignments. In the second session, relaxation skills were further rehearsed and linked to actual behavior in difficult situations. A large part of the session was devoted to video self-modeling (Meharg & Woltersdorf, 1990). A difficult situation was created with the help of an accompanying background noise played on a tape-recorder. Subjects were instructed on how to handle conversation by means of hearing tactics. During this training the therapist prompted the subject until good performance was achieved. Then, the situation was video-recorded and later the group watched the video and saw themselves communicate successfully. During this training the use of hearing tactics was reinforced and the ability to concentrate on one person at a time without being tense and disturbed by the background noise was supported. The third session began with rehearsal of the relaxation skills and a refinement of these. The main theme of the third session was on how to cope with loud noises. In a relaxed state, subjects were gradually exposed to tones (440 Hz, 1 kHz, and white noise) and a tape of people talking that slowly increased in loudness. Subjects were never exposed to loud or potentially dangerous volumes, but rather the natural volume of sounds in daily life. The purpose of the exercise was to teach the subjects to be relaxed in a noisy environment. Coping skills including the use of hearing aid(s) were practiced. A leaflet with advice on communication with hearingimpaired people was provided, and discussion of this with relatives was set as a homework

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assignment. Earlier treatment ingredients were rehearsed in the final session. Attention was given to cognitive skills and motivation to engage in activities while having impaired hearing. Outcome measures included a structured video interview measuring coping behavior, daily ratings of hearing problems on visual analogue scales, a questionnaire, and a followup telephone interview. The structured interview included tasks with minor provocations, making communicating more difficult with the aim of eliciting coping behavior. Subjects were informed that the purpose of filming was to investigate communication during the interview. Significant beneficial effects in favor of the treatment package were found in terms of behavioral changes and self-reported problems. A two-year follow-up showed positive effects of the treatment in terms of self-assessed hearing problems (Andersson, Melin, Scott, & Lindberg, 1995a). Unfortunately, these studies have not been replicated but, given the large number of older people with hearing loss, clinical psychology methods could be an asset to audiology. Far more empirical work has been done on the psychological treatment of tinnitus (Andersson, Melin, HaÈgnebo, Scott, & Lindberg, 1995g). The psychological treatment studies can be divided into hypnosis, biofeedback, relaxation, and cognitive-behavioral therapy (CBT) with or without applied relaxation. A cognitivebehavioral approach to tinnitus was formulated by Hallam et al. (1984) and by Scott, Lindberg, Melin, & Lyttkens (1985), but behavioral applications had been described earlier (Malesta, Sutker, & Adams, 1980). Andersson, Melin, HaÈgnebo et al. (1995) drew the conclusion that CBT in combination with applied relaxation was the treatment approach that had received the most empirical support. In one of the earlier controlled studies, Scott et al. (1985) investigated the effects of combining relaxation and distraction techniques with a waiting-list control condition. Treatment consisted of one-hour sessions during a three-week period and included training in self-control by distraction exercises. Visual analogue measures of loudness and annoyance were used as dependent measures. Significant decreases in ratings of annoyance but not loudness were observed. Lindberg, Scott, Melin, and Lyttkens (1987) carried out a nine-month follow-up and reported positive results. More recent studies corroborate these findings (Henry & Wilson, 1996; KroÈnerHerwig et al., 1995; Lindberg, Scott, Melin, & Lyttkens, 1989). The use of relaxation training only (Ireland, Wilson, Tonkin, & Platt-Hepworth, 1985) or of strictly cognitive methods (Jakes, Hallam, McKenna, & Hinchcliffe, 1992) seem to lead to poorer results.

9.05.6 FUTURE DIRECTIONS FOR RESEARCH AND PRACTICE The application of clinical psychology within the field of hearing disorders is comparatively new and the possibilities for further developments in research and practice are considerable. We will touch on only some of the more obvious ones here. Although there is evidence for the effectiveness of psychological treatment in the management of patients with hearing disorders, there is a need for this body of knowledge to be expanded. The development of effective management techniques, particularly for tinnitus, remains a priority. The relatively modest benefits reported in tinnitus treatment outcome studies are at odds with much clinical experience which suggests that psychological therapy leads to considerable reductions in distress. This disparity may be due to factors such as subject selection techniques used in formal outcome studies or to the use of inappropriate measures. These issues merit investigation. The study of central factors in tinnitus perception is still in its infancy. Complaints of concentration problems and other minor neuropsychological difficulties are common among tinnitus patients. These complaints have traditionally been regarded as part of the emotional distress associated with tinnitus. Whether this is so or whether these cognitive difficulties represent a separate aspect of tinnitus complaint is open to question. To our knowledge there has been only one study (McKenna, Shurlock, & Hallam, 1996) of the cognitive effects of tinnitus. Neurophysiological studies (Attias et al., 1993) have pointed (although inconsistently) to the involvement of brain areas in tinnitus perception that can also be implicated in neuropsychological functioning. Investigations of cognitive functioning in tinnitus patients will offer a complementary line of study of this issue and may assist in the development of models of tinnitus perception. There is some controversy about whether the natural history of tinnitus is characterized by habituation or by some other process. Clarification of this central issue would guide future management strategies. Surprisingly little longitudinal data are available on tinnitus and such data could make a valuable contribution to tinnitus research and management. Much of the research carried out on emotional factors in hearing disorders has been psychiatric in nature. Historically, there has been an interest in classifying patients in psychiatric terms. Although there are areas that require further clarification, such as the extent to which hearing-impaired people suffer

Summary from anxiety disorders, there is a need now for further work on the psychological processes that underlie the changes which accompany hearing disorders. The cognitive±behavioral approach to hearing tactics is a field in which little controlled treatment research has been done. The approach could benefit a very large group of people should the principles be applied in everyday audiological management. Little is known about what tactics are the most effective ones, and here some experimental work is needed (Andersson, Melin, Lindberg, & Scott, 1996). Assessment of social skills in hearingimpaired people would be an important research task and one that is especially relevant for planning of intervention strategies. Also, the benefits of hearing tactics training before the provision of hearing aids should be investigated. So far, this has not been done. The development of self-help treatments is another important research goal. In a controlled study, Andersson, Green, and Melin (1997) found positive effects of a self-help manual supported by telephone contacts in teaching hearing tactics. Cochlear implants are now issued on a routine service basis; however, there is still considerable scope for psychological research in this field. In particular, there is a need to develop predictors of outcome. There are large individual differences in the success of implant use that can be only poorly predicted. Intuitively it might be supposed that differences in information processing abilities might be involved in determining the success of implant use, but this is an area that is largely unexplored. Clinically it is also apparent that a small number of implant users, who are successful in terms of the acoustic benefit derived, experience adverse psychological consequences. Although this matter has received no formal research attention, it appears that this is a result of the restoration of hearing leading to unfavorable changes in the dynamics of everyday life. Few clinical psychologists work within audiology clinics. This chapter has focused on the problems of hearing loss and tinnitus; other audiological disorders, such as balance disorders (Yardley, 1994) and hypersensitivity to noise (Vernon, 1987), also have major psychological elements to them. The need for more clinical psychologists to be involved in this field is clear. The task here is twofold: to educate other health-care professionals and patients of the benefits of clinical psychology, and also to persuade clinical psychologists that this is an area that merits their attention. It may be that lessons can be learnt from the field of chronic pain where clinical psychologists are more firmly established. The development of multi-

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disciplinary teams, including psychologists, for the management of hearing disorders are likely to be of benefit as they have been in the field of pain management. Wilson, Henry, and Nicholas (1993) are beginning to elaborate on the parallels between pain and tinnitus. It might be argued that because of the sacristy of resources, psychologists should not work with people who are only moderately distressed by their medical condition (although this cannot be said about hearing loss in general, many do adjust to their problems without the need for counseling). Preventive work, however, can be very costeffective and could prevent the development of psychological problems in association with hearing disorders. To our knowledge nothing has yet been written about prevention in this field, in contrast to the field of chronic pain (Linton, 1987).

9.05.7 SUMMARY Hearing impairment and tinnitus are among the most prevalent of symptoms that affect people and particularly elderly people. There are many prejudices associated with these symptoms. In reality, the experience of these symptoms can be very different from the widely held beliefs about them. An understanding of hearing disabilities may assist a clinical psychologist to help large numbers of people with these potentially very distressing symptoms. From the evidence available it seems that hearing impairment does not directly cause severe psychological disturbances, although an elevated risk for depression might exist, mainly by its association with isolation (GilhomeHerbst, 1983). Instead, it is likely that a vulnerability for psychological disturbance or premorbid/comorbid psychological or physical problems interact with hearing impairment to produce adverse consequences, that is, a stress± diathesis conception. There is more widespread agreement on the link between tinnitus and emotional disturbance, but no study has established a causal link between tinnitus and psychological complaints. In fact, Stouffer and Tyler (1992) have suggested that psychological complaints may precede tinnitus complaints. Again, a stress±diathesis conception is appealing; certainly, tinnitus may be an important cause of, for example, depression. Psychological concepts have been used in the study of hearing impairment and tinnitus and individual differences are evident. The concepts of coping and personal control have been applied to describe the process of adjusting to hearing loss and tinnitus. Ecological, cognitive± behavioral, and functional approaches have

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been presented as alternatives to the predominating medical and technical models in audiological rehabilitation. In the field of tinnitus, a habituation model describing the natural history of tinnitus has been predominant since the late 1980s. A neurophysiological model that has some parallels to the habituation model has begun to receive empirical support. Assessment of patients with hearing disorders must include audiological tests and medical screening. Self-assessment is an important but not a sufficient tool. Discussing the results of the self-assessment helps clarify issues surrounding the severity and situation characteristics of the problems. Cognitive-behavioral assessment methods are usually applicable with hearingimpaired patients, but the communication situation requires certain precautions. Summarizing and clarifying the content of the interview and asking the patient for their questions and views is all the more important when working with hearing-impaired people. Psychological treatment methods have been successfully applied in controlled studies. Studies of cognitive-behavioral hearing tactics suggest that clinical psychology can be applied in the rehabilitation of elderly hearing-impaired people. More studies are needed in this field and the techniques need to be applied with other patient groups (for example, adults with noiseinduced hearing loss). Controlled studies suggest that the psychological management of tinnitus patients leads to positive benefits. Few psychologists are involved in tinnitus treatment. In a survey of tinnitus management in Britain, Coles (1992) claimed that there were few clinical psychologists working with tinnitus patients and that few patients were referred to psychiatrists or psychologists. The field is much in need of more psychologists to help in the development of research and in the provision of clinical services. ACKNOWLEDGMENTS This work was supported by grants to Dr. Gerhard Andersson from the Swedish Council for Research in the Humanities and Social Sciences and The Sasakawa Young Leaders' Fellowship Fund. 9.05.8 REFERENCES American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Andersson, G. (1995). Hearing as behaviour: Psychological aspects of acquired hearing impairment in the elderly (Doctoral dissertation). Comprehensive Summaries of Uppsala Dissertations from the faculty of Social Sciences 53. Uppsala, Sweden: Acta Universitas Upsaliensis.

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References loss and child abuse: Beyond the sound booth. British Journal of Audiology, 29, 195±197. Rosenhall, U., & Axelsson, A. (1995). Auditory brainstem response latencies in patients with tinnitus. Scandinavian Audiology, 24, 97±100. Russo, J. E., Katon, W. J., Sullivan, M. D., Clark, M. R., & Buchwald, D. (1994). Severity of somatization and its relationship to psychiatric disorders and personality. Psychosomatics, 35, 546±556. Salah, R. S., DeQuardo, J. R., Jibson, M. D., Carli, T., & Tandon, R. (1995). Tinnitus and ECT. Convulsive Therapy, 11, 122±125. Salkovskis, P. M. (1989). Somatic problems. In K. Hawton, P. M. Salkovskis, J. Kirk, & D. M. Clark (Eds.), Cognitive behaviour therapy for psychiatric problems (pp. 235±276). Oxford, UK: Oxford University Press. Scheier, M. F., & Carver, C. S. (1985). Optimism, coping, and health: Assessment and implications of generalized outcome expectancies. Health Psychology, 4, 219±247. Schow, R. L., & Gatehouse, S. (1990). Fundamental issues in self-assessment of hearing. Ear and Hearing, 11, 6±16. Scott, B., Lindberg, P., Melin, L., & Lyttkens, L. (1985). Psychological treatment of tinnitus. An experimental group study. Scandinavian Audiology, 14, 223±230. Scott, B., Lindberg, P., Melin, L., & Lyttkens, L. (1990). Predictors of tinnitus discomfort, adaption and subjective loudness. British Journal of Audiology, 24, 51±62. Scott, B., Lindberg, P., Melin, L., & Lyttkens, L. (1994). Control and dispositional style among the hearingimpaired in communication situations. Audiology, 33, 177±184. Shimon, D. A. (1992). Coping with hearing loss and hearing aids. San Diego, CA: Singular Publishing Group. Simpson, R. B., Nedzelski, J. M., Barber, H. O., & Thomas, M. R. (1988). Psychiatric diagnoses in patients with psychogenic dizziness or severe tinnitus. Journal of Otolaryngology, 17, 325±330. Singerman, B., Riedner, E., & Folstein, M. (1980). Emotional disturbance in hearing clinic patients. British Journal of Psychiatry, 137, 58±62. Skinner, B. F. (1957). Verbal behavior. New York: Appleton-Century-Crofts. Skinner, B. F., & Vaughan, M. E. (1983). Enjoy old age. A program for self-management. London: Hutchinson. Slater, R. (1987). On helping people with tinnitus to help themselves. British Journal of Audiology, 21, 87±90. Stephens, S. D. G. (1980). Evaluating the problems of the hearing impaired. Audiology, 19, 205±220. Stephens, S. D. G., Lewis, P. A., Charny, M. C., Farrow, S. C., & Francis, M. (1990). Characteristics of self-reported hearing problems in a community survey. Audiology, 29, 93±100. Stouffer, J. L., & Tyler, R. S. (1992). Ratings of psychological changes pre- and post-tinnitus onset. In J. M. Aran & R. Dauman (Eds.), Tinnitus 91; Proceedings of the fourth international tinnitus seminar. (pp. 449±452). Amsterdam: Kugler Publications. Stouffer, J. L., Tyler, R. S., Kileny, P. R., & Dalzell, L. E. (1991). Tinnitus as a function of duration and etiology: Counselling implications. American Journal of Otolaryngology, 12, 188±194.

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Sullivan, M. D., Katon, W. J., Russo, J. E., Dobie, R. A., & Sakai, C. (1993). A randomized trial of nortriptyline for severe chronic tinnitus. Archives of Internal Medicine, 153, 2251±2259. Sullivan, M., Katon, W., Russo, J., Dobie, R., & Sakai, C. (1994). Coping and marital support as correlates of tinnitus disability. General Hospital Psychiatry, 16, 259±266. Surr, R. K., Montgomery, A. A., & Mueller, H. G. (1985). Effect of amplification of tinnitus among new hearing aid users. Ear and Hearine, 6, 71±75. Swan, I. R. C., & Gatehouse, S. (1990). Factors influencing consultation for management of hearing disability. British Journal of Audiology, 24, 155±160. Thomas, A., & Gilhome-Herbst, K. (1980). Social and psychological implications of acquired deafness for adults of employment age. British Journal of Audiology, 14, 76±85. Tye-Murray, N. (1991). Repair strategy usage by hearingimpaired adults and changes following communication therapy. Journal of Speech and Hearing Research, 34, 921±928. Tye-Murray, N. (1992). Preparing for communication interactions: The value of anticipatory strategies for adults with hearing impairment. Journal of Speech and Hearing Research, 35, 430±435. Tyler, R. S., & Baker, L. J. (1983). Difficulties experienced by tinnitus sufferers. Journal of Speech and Hearing Disorders, 48, 150±154. Tyler, R. S., Baker, L. J., & Armstrong-Bednall, G. (1983). Difficulties experienced by hearing-aid candidates and hearing-aid users. British Journal of Audiology, 17, 191±201. Tyler, R. S., & Stouffer, J. L. (1989). A review of tinnitus loudness. Hearing Journal, 42, 52±57. Uhlmann, R. F., Larson, E. B., Rees, T. S., Koepsell, T. D., & Duckert, L. G. (1989). Relationship of hearing impairment to dementia and cogntive dysfunction in older adults. Journal of the American Medical Association, 261, 1916±1919. Vernon, J. A. (1987). Pathophysiology of tinnitus: A special caseÐHyperacusis and a proposed treatment. American Journal of Otology, 8, 201±202. Weinstein, B. E., & Ventry, I. M. (1982). Hearing impairment and social isolation in the elderly. Journal of Speech and Hearing Research, 25, 593±599. Weiss, L. H., & Kerns, R. D. (1995). Patterns of painrelevant social interactions. International Journal of Behavioral Medicine, 2, 157±171. Wilson, P. H., Henry, J., Bowen, M., & Haralambous, G. (1991). Tinnitus reaction questionnaire: Psychometric properties of a measure of distress associated with tinnitus. Journal of Speech and Hearing Research, 34, 197±201. Wilson, P. H., Henry, J. L., & Nicholas, M. K. (1993). Cognitive methods in the management of chronic pain and tinnitus. Australian Psychologist, 28, 172±180. Yardley, L. (1994). Vertigo and dizziness. London: Routledge. Zimbardo, P. G., Andersen, S. M., & Kabat, L. G. (1981). Induced hearing deficit generates experimental paranoia. Science, 212, 1529.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

9.06 Jail and Prison Inmates RONALD ROESCH, JAMES R. P. OGLOFF, PATRICIA A. ZAPF, and STEPHEN D. HART Simon Fraser University, Burnaby, BC, Canada and RANDY OTTO University of South Florida, Tampa, FL, USA 9.06.1 INTRODUCTION

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9.06.2 THE PREVALENCE OF MENTAL ILLNESS AND SUBSTANCE ABUSE AMONG INMATES IN JAILS AND PRISONS

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9.06.2.1 Substance Abuse 9.06.2.2 Prevalence and Assessment of Women in Jails and Prisons

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9.06.3 THE DIVERSION OF MENTALLY ILL OFFENDERS

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9.06.4 PRETRIAL ASSESSMENT

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9.06.4.1 Competency to Stand Trial 9.06.4.1.1 Community-based screening 9.06.4.1.2 Competency to be executed 9.06.4.2 Criminal Responsibility 9.06.4.3 Mental Disorder and Violence 9.06.5 THE TREATMENT OF MENTALLY ILL OFFENDERS IN JAILS AND PRISONS 9.06.5.1 The Surrey Pretrial Mental Health Project 9.06.5.2 Unique Concerns for the Treatment of Female Offenders

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9.06.6 CONCLUSION

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9.06.7 REFERENCES

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(1976) reported that Benjamin Franklin was instrumental in establishing the first mental hospital in the American colonies because of his belief that people with mental illness should be confined given their proclivity toward dangerousness. In many ways, then, the current attention that is being paid to mentally ill offenders is long overdue. This chapter provides an overview of many of the issues regarding mentally ill inmates in jails and prisons, focusing on the role of psychologists in assessing and treating mental disorder

9.06.1 INTRODUCTION Although greater attention has been paid to the issue of mentally ill offenders in the criminal justice system since the early 1980s (e.g., Monahan & Steadman, 1983; Steadman & Monahan, 1984; Teplin, 1983, 1984), this certainly is not a new issue. Historically, people with mental illness and mental retardation were often incarcerated with offenders and ªtreatedº by cruel methods similar to those used to punish offenders (Ives, 1914). Monahan and Geis 85

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within the criminal justice system. It begins with a review of the prevalence of mental disorder and substance abuse in jail and prison inmate populations. While males comprise the majority in these facilities, these issues for female offenders are also considered. The literature on diversion of mentally ill offenders out of the criminal justice system is then reviewed. Pretrial assessment of several major mental health/law issues, including competency to stand trial, criminal responsibility, and risk, are reviewed. Finally, the issue of treatment of mentally disordered offenders in jails and prisons is considered, and a current project in a pretrial jail facility is described in some detail.

9.06.2 THE PREVALENCE OF MENTAL ILLNESS AND SUBSTANCE ABUSE AMONG INMATES IN JAILS AND PRISONS Perhaps at the very heart of the issue of people with mental illness in the criminal justice system is the question of how many inmates in jails and prisons are mentally ill. Not surprisingly, there is no simple answer to this question. The number of inmates with mental illness varies considerably across institutions and studies depending on such factors as whether the institution is a jail or prison; whether the institution draws inmates from urban, suburban, or rural areas; the definition of ªmental illnessº that is employed; and how the assessment of mental illness is made. The terms jail and prison are often used interchangeably; however, jails and prisons are very different types of facilities. Prisons typically house inmates who have been convicted and sentenced to serve one or more years in a correctional facility. By contrast, jail inmates generally are detained for relatively short periods of time (often just one or two days) prior to arraignment or trial, or for short sentences (less than a year) if found guilty of a misdemeanor and sentenced to jail (Ogloff, Tien, Roesch, & Eaves, 1991). Due to the very different mandates of jails and prisons, the number of inmates with mental illnesses that they house likely varies considerably. Indeed, as the jail is the point of entry in the criminal justice system, and serves as a short-term holding facility, one might expect the prevalence of mental illness among offenders to be higher than it is in prisons. Presumably, the criminal justice system servesÐat least to some extentÐas a filtering system to identify those offenders with serious mental illness and to divert them to the mental health system (i.e., those who are mentally ill and commit minor offenses, those

who are incompetent to stand trial, or are not guilty by reason of insanity). Several studies show that a small but significant number of inmates in prisons are mentally ill (see Daniel, Robins, Reid, & Wilfey, 1988; Dvoskin, & Steadman, 1989; Hodgins & Cote, 1990; Roth, 1980; Steadman, Fabisiak, Dvoskin, & Holohean, 1987; Teplin, 1983, 1984, 1990). Steadman, Dvoskin and their colleagues (Dvoskin & Steadman, 1989; Steadman et al., 1987) conducted a survey of 9.4% of the then 36 144 inmates in the New York state prison system to determine the extent of psychiatric disabilities among inmates. The results showed that 5% of inmates were ªseverely psychiatrically disabled,º demonstrating psychopathology similar to that found in state psychiatric center acute inpatients. Another 10% were ªsignificantly psychiatrically disabled,º similar to patients in crisis beds in the community. Similar results have been obtained in other jurisdictions with other assessment procedures. In one study, interviewers administered a structured diagnostic interview to 1240 inmates of the Michigan state prison system (Neighbors, 1987). The interview yielded diagnoses of mental disorder based on the American Psychiatric Association's Diagnostic and statistical manual of mental disorder (DSM-III) criteria (American Psychiatric Association, 1987). The prevalence of severe mental disorders (i.e., any active psychotic disorder in the sample was 10.4%, and a further 38.4% had a less serious mood or anxiety disorder. Mental health professionals conducted follow-up interviews with 379 inmates and confirmed the high prevalence of severe mental disorder. They also rated 19.7% of the inmates as having ªseverely impairedº social functioning and judged that 4.4% were in need of immediate psychiatric hospitalization. As with prisons, a number of studies examining the prevalence of mental disorder in jail populations have been conducted. Rates of mental illness reported for jail inmates vary considerably among studies. Prevalence rates of major mental illness among random samples of inmates vary between 3% (Schuckit, Herrman, & Schuckit, 1977) and 59% (Petrich, 1976), depending upon the criteria and diagnostic system used. Not surprisingly, higher prevalence rates have been obtained when samples have consisted only of those inmates referred by jail staff for mental health evaluations. In these cases, prevalence rates ranging from 24% (Nielsen, 1979) to more than 75% (Lamb & Grant, 1983) have been reported. Similar findings were reported by Allodi, Kedward, and Robertson (1977) in a Canadian study.

The Prevalence of Mental Illness and Substance Abuse Among Inmates In one study that examined mental disorder among detainees in a large jail in Chicago, layinterviewers assessed the detainees using a structured diagnostic interview (Teplin & Swartz, 1989). The prevalence of severe mental disorder (i.e., schizophrenia, bipolar affective disorder, major depression) was 8.5%. This rate was significantly higher than that of community residents with similar demographic characteristics (Teplin, 1991). Corrections staff failed to detect many cases of severe mental disorder during routine intake procedures. Research in a pretrial facility in British Columbia, Canada, demonstrated that a substantial number of jail detainees have mental health problems. Although Canada's per capita prison population is considerably lower than in the USA, many similarities exist. Data was collected from a random sample of Englishspeaking admissions to the Vancouver Pretrial Services Centre, a large pretrial facility in the province of British Columbia, for a one-year period (Roesch, 1995). The total sample of 861 represented approximately 50% of all Englishspeaking males admitted to the jail during the study period. The estimate of the rate of major mental disorder (primarily schizophrenic and major affective disorders) in the total pretrial population was 15.6%. In addition, the prevalence of substance use disorders was exceptionally high, with over 77% considered to have alcohol use or dependence disorders, and over 63% with drug use disorders. Many of these individuals had co-occurring disorders (e.g., schizophrenia and substance abuse), further compounding the mental health and social problems these individuals experience. When considering the research on the prevalence of mental illness in jails and prisons, it is important to keep in mind that the extant research on prevalence and assessment cannot be easily compared across studies as no consistent methodology has been utilized. The diagnostic systems used vary across studies as do the assessment procedures and protocols. Teplin, Abram, and McClelland (1996), in a review of the research on women in jail, argued that there has been little epidemiological research conducted on women in jail and that there are methodological problems with the studies that have been done. Three common methodological problems outlined by Teplin et al. (1996) would apply equally to the research on men in jails. First, most studies use only selected samples of jail inmates such as those referred for evaluation and/or treatment. Second, sample sizes are often too small to generate reliable rates of rare psychiatric disorders, and many of the studies have been conducted using nonstandardized instruments to assess psychia-

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tric disorder. Despite the methodological flaws of some of the research, it appears that mental disorder is at least as common, and probably far more common in jails than in the community (Teplin, 1983). A number of observations can be made upon reviewing studies investigating the prevalence of mental illness in jails and prisons. Foremost, findings from studies examining randomly selected inmates suggest that there are a large number of persons incarcerated in jails with significant mental disorders. Substantial numbers of inmates (perhaps as many as 10%) suffer from psychotic disorders and an even greater number suffer from anxiety or personality disorders. These disorders significantly impair the inmates' social functioning and require immediate treatment or management, and some of the inmates are so acutely ill that they require inpatient psychiatric care. The rate of serious mental disorder among inmates is significantly higher than the rate of serious mental disorder among community residents from similar socioeconomic conditions. Although the data are not clear on the point, the rate of mental illness in jails and prisons may increase over time due to deinstitutionalization and other factors (e.g., Pogrebin & Poole, 1987; Rabkin, 1979; Roesch & Golding, 1985). Also, in most cases, the onset of mental disorder precedes the onset of criminal behavior (Hodgins & Cote, 1990). There is a general perception shared by jail healthcare administrators and jail mental heath professionals that the number of persons with mental illness entering jails has increased over the years. Sixty-nine percent of jail administrators responding to a survey prepared by Torrey et al. (1992) reported that the number of persons with mental illness who were entering jail had increased over the course of 10 years. Moreover, others have claimed that the proportion of mentally disordered jail inmates is increasing (Teplin, 1983; Torrey et al., 1992). For example, Teplin (1983) concluded that the ªresearch literature, albeit methodologically flawed, offers at least modest support for the contention that the mentally ill are (now) being processed through the criminal justice systemº (p. 54). The contention that the mentally ill are entering jails in increasing numbers is not accepted by all, however (Monahan, Caldiera, & Friedlander, 1979). For example, some investigators have proposed that it is simply heightened awareness among professionals and the public of the problem of mentally ill in the jails that has resulted in the perception that they are entering in increasing numbers (Morrisey, Steadman, & Kilburn, 1983; Steadman & Ribner, 1980). If indeed the number of mentally

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disordered inmates entering the jails and prisons is increasing, it may be attributed to several societal changes that have occurred since the 1960s. Though separate, each of these factors is related to the general trend in which the methods used by the state to control the mentally ill have gradually eroded. Adopting a sociological perspective, those with mental illness may be considered deviant persons for whom society has little tolerance or concern (Goffman, 1961; Heller & Monahan, 1977; Kiesler, 1980). Persons with mental disorder have been traditionally controlled and removed from society by the state mental healthcare system. Financial and legal factors have converged, however, so that the state mental health system has lost much of its ability to treat and control persons with mental illness, as mandated by society. The issue of inmates with mental disorders is a major concern among jail administrators and mental health professionals who work in jails. Gibbs (1983) surveyed 39 jail managers and social service providers working in jails around the nation and found that mentally disordered inmates were their second most significant concern, with jail overcrowding being the first. Jail administrators believe persons with mental illness to be at significantly increased risk for suicide, violence, and abuse at the hands of other inmates than inmates without mental disorder. Jail administrators also see inmates with mental illness as requiring more attention from jail staff and being much more likely to disrupt jail activities than their nondisordered counterparts. In addition, it appears that correctional officers are most likely to identify inmates with psychotic disorders. This is suggested by the large percentage of inmates when referred for mental health evaluations by correctional staff (who receive diagnoses of schizophrenia or affective disorder). This is of significance in terms of training correctional officers, who are front line personnel and, therefore, are in the best position to identify inmates with mental disorders. A number of authors have expressed a concern that depressed inmates are especially likely to go unnoticed by correctional officers and, thus, are not referred to psychologists for evaluation and treatment. Depressed persons, unfortunately, may be considered ªmodel inmatesº by correctional officers. As a function of their depression, these inmates are unlikely to make demands upon staff or become involved in altercations with other inmates. Thus, they may not get referred for evaluation. Given the relationship between depression and self-injurious behavior, however, the referral of these

inmates is crucial for their well-being and the successful operation of the institution. Thus, psychologists should take special care to alert correctional officers to this potential hazard. Regardless of whether their number is increasing, extant research indicates that there are considerable numbers of mentally ill individuals in jails and prisons. Given the history of the lack of adequate mental health services in correctional facilities, it is clear that this group has been underserved and neglected. Thus, steps should be taken to increase the availability of mental health services in jails and prisons (Ogloff, Roesch, & Hart, 1993; Steadman, McCarty, & Morrisey, 1989). 9.06.2.1 Substance Abuse Unfortunately, more is known about the number of mentally ill in jails than those who abuse or are addicted to alcohol and other drugs. The few studies that have examined the prevalence rates of mental illness in jails generally have often ignored or paid minimal attention to the problems of incarcerated substance abusers. A number of studies examining mental disorder in jails ignore or fail to report prevalence estimates of alcohol and drug abuse addiction (e.g., Lamb & Grant, 1983). This cursory treatment of substance abuse problems in jails may be due to two factors. Although it is a significant mental health problem, substance abuse among jail inmates is unlikely to be a major concern for those administering or working in jails. The limited access to alcohol and drugs in the jail setting makes the problem of abuse during incarceration a minor issue for caretakers. When not under the influence or withdrawing, substance abusers are not likely to pose special problems to jail staff, although the problem of individuals being placed in jail while intoxicated or under the influence of other drugs remains. Addicted inmates might be expected to pose a significant problem to the jail operation. Those withdrawing from alcohol and other drugs undergo considerable distress and in some cases may be in a life-threatening situation. In addition to the risk and discomfort to the individual, withdrawal from alcohol and drugs poses a clear management problem in terms of its effects on other inmates. Thus, the problem of substance abuse and addiction among jail inmates is an important issue with respect to the provision of mental health services in jails. The few studies examining the prevalence of substance abuse and addiction suggest that the problem is considerable. In its 1983 census, the Department of Justice (1984) reported that 75% of the 5785 inmates surveyed reported using

The Prevalence of Mental Illness and Substance Abuse Among Inmates substances of some kind. Twenty-six percent indicated that they were using drugs of some type, and 46% indicated that they used alcohol immediately prior to committing the offense for which they were arrested. At the very least, these figures suggest that many individuals enter confinement under the influence of alcohol or drugs, a large number of whom may be serious abusers or addicted. Findings from more thorough studies are consistent with the above information. Of 445 jail inmates self-referred or referred by correctional staff for psychiatric evaluation, Swank and Winer (1976) reported alcoholism and drug addiction rates of 11.9 and 8.5%, respectively. In their sample of 100 randomly selected inmates who were interviewed, the authors reported alcoholism and drug addiction rates of 18.0 and 6.0%. Somewhat higher rates were reported by Guy, Platt, Zwerling, and Bullock (1985). Upon interviewing 96 randomly selected inmates from the Philadelphia County Prison (county jail), the authors reported alcohol dependency and drug dependency rates of 25.0 and 11.5%, respectively. Moreover, 28% of a larger sample surveyed by the authors expressed a self-assessed need for alcohol or drug treatment. As with prevalence studies of mental disorder, the differences between these studies may be explained by different sampling procedures, small sample sizes, different sampling periods, geographic differences, and varying diagnostic criteria. But even if the lowest estimates of substance abuse and dependence are assumed to be accurate, it remains clear that this is a significant problem among jail inmates. Unfortunately, substance abuse treatment may be the most neglected aspect of mental healthcare in jails. In addition to the research investigating the prevalence of mentally disordered offenders in prisons, research shows that correctional officers perceive mentally disordered offenders less favorably than other inmates, and the officers feel the need for training in the area of identifying and handling mentally disordered offenders (Kropp, Cox, Roesch, & Eaves, 1989). Finally, mentally disordered offenders have higher rates of institutional infractions and incidents of misconduct than other offenders (Adams, 1986). 9.06.2.2 Prevalence and Assessment of Women in Jails and Prisons Prevalence and assessment of mental disorder among female inmates will be reviewed simultaneously as much of the research on prevalence has been based on intake screening and

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assessment procedures in jails and prisons. The majority of the empirical research on the prevalence, assessment, and treatment of mental disorder in offender populations has focused on male offenders and has virtually ignored female offenders. Teplin et al. (1996) argued that the findings from studies of men cannot be generalized to women for three reasons. First, service utilization and diagnostic profiles are different for men and women. Second, men and women are managed differently in correctional settings, and third, the resources that are available in male correctional facilities are different from those available in female facilities. Thus, it is important to review studies conducted specifically with female offenders. In recent years there has been a demonstrable increase in the number of incarcerated female offenders, although the number of women in prisons and jails in the USA is still relatively small when compared to men. A report by the US Department of Justice (1995) indicated that in 1994 there were almost 50 000 female jail inmates, representing approximately 10% of the total jail population. The report noted that this figure has more than tripled between 1983 and 1994. A number of studies have examined the rates of mental disorder in women who have been screened and referred for mental health services within jails or prisons. A high rate of mental disorder would be expected in these samples as these individuals have already been flagged as having possible mental health problems. These studies do not examine prevalence rates per se but rather only the rates of certain disorders found in a referred population of women. Lamb and Grant (1983) examined a sample of 101 women who had been referred for psychiatric evaluation to the Forensic Mental Health Unit in Sybil Brand Institute, Los Angeles county jail for women. This mental health unit receives approximately 4% of all the women who are booked into the jail. In this referred sample, 86% of the women had a history of psychiatric hospitalization and more than half met criteria for involuntary hospitalization. Birecree, Bloom, Leverette, and Williams (1994) assessed the need for mental health care in a sample of 91 women screened and referred for clinical interview upon entry in Oregon's prison system. Over half (55%) of these women had prior contact with the mental health system. The first study to examine the rates of mental disorder in jails using a random of the entire jail population rather than a sample of previously identified patients was conducted by Washington and Diamond (1985) in California. They screened a random sample of inmates from five county jails. There were 115 women in their

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sample, 41.7% of whom had a DSM-II diagnosis. Washington and Diamond (1985) expressed concern at the high numbers of women in need of mental health treatment and questioned whether these women should be in the mental health system rather than the criminal justice system given that jails have limited and often inadequate mental health services. Daniel et al. (1988) administered a structured diagnostic interview to 100 women admitted to the Missouri Correctional Classification Centre to determine lifetime and six-month prevalence rates for psychiatric disorders. They reported that the offender sample of women had significantly higher rates of schizophrenia (7%), major depression (21%), substance abuse (36%), and antisocial personality disorder (29%) compared to women from the general population. Daniel et al. concluded that mental health treatment and systematic screening needs to be available for all prisoners. Ingram-Fogel (1991) interviewed 135 women during the first week of incarceration at a major correctional facility in a southern state and concluded that substance abuse and depression were major health problems among these incarcerated women and that the incidence of alcohol and drug abuse among these women was far greater than that reported in the general population. Teplin et al. (1996) administered a structured diagnostic interview to 1274 female arrestees awaiting trial. The results indicated that over 80% met criteria for one or more lifetime psychiatric disorders. The lifetime prevalence rates for the specific disorders were as follows: 2.5% met criteria for schizophrenia, 2.6% for manic disorder, 16.9% for major depressive episode, 33.5% for post-traumatic stress disorder, 63.5% for drug abuse/dependence, and 32.3% for alcohol abuse/dependence. With the exception of schizophrenia, the prevalence rates for all these disorders were significantly higher than in the general population. Teplin, Abram, and McClelland (1997) also investigated the percentage of incarcerated women that required mental health services, the percentage that received mental health services, and the variables that predicted which females would receive these services. The results indicated that 10.7% of the participants needed mental health services and, of those, 23.5% actually received services. As far as variables that predicted who would receive services, a history of psychiatric treatment greatly increased the odds of receiving services, whether or not the individual currently required services. Women with major depression were less likely to receive services unless it was comorbid with drug abuse or dependence and then they were more likely to receive

services. Those women with schizophrenia or manic disorder were 65 times more likely to receive services than those without these disorders (except when these disorders were comorbid with drug abuse or dependence and then they were less likely to receive services). Finally, severely depressed white high school graduates had higher odds of receiving services than was predicted. As in the USA, females make up only a small proportion of the total population of prisoners in other countries. In Canada, females comprise approximately 9% of the total jail population and 2% of the total prison population (Shaw, 1994). Turner and Tofler (1986) estimated that women constitute about 3% of the total prisoner population in the UK and the results of a study by Maden, Swinton, and Gunn (1994) indicated that women make up about 3.5% of the total prisoner population in England and Wales. The prevalence rates of mental disorder among women in jails and prisons in the USA is typical of that found in other countries. The UK data suggest much lower rates, although it should be remembered that it is unclear whether the differences are real or a function of differences in the manner in which mental illness is defined and assessed. Robertson, Bankier, and Schwartz (1987) interviewed 100 consecutive female admissions to a jail in Winnipeg, Manitoba, Canada. They reported that 12% of these women had a psychiatric history, 34% had alcohol use disorders, 6% had drug use disorders, and 4% had psychotic disorders. Hurley and Dunne (1991) screened the entire population of 92 prisoners at the Brisbane (Australia) Women's Prison for psychological distress and psychiatric morbidity. This institution receives remanded and sentenced prisoners from the courts of the entire state of Queensland and comprises about 85% of Queensland's population of women prisoners. The results indicated that high levels of psychological distress were evident in this sample of women prisoners and that 53.3% were diagnosed with a current psychiatric disorder. Turner and Tofler (1986) screened a sample of 708 women admitted to Holloway prison in the UK. Three variables±±drug abuse, self-harm, and a history of psychiatric treatment±±were used as indicators of psychiatric disorder. Although this research can be criticized because of the lack of standardized instruments to assess psychiatric disorder, these authors reported a high rate of drug abuse (14%), self-harm (27.5%), psychiatric history (17.7%), and a moderate amount of overlap between these variables. Turner and Tofler concluded that psychiatric units are needed in women's prisons

The Diversion of Mentally Ill Offenders and that changes to policies for admission to psychiatric hospitals should be vigorously pursued. Finally, Maden et al. (1994) collected interview and file data for 25% of the population of women serving a prison sentence in England and Wales to determine the prevalence rates of psychiatric disorder. The specific prevalence rates found were: 1.6% for psychotic disorder, 18% for personality disorder, 26% for drug abuse or dependence, and 9% for alcohol abuse or dependence. Prior psychiatric contact was reported by 45% of the women. In summary, the available research indicates that the prevalence rates of mental disorder among women in jails and prisons throughout the USA and other countries are similar. In general, it appears that the highest prevalence rates occur for alcohol and drug use disorders, depression, and personality disorders.

9.06.3 THE DIVERSION OF MENTALLY ILL OFFENDERS A substantial number of inmates in both jails and prisons are mentally ill and, for some of these offenders, it may be appropriate to divert them out of the jail or prison system into the mental health system where they can receive the treatment they need to remain offense free. The term diversion has many applications. For example, already incarcerated offenders, or offenders awaiting sentence, may be said to be diverted from prison through various means (probation, parole, electronic monitoring, and house arrest). In addition, prisoners may be deemed mentally unfit and diverted to a psychiatric facility. Pretrial diversion programs are used as an alternative to formally processing people charged with committing offenses in the criminal justice system. Rather than proceeding to trial in the usual manner, pretrial diversion involves redirecting offenders from the courts to other agencies for disposition. It was hoped that diversion programs would result in keeping the diverted accused out of the criminal justice system, making them less susceptible to committing other offenses (see Austin & Krisberg, 1981). The movement toward diversion in the criminal justice system began in the USA in the 1960s, and in Canada in the 1970s, as a result of the increasing number of minor cases being processed by the clogged courts. Also instrumental in the genesis of pretrial diversion programs was an increasing dissatisfaction with the criminal justice system coupled with the emerging rehabilitative philosophy (Lawrence, 1991). Initially, diversion occurred when prosecutors and courts made informal arrange-

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ments with offenders and community agencies in an effort to rehabilitate offenders in order to prevent them from recidivating. Federal commissions in the 1960s in the USA sought reorientation of the correctional system away from punishment and incarceration and toward formal community correctional models, including diversion programs (Gottheil & Ghosh, 1983). Gottheil and Ghosh noted that by 1993 the number of diversion programs in the USA had skyrocketed. Similarly, the movement toward pretrial diversion gained considerable acceptance in other countries (e.g., Australia, Canada, and the UK; see Cooke, 1992; Davis, Boucherat, & Watson, 1989; Kraus & Hasleton, 1982; LeBlanc & Beaumont, 1992; Pratt, 1986). Underlying any diversion program is the assumption that formal contact with the criminal justice system has inherently negative effects (Roesch & Corrado, 1983). Another assumption is that offenders need treatment or some other form of intervention to transform them into stable, law-abiding, community members (Lawrence, 1991; Roesch & Corrado, 1983). Finally, it is assumed that pretrial diversion is a more effective means of reintegrating offenders into the community than incarceration (Curran, 1988). Five specific goals of pretrial diversion programs flow from the rationale behind pretrial diversion, and the assumptions that underlie it: (i) to reduce recidivism, thereby lowering the crime rate (Gottheil & Ghosh, 1983); (ii) to decongest the criminal justice system, thereby improving cost-effectiveness and allowing prosecutors and judges to attend to more serious offenders who pose greater threats to the community (Gottheil & Ghosh, 1983); (iii) to provide necessary services (e.g., therapy, counseling, job training) to individuals to better prepare them for the demands of society (Covey & Menard, 1984); (iv) to reduce the coercive, punitive social control of the criminal justice system by removing many less-serious offenders from the system (Lipsey, Cordray, & Berger, 1981); and (v) to avoid the negative stigma and labeling (as a criminal) that occurs in the formal criminal justice system (Decker, 1985). Regardless of the goal of the diversion program, pretrial diversion programs have certain eligibility criteria and program requirements. Accused who successfully meet the eligibility criteria and also satisfactorily complete the program requirements have the charges against them dismissed. Referral to a diversion program is typically at the prosecutor's discretion. Eligibility for pretrial diversion programs is usually restricted to first-time

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offenders charged with minor offenses. Selected individuals preferably should pose little threat to the community and require little supervision (Lawrence, 1991). Roesch, (1978a) reviewed 30 diversion programs and found that all excluded people accused of serious felonies (e.g., rape, murder, armed robbery), and seven excluded individuals accused of any felony. Roesch and Corrado (1983) noted that although many diversion projects purport to accept those accused of certain, less serious felonies, in practice this is rare since programs predominantly admit those accused of misdemeanors such as shoplifting. There also is variability in eligibility criteria regarding the defendant's prior criminal record. Some programs exclude individuals with any prior record (see Royse & Buck, 1991) while others exclude only those who have committed a felony within the last five years, or who have ever committed a major felony (see Gottheil & Ghosh, 1983). Yet others exclude only those with records of major felonies (e.g., Fische & Jeune 1987). Also, there are many programs with selection criteria that fall between the extremes presented here, with differing combinations of offense history, time since last offense, and severity of present offense factored in. Although there are many varying eligibility criteria, the majority of programs accept only those accused of minor offenses with no prior felony convictions and few, if any, misdemeanor convictions. Psychologically treatment-based pretrial diversion programs very often involve group therapy designed to help offenders gain insight into their behavior and to develop strategies for living in the community without committing further crimes. Specific therapeutic strategies are extremely broad ranging from psychoeducational treatment, stress management, and anger management to very specific treatment approaches for specific types of offenses (e.g., assaultive husbands programs). Given that many offenders are not particularly well educated and have few job skills, diversion programs have been developed to provide offenders with practical, hands-on, skills that will enable them to become gainfully employed and to decrease their need to rely on criminal behavior as a means of existence. The number of diversion programs increased rapidly and gained widespread acceptance by the 1970s; however, little attention was paid to systematically evaluating the effectiveness of the programs (Roesch & Corrado, 1983). As Roesch (1978a) pointed out, although pretrial diversion programs are very expensive and require major resource commitments, the agencies that provide funding for the programs very often did not

require ªevaluation procedures to be included, and . . . did not present any guidelines, beyond requesting certain demographic information on project participants, for such evaluationº (p. 80). By 1993, however, an extensive body of literature on the effectiveness of diversion programs had been published. Most of the studies investigated whether the goals of diversion were met. In general, although there have been some successful programs, the results are equivocal and diversion is not the panacea it was initially imagined to be. A major issue is whether diversion programs actually reduce the number of individuals processed by the criminal justice system. Critics argue that many individuals referred to diversion programs would, in the absence of diversion programs, simply have been released from custody due to the minor nature of the offense or the lack of evidence for prosecution (see Roesch & Corrado, 1983). Thus, diversion programs may function to increase, not decrease, the extent to which the state is involved in people's affairs; the number of individuals who actually come into contact with the system increases because of diversion, a concept known as ªwidening the net of social control.º Several studies have indeed found evidence of this ªwidening of the netº phenomenon (e.g., Decker, 1985; Laberge & Morin, 1995; Lipsey et al., 1981; Sarri & Bradley, 1980) and it is widely considered a common, though undesirable, result of diversion programs (Decker, 1985). A corollary to this finding is that if diversion functions to increase the number of individuals in contact with the criminal justice system, then it is also failing to provide costeffective service. However, there have also been studies which have failed to find evidence of net widening (e.g., Fischer & Jeune, 1987), and others have argued that it is the manner in which programs are implemented that determines whether they succeed, not any inherent weakness of the concept of diversion itself (Curran, 1988; Roesch & Corrado, 1983; Roesch & Foisy, 1986). Another contested issue is whether diversion programs succeed in reducing recidivism, and consequently the crime rate. Again, there are mixed results. Many researchers have found that diversion programs do not decrease recidivism or prevent crime (Roesch & Corrado, 1983; Severy & Whitaker, 1982), others have found that diversion does decrease recidivism (Binder & Binder, 1983; Davidson, Redner, Blakely, Mitchell, & Emshoff, 1987; Land, McCall, & Williams, 1990; Lipsey et al., 1981; Quay & Love, 1979; Royse & Buck, 1991) while others have criticized the methodology of studies (Mrad, 1979; Roesch, 1978a; Roesch

Pretrial Assessment & Corrado, 1979). Moreover, Osgood (1983) found no relationship between program effectiveness and the seriousness of offenders' criminal history. Again, while it is clear that diversion has not been as successful as was initially hoped, its failure may be due to poor implementation strategies such as applying the same counseling program to individuals with different needs (Roesch & Foisy, 1986). Diversion also aims to be less coercive than formal processing, although critics maintain that the right to due process is violated because individuals are indeed coerced into diversion programs, because if they do not participate and successfully complete the program, they will be prosecuted (O'Brien, 1984). Participants must also admit responsibility without legal proof, which has been deemed coercive. However, there have been some attempts to reduce any coercive elements of diversion. Several programs provide legal counsel to individuals before the decision to participate is made (O'Brien, 1984) while others do not require that the program be successfully completed in order for charges to be dismissed (Gottheil & Ghosh, 1983). Diversion can only work if it is applied to people who otherwise would have been prosecuted for their offense. Roesch and Corrado (1983) argued that diversion programs should include those charged with more serious offenses, and that dismissal of charges should not be contingent upon completion of a program, but should be automatic upon the decision to divert. The authors also suggested that program participation be voluntary, and that the type of program employed should have strong theoretical support and justification. Some mentally ill inmates could benefit from psychological intervention which, in turn, might reduce the likelihood of them committing future offenses. Therefore, diversion programs may be particularly effective with this population. As with any program, care and attention will be required to identify and divert those persons who pose a low risk to society and demonstrate some likelihood of reducing their chance of reoffending. Of course, with mentally ill inmates who rely upon psychotropic medication to control their mental illness, particular care must be taken to ensure that they will remain compliant with the medication.

9.06.4 PRETRIAL ASSESSMENT Pretrial assessment perhaps accounts for the greatest proportion of time spent by forensic clinicians working in the criminal justice system. There are three primary areas of pretrial

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assessment that we will review in this section: competency to stand trial, criminal responsibility, and risk assessment.

9.06.4.1 Competency to Stand Trial Competency to stand trial is a legal provision that allows the postponement of judicial proceedings for defendants who do not have the capacity to assist in their defense. The competency to stand trial criteria specified in state statutes generally refer to variations of the standard set forth by the US Supreme Court in Dusky v. USA (1960). In Dusky, the Court held that for a defendant to be considered competent to stand trial, the defendant must have ªsufficient present ability to consult with his attorney with a reasonable degree of rational understanding [and] a rational as well as factual understanding of the proceedings against himº (p. 402). Psychologists have long been involved in providing information to the courts to assist in decisions about competency. Competency evaluations have not been uniform, varying widely from clinician to clinician (Roesch, Ogloff, & Golding, 1993), but a number of interview guides and rating scales have been developed to aid evaluators in assessing competency to stand trial. These include the competency screening test (Lipsitt, Lelos, & McGarry, 1971) the Competency Assessment Instrument (McGarry & Curran, 1973), the Interdisciplinary Fitness Interview (Golding, Roesch, & Schreiber, 1984; McDonald, Nussbaum, & Bagby, 1991), the Fitness interview Test-Revised (FIT-R, Roesch, Zapf, Eaves, & Webster 1998), the Competence Assessment for Standing Trial for Defendants with Mental Retardation (Everington, 1990), and the Georgia Court Competency Test (Wildman, White, & Brandenburg, 1990; see also Nicholson & Johnson, 1991). More recently, the MacArthur Research Network on Mental Health and the Law has been developing assessment tools for evaluating adjudicative competency (Bonnie, 1992; Hoge et al., 1997). One criticism of the manner in which competency is assessed is that the evaluations focus too heavily on a defendant's mental status with little attention paid to the legal issues involved in a particular case. The recommendations resulting from these evaluations are typically global in nature, usually resulting in statements offering a conclusion about whether or not a defendant is competent to stand trial. These recommendations are based largely on a finding of psychosis or mental retardation, with virtually no attempt to relate these factors to the

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specific requirements of the instant criminal case (see Grisso, 1986; Roesch & Golding, 1980). This is unfortunate because the legal concept of competency to stand trial is quite specific and focuses on questions surrounding a defendant's functional abilities that are directly relevant to the criminal process in the law. Thus, information derived from traditional clinical assessments indicating the defendant's IQ score, personality profile, and mental status generally, is often not relevant to the legal question of the defendant's competence. It has been suggested elsewhere that incompetency should be evaluated and treated in a context-dependent manner, taking into account the demands of a defendant's specific legal situation and what is likely to be required of that defendant in a given legal procedure (Golding et al., 1984; Roesch, Hart, & Zapf, 1996). It is quite possible for defendants to be competent for certain types of legal proceedings but not for others (Whittemore, Ogloff, & Roesch, 1997), so it is necessary that competency evaluations and the treatment of incompetent defendants consider the specific demands and contextual factors related to a particular case. 9.06.4.1.1 Community-based screening In the USA and Canada, there has been a tradition of remanding large numbers of individuals to inpatient facilities for assessments of competency to stand trial. Grisso, Cocozza, Steadman, Fisher, and Greer (1994) conducted a survey to determine the organization of pretrial forensic evaluation services in the USA. The results of this research indicated that the traditional approach, though the dominant approach in only a minority of states, was still widely used throughout the USA. However, a number of states have implemented models that employ various types of outpatient approaches. One approach is to use screening evaluations, defined as ªbrief evaluations at jail or courthouse to determine whether there was a need for a full evaluation for competence to stand trialº (Grisso et al., 1994, p. 389). In the late 1970s, Roesch (1978b) concluded that a brief, immediate screening interview could be used to evaluate competence to stand trial and that this method resulted in a reduced cost and an increase in the protection of individual rights over the traditional method of remanding an individual to an inpatient facility. He reported a high agreement between judgments of competence based upon a brief screening interview and lengthy institutional evaluations of competence and concluded that screening interviews are an effective alternative to inpatient evaluations holds true today, and

more states are adopting brief screening interviews as the preferred model of evaluation (Grisso et al., 1994). Instruments for conducting these assessments are available. For example, research in 1997 conducted using the FIT-R has indicated that this measure demonstrates excellent utility as a screening instrument and that it can reliably screen out those individuals who are clearly fit to stand trial before they are remanded to an inpatient facility for evaluation (Zapf & Roesch, 1997). Zapf and Roesch found that about four of every five defendants could have been screened out before being remanded to an inpatient facility for assessment. 9.06.4.1.2 Competency to be executed A specific form of criminal competency may arise with prison inmates sentenced to death, and that is the issue of competency to be executed. This is an infrequently raised issue, affecting only a small minority of inmates on death row, but the assessment and treatment issues, particularly ethical dilemmas for psychologists, warrant consideration in this chapter. The American Bar Association (1989) proposed the following definition of the legal principle, ªcompetency to be executedº: A convict is incompetent to be executed if, as a result of mental illness or mental retardation, the convict cannot understand the nature of the pending proceedings, what he or she was tried for, the reason for the punishment, or the nature of the punishment . . . [or] lacks sufficient capacity to recognize or understand any fact which might exist which would make the punishment unjust or unlawful, or lacks the ability to convey such information to counsel or to the court. (Standard 7-5.6, p. 290)

The US Supreme Court affirmed common law prohibitions against the execution of incompetent defendants in the case of Ford v. Wainright (1986), holding that such executions are prohibited by the Eighth Amendment provision against cruel and unusual punishment. In essence, the Court held that prisoners sentenced to death who subsequently become incompetent have a constitutional right not to be executed. There are several rationales that form the basis of common law and state statutes that prohibit the execution of incompetent prisoners. Perhaps the most compelling rationale is that incompetent individuals cannot assist counsel in the appeal process and other challenges of the original sentence. Other reasons include the belief that the goals of deterrence or retribution cannot be achieved by executing an incompetent person, it is inhumane and cruel, and it prevents the individual from making a final religious

Pretrial Assessment peace (Heilbrun, 1987; Melton, Petrila, Poythress, & Slobogin, 1987; Radelet & Barnard, 1986). The issue of competency to be executed raises a number of ethical concerns for clinicians involved in the assessment and treatment of incompetent defendants. Is it possible to conduct such evaluations given that the major implication of a finding that an offender is competent to be executed, is that he or she will be executed? Would clinicians opposed to the death penalty be more inclined to find a defendant incompetent? Is it reasonable to ask clinicians to treat these defendants given that successful treatment will result in the execution of the defendant? Many clinicians have refused to participate in assessment or treatment, citing ethical objections (Deitchman, Kennedy, & Beckham, 1991). Appelbaum (1986) makes the distinction that other competency evaluations (e.g., competency to stand trial) are based on the administration of justice whereas competency to be executed is an aspect of the administration of punishment. Bonnie (1990) took issue with this distinction and argued that clinicians should not rely on ethical objections as a basis for refusing to participate in such evaluations. He considered whether participation in competency for execution evaluations forces the clinician to cross the boundary between participation in the administration of justice to participation in the administration of punishment, since the latter may be considered ethically objectionable (see Appelbaum, 1986, for a discussion of this issue). Bonnie contended that clinicians have traditionally been involved in many aspects of the sentencing process and other postsentence evaluations, but he recognized that clinicians may make a personal choice that their ªpersonal scruples against the death penalty are so strong that an objective evaluation is not possibleº (p. 81), and on this ground, may decide against participation in the evaluation of competency to be executed. Bonnie did not extend his arguments about the ethics of participation in evaluations to the treatment of offenders found incompetent. This is because treatment would not be beneficial to such defendants but rather would serve the interests of the state to carry out the execution. In the case of treatment, Bonnie favored refusal based on ethical objections, and added that one way out of the dilemma would be to automatically commute the sentence of any prisoner found incompetent to be executed. Bonnie recognized that this would open up the competency process as the last line of defense against execution, making the ethical and moral dilemmas even more pronounced.

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Appelbaum (1986) commented on three positions that could be taken by psychologists regarding participation in competency for execution evaluations. The first is that since participation in these evaluations is no different from participation in any other forensic evaluation, there are no valid ethical objections. The second position allows participation, although it places conditions intended to serve as protections for prisoners, such as clarifying standards for determining competency, ensuring that prisoners be allowed to contest the finding and call their own experts. The third position is that psychologists should never participate in these evaluations. This position rests on the assumption that to do otherwise would require evaluators to cross the boundary between participation in the administration of justice and the administration of punishment. While the former is ethically defensible, the latter would not be considered so. Forensic clinicians engaging in these evaluations will find that the evaluation of competency to be executed is similar to evaluations of other forms of criminal competency. Evaluations should be based on a functional assessment of an offender's competency. If communication between an attorney and an offender is an issue, the clinician may want to observe sessions between them. Because much is at stake for the offender, there may be considerable motivation for faking incompetency, so clinicians will likely want to obtain third party information and also conduct some assessment of the likelihood that the defendant is feigning incompetence (Rogers, 1988; Small & Otto, 1991). 9.06.4.2 Criminal Responsibility Although the issues surrounding the insanity defense are complex and difficult, psychologists working in jails and prisons sometimes are asked to make determinations concerning an inmate's mental state at the time of the offense. Generally speaking, states employ one of two standards for insanity: the M'Naghten standard or the American Law Institute (ALI) standard (Ogloff, Roberts, & Roesch, 1993a). The M'Naghten standard comes from English common law and comprises three substantive elements. First, it must be determined that the defendant was suffering from a defect of reason and/or from disease of the mind. Next, evidence must show that, as a result of the mental disease or defect, the defendant did not know the nature and quality of the act. Finally, the M'Naghten standard also requires an inquiry to determine whether the defendant knew what he or she was doing was wrong. Therefore, the defendant who has a cognitive understanding or knowledge of

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his or her act, but who does not demonstrate knowledge that the act was morally wrong, may also be acquitted under the M'Naghten test. The M'Naghten test is referred to as a cognitive test of insanity because of its focus on the quality of the defendant's thought processes at the time of the crime (e.g., Low, Jeffries, & Bonnie, 1986). The M'Naghten standard was criticized for focusing exclusively on a defendant's cognitive capacity (Golding & Roesch 1987; Goldstein, 1967; Ogloff, Roberts, & Roesch, 1993). The second common standard in place in many states is the ALI standard. In drafting the new insanity defense standard, the ALI subcommittee attempted to redress the shortcomings of earlier formulations, especially the requirement of total incapacity which seemed implicit in the M'Naghten test (American Law Institute, 1962, s. 4.01). The ALI standard introduced several important modifications. First, the ALI test recognizes that impairments in cognitive and volitional functioning which are caused by mental disease or defect may provide a basis for exculpation by reason of insanity. Second, the ALI test is founded upon an assessment of substantial rather than total incapacity, a standard which was seen as comporting more adequately with both medical facts and actual jury behavior. Third, the term appreciate rather than know was employed. Appreciate connoted affective as well as cognitive understanding and was perceived as fitting more consonantly with modern mental health perspectives on the unified nature of personality. Use of the word conform provided continuity with the older irresistible impulse notion of impairments in capacity for volitional control. At the federal level, Congress passed the Insanity Defense Reform Act (1984) following John Hinckley, Jr.'s acquittal by reason of insanity for the attempted assassination of President Reagan, which removed the volitional prong of the ALI ruleÐleaving it substantively like M'Naghten, with its focus on the defendant's cognitive appreciation for purposes of determining whether he or she should be found not guilty by reason of insanity (Perlin, 1989). The modifier substantial was also removed, so that the substantive federal insanity test is whether the defendant lacks capacity to appreciate the wrongfulness of his or her conduct; thus federal legislators successfully re-introduced the historically earlier absolute or total deprivation of capacity standard. In addition, the new standard specified that the mental disease or defect must be severe (Finkel, 1989, Perlin, 1989). In addition to more traditional not guilty by reason of insanity (NGRI) standards, the guilty

but mentally ill (GBMI) verdict has been adopted by some states as a supplement to the insanity defense standards (Ogloff et al., 1993a). The GBMI verdict holds defendants criminally responsible for their acts, but recognizes that the defendant is mentally ill. The GBMI plea has been termed an in-between classification because defendants are neither acquitted nor found guilty in the traditional sense (Ogloff et al., 1993). Although a review of scholarly analyses of the GBMI verdict is beyond the scope of this article, readers should be aware that the verdict has stirred a great deal of controversy (e.g., Blunt & Stock, 1985; Golding & Roesch, 1987; Roberts & Golding, 1991; Slobogin, 1983). Ogloff et al. (1993) described a clinical assessment procedure for helping to determine whether a defendant is NGRI. Such an assessment involves an investigation of the defendant's mental state at the time of the offense. However, a retrospective evaluation is difficult even under ideal circumstance where the clinician has access to perfectly valid information about the defendant's mental state immediately prior to and during the offense. As Ogloff et al. (1993) noted, it is important for clinicians to be cognizant of the limitations inherent in the mental nonresponsibility evaluationÐthat is, the retrospective nature of the evaluation always require some degree of speculation and the necessity of placing the data in a psychological conceptual framework that is relevant to the legal issues. (p. 168)

The assessment procedure described by Ogloff, Roesch, and Hart (1993) involves five phases. In Phase 1, the clinician establishes rapport and reviews with the defendant the nature of the proposed evaluation, along with the defendant's rights during the process, the limitations on psychosocial history from multiple sources of information (e.g., by reviewing the defendant's educational, mental health, and correctional records). To explore missing data and to continue the rapport-building process, defendants should be encouraged to provide their account of their psycho-social history as well and, where relevant, standardized tests or structured interviews are employed. Phase 3, the clinician assesses the defendant's present mental state, much as would be done in a more traditional assessment. Phase 4 is the most important phase insofar as the clinician must attempt to reconstruct the cognitive, conative, emotional, motivational, and psychopathological concomitants and determinants of the defendant's behavior at the time of the offense. Phase 5, the examiner must formulate the

The Treatment of Mentally Ill Offenders in Jails and Prisons reconstructed elements in terms of their legal relevance while taking care to avoid conclusory pronouncements of the ultimate legal issues. At all times, clinicians are constrained by their general competence to render judgments about an individual's mental state at some time in the past and must acknowledge the limitations in their evaluation. 9.06.4.3 Mental Disorder and Violence Another form of assessment frequently conducted by psychologists working in prisons and jails is risk assessment. Most often, the professional is asked to determine whether, as a consequence of any mental disorder from which they may suffer, offenders are likely to cause harm to themselves or to others. The focus of the evaluation may be institutional, that is, risk of violence during incarceration. Common concerns here are the likelihood of self-injurious behavior, for violence in the community after release from an institution. The primary concerns here are risk for violent and sexually violent recidivism, although risk for general recidivism (e.g., new property or drug offenses) may also be an issue. Risk assessment differs from traditional mental health assessment in several ways. Traditional mental health assessments determine the presence, nature, and severity of symptoms of mental disorder, and then suggest appropriate strategies for alleviating those symptoms via psychotherapy and/or pharmacotherapy. Risk assessments determine the presence of risk factors, including symptoms of mental disorder, that are associated with the likelihood that an individual will be involved in some kind of critical incident, and then suggest strategies for reducing or managing the risks posed by the individual. The primary goal of traditional assessments is to improve the wellbeing of offenders, whereas the primary goal of risk assessments is the protection of institutional security or public safety. A second difference is that risk assessment requires the evaluator to have some expertise in crime and violence. These areas are outside the usual domain of training for psychologists, with the exception of those who completed specialized graduate programs or clinical internships in forensic psychology. A third difference is that whereas traditional mental health assessments are based principally on a clinical interview with the individual, risk assessments place much greater emphasis on historical factors that can be assessed through case records or collateral informants. Thus, risk assessments can, and often must, be done without the cooperation of the person who is being evaluated.

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There are three primary methods of conducting risk assessments. They can be differentiated on the basis of the structure or systematization they impose on the assessment process: gathering information, collating it, and using it to reach a judgment. The first method, commonly referred to as the clinical method, has no structure. All the parameters for the assessment of the individual are determined by the evaluator. The second method relies on professional guidelines which provide recommendations concerning what information should be obtained, as well as specific risk factors that should be considered. The third method is highly structured. The defining feature of the actuarial method is that a decision-making process is specified. Typically, assessment information is reduced to a set of numbers, which are then combined using an arithmetic algorithm to yield a decision. Increased structure in the assessment process has both positive and negative effects. On the negative side, it decreases flexibility and limits the evaluator's ability to consider case-specific information. On the positive side, it helps to ensure a reasonably comprehensive assessment, increases the accuracy of decisions, and reduces the risk of liability. In the view of the authors the professional and research literatures are sufficiently large that evaluators should not rely solely on clinical methods to assess risk in the vast majority of cases. Professional guidelines and actuarial instruments have been developed specifically to assist in the assessment of risk for institutional self-harm (e.g., Polvi, 1997), institutional misconduct (e.g., Cooke, 1996), postrelease general recidivism (e.g., Andrews, 1983), postrelease general violence (e.g., Violence Prediction Scheme, Webster, Harris, Rice, Cormier, & Quinsey, 1994); 2HCR-20 (Webster, Eaves, Douglas, & Wintrup, 1995), and postrelease spousal and sexual assault (e.g., Spousal Assault Risk Assessment Guide, Kropp, Hart, Webster, & Eaves, 1995); SVR-20 (Sexual Violence Risk Guide, Boer, Wilson, Gauthier, & Hart, 1997).

9.06.5 THE TREATMENT OF MENTALLY ILL OFFENDERS IN JAILS AND PRISONS Being arrested is typically a traumatic experience. Individuals entering jail are often in a state of crisis, with high levels of stress and anxiety being quite common. In addition, many who are arrested have a history of mental health problems. Consequently, pretrial jail facilities may be a highly appropriate place for mental health interventions (Ogloff & Roesch, 1992). A

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jail can provide an excellent opportunity to deliver mental health services to those who need and are interested in obtaining such services. While many jail inmates do not need or desire mental health services, it is likely that a substantial number would benefit from such services, if they were available. It is important to note that inmates retain the right to refuse to participate in treatment so, with few exceptions such as an emergency situation to prevent harm to self or others, the provision of treatment is on a voluntary basis. Since most detainees remain in jail for only a short time, mental health interventions in jails are fairly limited in scope, but inmates may wish to continue involvement after release. For this reason, it is important to ensure that treatment services can be continued outside jail. In this way, interventions in jails can be seen as a starting point, an opportunity to evaluate individuals and provide some short-term crisis intervention if needed, and then provide followup services in the community. A model of treatment that is integrated with community services is more likely to be successful (Ogloff & Roesch, 1992). Jails, however, have traditionally provided little in the way of mental health services. Teplin (1990) noted that most mental health problems go undetected in jails so treatment is unlikely. Even if detected, there is considerable variability in the availability of mental health services in jails. For example, Steadman et al. (1989) conducted a national survey of jail mental health services and found that the emphases in most were on problem identification, including screening and evaluation, and dispensing of medication. Some type of drug or alcohol service was available in the majority of programs, but psychological counseling was available in less than one-half of the jails surveyed. Size of the jail seemed to have some impact on the type of services available. Therapies were unavailable in most small jails but medium-sized jails (51±250 inmates) were more likely than large jails to employ professional staff to deliver therapy and referral services. What mental health services should be available in jail? The first step in determining services is to identify the needs of the jail population. An effective jail mental health program must begin with a brief mental health evaluation of all inmates soon after their admission. Ideally, this would be done by a mental health professional, but this is not always feasible. In some jails, correctional officers have been trained to conduct these interviews. The evaluation focuses on immediate mental health needs and, in particular, the risk for suicide or violent behavior. Research has consistently

reported that suicide is the leading cause of death among jail detainees, often occurring within the first day or two after arrest. Selfmutilation is also a common problem. Early identification and subsequent crisis or suicide intervention programs, therefore, are of paramount importance. Cox, Landsberg, and Paravotti (1989) suggested that suicides in a jail can be reduced if correctional officers are trained to identify inmates at risk, provided that clinical services are available to these referrals. Their model for crisis intervention incorporates the following procedures to identify suicidal and seriously mentally ill inmates, and provide for their safety and timely access to appropriate levels of mental health care: (i) policy and procedural guidelines that outline administrative and direct service actions that enable staff to identify, manage, and serve high-risk mentally ill and suicidal inmates; (ii) suicide prevention intake screening methods that can be administered by jail officers during intake to identify high-risk inmates; (iii) a training program for jail officers in suicide prevention; and (iv) the use of a mental health practitioner's manual designed to provide basic information to staff providing clinical care in the jail. It was further suggested that emergency outpatient services, inpatient services, and nonemergency mental health services are also essential components in effectively meeting the needs of suicidal and other high risk inmates. Implementation of this program in one jail resulted in a 33% decline in suicides during the first year of their study. Although identification and treatment services are becoming increasingly available in local jails, few jail programs are coordinated with outpatient services for the continuation of treatment after release. Steadman et al. (1989) proposed a comprehensive approach where identification, treatment, and referrals for ongoing care with inpatient mental health facilities or community service agencies are essential components. The key to a well-functioning system of ongoing treatment and integration into the community is interagency cooperation between the criminal justice and mental health systems. Adequate communication between these two systems permits the essential continuity of care necessary for mentally disordered offenders to ªdevelop appropriate coping behaviors for situational catalysts that may contribute to recidivism' (Ogloff & Otto, 1989, p. 366). Unfortunately, such continuity of treatment and intra-agency cooperation occurs all too infrequently. Based on their jail study, Steadman

The Treatment of Mentally Ill Offenders in Jails and Prisons et al. (1989) found that one consistent factor seemed to be associated with more effective jail/ community programs, and that was the existence of a core position that was responsible for managing the interactions of mental health, jail, and judicial personnel. Steadman (1992) used the term boundary spanners to characterize these individuals because they were able to cross over the boundaries of the separate systems and ensure that the needed services were being provided. For those interested in establishing a viable program, it may be essential to have an individual who is responsible for ensuring that the two systems interact effectively and efficiently. In contrast to jails, inmates in prisons typically are detained for longer periods of time. This increased detention period provides an opportunity to provide more intensive and longer-term interventions with inmates (Ogloff, Roesch, & Hart, 1994; Webster, Hucker, & Grossman, 1993). Once an inmate is assessed, he or she should be referred to an appropriate treatment program within the correctional facility. If the inmate has a serious mental illness, and there is no existing treatment program available, the law would require that the prison provide individual psychological or psychiatric treatment to the inmate (Ogloff et al., 1994). Despite the legal requirements for providing mental health services and treatment in prisons, one of the primary impediments to prison treatment is a lack of motivation among many prison inmates to participate in the treatment programs. Consequently, inmates who might otherwise benefit from treatment do not take advantage of such programs. The most common form of treatment in prisons is psychotropic drug therapy (Bloom & Bradford, 1988; Gudjonnson, 1990). Various forms of behavior therapy, particularly cognitive behavior therapy, are among the more popular types of psychotherapy (Gudjonnson, 1990). Some prisons have developed specific treatment programs for subgroups of inmates, such as sexual offenders (Bloom & Bradford, 1988), suicidal inmates (Ramsey & Tanney, 1987), or psychopaths (Ogloff, Wong, & Greenwood, 1990; Rice, Harris, & Cormier, 1992). There are several subpopulations in jail that could be identified for treatment. One group would comprise those who have been arrested for domestic violence. Spousal assault is especially common among offenders. For example, Dutton and Hart (1992) surveyed male prison inmates and found that nearly 30% had a history of family violence, with the most common type of violence being wife assault. In recognition of the prevalence rates, some jails

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and prisons are developing institution- and community-based programs for treating offenders with a history of wife assault, as well as establishing training programs to help staff better identify and manage such offenders. One of the most comprehensive treatment programs for mentally disordered offenders was developed in the New York Correctional System (see Steadman et al., 1989). The New York City Board of Corrections proposed minimum standards for mental health services in jails and prisons with the following service goals: crisis intervention and the management of acute episodes; suicide prevention; stabilization of the mentally ill and the prevention of deterioration in the prison setting; and elective therapy services and preventive treatment where resources exist. The standards further include criteria for identification and detection, training of staff, suicide prevention, diagnosis and referral, 24 hour access to nonemergency mental health services, and inpatient mental healthcare. Treatment options in the program are based on a needs assessment that determines the type and prevalence of problems requiring treatment, such as depression, suicide, or disruptive behavior (Dvoskin & Steadman, 1989; Steadman & Holohean, 1991; Toch & Adams, 1986). This more specific, problemoriented approach could lead to the development of more effective treatment programs. One subpopulation that already receives considerable attention are those whose competency to stand trial is being evaluated. Some studies have found that evaluations of competency are increasing, perhaps due to the changes in mental health commitment laws noted above (Roesch & Golding, 1985). Defendants are often transferred to a forensic facility for a period of up to 30 days for an assessment. The vast majority of these referrals are found competent, a finding that is at least in part due to the fact that many defendants are referred as a means to get them out of jail and into a mental health treatment facility rather than the result of a real concern for their fitness to stand trial. Again, this supports the need for mental health services in jails in order to minimize the inappropriate use of other mechanisms for obtaining treatment. Inmates with alcohol and substance abuse comprise another identifiable group. Abram and Teplin (1991) found considerable overlap of mental disorder and drug or alcohol abuse in jail populations. This has been referred to as cooccurring disorders. The high rate of individuals with co-occurring disorders suggests the need for treatment programs both within jail and subsequent to release. Abram and Teplin suggested that these individuals might be

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particularly appropriate for alternative to prosecution, such as pretrial diversion programs. 9.06.5.1 The Surrey Pretrial Mental Health Project The authors have been involved in the development of a comprehensive mental health program in a pretrial jail (Ogloff & Roesch, 1992). This project will be described briefly as an example of the type of program that forensic clinicians might help develop in local jails. The Mental Health Project at the Surrey Pretrial Services Centre (SPSC) began when SPSC opened in 1991. The facility houses approximately 160 inmates. Services offered by the project include screening for mental illness, assessment, treatment, institutional and community case planning and case management, liaison with other correctional institutions, as well as the training and utilization of correctional staff in the identification and management of mentally disordered inmates. The participation of community mental health services and forensic outpatient services makes community linkage possible. A key aspect of the project is the initial interview conducted by senior doctoral students in a clinical psychology program at a local university. The screening interviews last approximately 10±15 minutes each and consist of a brief semistructured mental status interview covering seven content areas: personal/demographic information, suicide risk, orientation to time and space, criminal history, social adjustment during the past month, mental status in the past month, and mental health history. Particular attention is also paid during the intake assessment to identify inmates who require crisis intervention services, and who may be at risk for self-harm or suicide. Such inmates are reported immediately to the correctional officer in charge so that necessary intervention/precautions may be taken. Similarly, attempts are made during the screening interview to identify those individuals who may be a danger to others. In 1995, 4412 inmates (85% of all admissions) were screened, with 1377 (31%) referred to the jail mental health team for further assessment and possibly intervention in the jail and following release. Approximately one-fifth of the referred inmates were considered to have a serious mental disorder. Because of the limited time that most inmates spend in the SPSC, there is little opportunity for ongoing individual psychotherapy. Thus, much of the mental health treatment is limited to focused treatment groups as well as limited counseling and/or psychotherapy. With its

community focus, one of the most important goals of the project is to identify the need for mental health intervention for inmates and to ensure that they are linked to appropriate mental health services agencies in the community, or in another correctional facility to which they may ultimately be sentenced. One problem in developing an integrated community-based treatment program is the manner in which treatment and other services are divided among many different agencies. Often, there are disagreements between agencies over which one is responsible for providing treatment. For example, many mentally disordered offenders have two or more DSM Axis I disorders, usually substance abuse along with some other diagnosis. The community mental health system may refuse to treat such individuals, arguing that they fall under the jurisdiction of the alcohol/drug programs, but the latter programs feel that these dual diagnosis cases are not appropriate for treatment by them because the mental disorder must be treated before treatment for the addiction can take place. In short, there is no coordinated treatment effort, no attempt to focus on the individual who may have a range of problems, and may require interventions from a variety of perspectives. Clearly, for a project like this to be successful, there is a need to develop an integrated service delivery system in which the individual, and not the type of problem, is seen as the primary focus. 9.06.5.2 Unique Concerns for the Treatment of Female Offenders It has been documented that women experience a variety of adjustment problems in jail and prison (e.g., Ingram-Fogel, 1991; MacKenzie, Robinson, & Campbell, 1989; Sultan et al., 1984). There have been some studies conducted on the effectiveness of different treatment approaches to women's adjustment and coping in jails and prisons (e.g., MacKenzie et al., 1989; Sultan, Kiefe, & Long, 1986; Sultan et al., 1984). There have also been studies conducted on treatment approaches to specialized problems, such as anger (Wilfley, Rodon, & Anderson, 1986) as well as sexual and physical abuse (Sultan & Long, 1988). However, there are no published studies on the treatment of mental disorder among women in jails and prisons. Steadman et al. (1989) surveyed 43 jail mental health programs in the USA and concluded that 100% of these institutions offer medication as a means of treating mental disorders, whereas only 30% offer any form of therapy or counseling. It may be that mentally disordered female inmates are either being diverted to the mental health system from the criminal justice

References system or are being treated only with medications while incarcerated. Research is needed to clarify the issue of the treatment of mental disorder among women in jails and prisons. 9.06.6 CONCLUSION The literature on the prevalence, assessment, and treatment of mentally disordered offenders in jails and prisons has been reviewed. The review of the jail literature suggests that the prevalence of mental disorder in jails is high and probably on the increase; consequently, it is believed that it is important that mental health services be made available in jails. The emphasis of these services should be on brief screening assessments, crisis intervention, and community follow-up after release from jail. Increased use of diversion program for some mentally ill pretrial defendants should also be considered. With respect to prison mental health issues, it is recognized that the population of mentally ill inmates is smaller than in the jails, but nevertheless a range of psychological services, including assessment and treatment, should be considered an integral part of prison programs. Finally, some unique issues related to women with mental health problems in prisons and jails were reviewed. 9.06.7 REFERENCES Abram, K. M., & Teplin, L. A. (1991). Co-occurring disorders among mentally ill jail detainees: Implications for public policy. American Psychologist, 46, 1036±1045. Adams, K. (1986). The disciplinary experiences of mentally disordered inmates. Criminal Justice & Behavior, 13, 297±316. Allodi, F., Kedward, H., & Robertson, M. (1977). Insane but guilty: Psychiatric patients in jail. Canada's Mental Health, 25, 3±7. American Bar Association (1989). ABA criminal justice mental health standards. Washington, DC: Author. American Law Institute (1962). Model Penal Code. Washington, DC: Author. American Psychiatric Association (1987). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. Andrews, D. A. (1983). The Level of Supervision Inventory (LSI): The first follow-up. Toronto, ON: Ontario Ministry of Correctional Services. Appelbaum, P. S. (1986). Competence to be executed: Another conundrum for mental health professionals. Hospital and Community Psychiatry, 37, 682±684. Austin, J., & Krisberg, B. (1981). Wider, stronger, and different nets: The dialectics of criminal justice reform. Journal of Research in Crime and Delinquency, 18 165±196. Binder, A., & Binder, V. L. (1983). Juvenile diversion. Counseling Psychologist, 11, 69±77. Birecree, E. A., Bloom, J. D., Leverette, M. D., & Williams, M. (1994). Diagnostic efforts regarding women in Oregon's prison system: A preliminary report. International Journal of Offender Therapy and Comparative Criminology, 38, 217±230. Bloom, J. D., & Bradford, J. M. (1988). An overview of

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Steadman, H. J., Fabisiak, M. A., Dvoskin, J., & Holohean, E. J. (1987). A survey of mental disability among state prison inmates. Hospital and Community Psychiatry, 10, 1086±1090. Steadman, H. J., & Holohean, E. J. (1991). Estimating mental health needs and service utilization among prison inmates. Bulletin of the Academy of Psychiatry and Law, 19, 297±307. Steadman, H. J., McCarty, D. W., & Morrissey, J. P. (1989). The mentally ill in jail: Planning for essential services. New York: Guilford. Steadman, H. J., & Monahan, J. (1984). Crime and mental disorder. Washington, DC: US Department of Justice. Steadman, H. J., & Ribner, S. (1980). Changing perceptions of the mental health needs of inmates in local jails. American Journal of Psychiatry, 137, 1115±1116. Sultan, F. E., Kiefer, A. A., & Long, G. T. (1986). The application of psychodidactic support groups to facilitate female offenders' adjustment to prison. Psychotherapy, 23, 469±471. Sultan, F. E., & Long, G. T. (1988). Treatment of the sexually/physically abused female inmate: Evaluation of an intensive short-term intervention program. Journal of Offender Counseling, Services, and Rehabilitation, 12, 131±143. Sultan, F. E., Long, G. T., Kiefer, A. A., Schrum, D. M., Selby, J. W., & Calhoun, L. G. (1984). The female offender's adjustment to prison life: A comparison of psychodidactic and traditional supportive approaches to treatment. Journal of Offender Counseling, Services, and Rehabilitation, 9, 49±56. Swank, G. E., & Winer, D. (1976). Occurrence of psychiatric disorder in a county jail population. American Journal of Psychiatry, 133, 1331±1333. Teplin, L. A. (1983). The criminalization of the mentally ill: Speculation in search of data. Psychological Bulletin, 94, 54±67. Teplin, L. A. (1984). Criminalizing mental disorder: The comparative arrest rate of the mentally ill. American Psychologist, 39, 794±803. Teplin, L. A. (1990). Detecting disorder: The treatment of mental illness among jail detainees. Journal of Consulting and Clinical Psychology, 58, 233±236. Teplin, L. A. (1991). The criminalization hypothesis: Myth, misnomer, or management strategy. In S. A. Shah & B. D. Sales (Eds.), Law and mental health: Major developments and research needs (pp. 149±183). Rockville, MD: US Department of Health and Human Services. Teplin, L. A., Abram, K. M., McClelland, G. M. (1996). Prevalence of psychiatric disorders among incarcerated women, I: Pretrial jail detainees. Archives of General Psychiatry, 53, 505±512. Teplin, L. A., Abram, K. M., & McClelland, G. M. (1997).

Mentally disordered women in jail: Who receives services? American Journal of Public Health, 87, 604±609. Teplin, L. A., & Swartz, J. (1989). Screening for severe mental disorder in jails: The development of the Referral Decision Scale. Law and Human Behavior, 13, 1±18. Toch, H., & Adams, K. (1988). Pathology and disruptiveness among prison inmates. Journal of Research in Crime and Delinquency, 23, 7±21. Torrey, E. F., Stieber, J., Ezekiel, J., Wolfe, S. M., Sharfstein, J., Noble, J. H., & Flynn, L. M. (1992). Criminializing the seriously mentally ill: The abuse of jails as mental hospitals. Washington, DC: Public Citizen's Health Research Group and the National Alliance for the Mentally Ill. Turner, T. H., & Tofler, D. S. (1986). Indicators of psychiatric disorder among women admitted to prison. British Medical Journal, 292, 651±653. US Department of Justice (1995). Jails and jail inmates 1993±94. Washington, DC: Bureau of Justice Statistics. Washington, P., & Diamond, R. J. (1985). Prevalence of mental illness among women incarcerated in five California county jails. Research in Community and Mental Health, 5, 33±41. Webster, C. D., Eaves, D., Douglas, K., & Wintrup, A. (1995). The HCR-20 scheme: The assessment of dangerousness and risk. Burnaby, BC: Mental Health, Law, and Policy Institute, Simon Fraser University and Forensic Psychiatric Services Commission of British Columbia. Webster, C. D., Harris, G., Rice, M. E., Cormier, C., & Quinsey, V. L. (1994). The violence prediction scheme: Assessing dangerousness in high risk men. Toronto, ON: Centre of Criminology, University of Toronto. Webster, C. D., Hucker, S. J., & Grossman, M. G. (1993). Treatment programmes for mentally ill offenders. In K. Howells & C. R. Hollin (Eds.), Clinical approaches to the mentally disordered offender (pp. 87±109). Chichester, UK: Wiley. Whittemore, K. E., Ogloff. J. R. P., & Roesch, R. (1997). An investigation of competency to participate in legal proceedings in Canada. Canadian Journal of Psychiatry, 42, 869±875. Wildman, R. W., II, White, P. A., & Brandenburg, C. A. (1990). The Georgia Court Competency Test: The baserate problem. Perceptual and Motor Skills, 70, 1055±1058. Wilfley, D. E., Rodon, C. J., & Anderson, W. P. (1986). Angry women offenders: Case study of a group. International Journal of Offender Therapy and Comparative Criminology, 30, 41±51. Zapf, P. A., & Roesch, R. (1997). Assessing fitness to stand trial: A comparison of institution-based evaluations and a brief screening interview. Canadian Journal of Community Mental Health, 16, 53±66.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

9.07 Violent and Chronic Offenders ISAAC K. WOOD Virginia Commonwealth University, Richmond, VA, USA 9.07.1 INTRODUCTION

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9.07.2 PHENOMENOLOGY

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9.07.3 EPIDEMIOLOGY AND ETIOLOGY

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9.07.4 INTERVENTION

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9.07.5 CLINICAL APPLICATION

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9.07.5.1 9.07.5.2 9.07.5.3 9.07.5.4

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Cognitive Problem-solving Skills Training Parent Management Training Functional Family Therapy Multisystemic Therapy

9.07.6 SUMMARY

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9.07.7 REFERENCES

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through age 27. More than half of all violent offenders initiate their violence between ages 14 and 17 and their careers last only one year, with only 4% with a career of five years or more (Elliot, 1994; Elliot, Huizinga, & Morse, 1986). In fact, aggression is a very stable behavioral trait and involvement in violent behavior at an early age is the best predictor of a youth becoming a chronic violent offender. Therefore, to understand violent and chronic offenders, an analysis of this small group of youth must be undertaken. The purpose of this chapter is to explore the characteristics of children and adolescents who become violent and chronic offenders. It is hoped that by understanding the antecedents to aggressive behavior, a more rational, comprehensive, and exhaustive plan of intervention may be developed. To best discern the attributes of youthful violent and chronic offenders, it is necessary to explore the various systems that contribute to the environments of these juveniles. This will require an analysis of the systems most intimate and internal to the child, namely

9.07.1 INTRODUCTION The crime rate in the United States, particularly among youthful offenders, is growing at an astronomical rate. Of most concern is the increase in the occurrence of youthful violent crime. From 1992 to 1993, the total juvenile arrest rate increased by 5% and juvenile arrests for violent crimes increased 6%. Arrests for weapons violations by youthful offenders rose by 12%, and the arrest rate for homicide increased 14%. At the same time, adult changes in these categories were negligible (Howell, 1995). Evidence continues to mount that a small proportion of offenders commit most of the serious and violent crimes. It is this small group that captures the public interest in making decisions about policies related to interventions with criminals as a whole. Furthermore, it is known that the onset of serious violent careers begins to increase at age 12, doubles between ages 13 and 14, peaks at ages 16 to 17, drops 50% by age 18, and continues to decrease 105

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the biology of chronic, violent offenders, and working outward to the most external spheres of influence on these youth. 9.07.2 PHENOMENOLOGY There is no uniform definition of a violent and chronic offender. In fact the term ªviolent and chronic offenderº is highly controversial and political. According to the Office of Juvenile Justice and Delinquency Prevention (Howell, 1995), states and local jurisdictions are responsible for establishing the criteria for designating an individual as a chronic and violent offender. Many factors, therefore, influence the specific criteria used to identify this group of criminals. For example, if a community has a particularly low threshold of tolerance for violent crime, the types of aggressive behaviors that would lead to the use of this label will be quite broad. However, in large metropolitan areas, the criminal justice system is often overwhelmed by the numbers of offenders. Designating a group as ªchronic and violentº usually carries with it the expectation that these individuals will be dealt with in the most restrictive settings. The most restrictive settings are also usually the most expensive. Therefore, in systems with limited financial resources and a high rate of crime, the criteria for a violent and chronic offender are likely to be quite limited. Regardless, there does seem to be some universal agreement that certain offenses are considered violent. For example, murder, manslaughter, and rape or sexual assault are usually included under the designation of ªviolent offenses.º Armed robbery, malicious wounding, and aggravated assault may also be included. However, beyond this, there is a great deal of variation. The chronicity of offenses may be determined based on police contacts or convictions. A conservative definition of criminal chronicity would be conviction of a least three felonies or three serious misdemeanors. In many ways, these designations are arbitrary and meaningless. Legal definitions do little to explain the trajectory of development of criminal behavior or the most effective methods of intervention. To arrive at this information, clinical definitions related to violent and chronic offenders must be explored. The vast majority of violent and chronic offenders first exhibit these behaviors in late childhood and early adolescence (Loeber & Stouthamer-Loeber, 1998). Therefore, it would seem prudent to begin an exploration of clinical definitions by looking at designations for juvenile offenders. The Diagnostic and statistical manual of mental disorders (DSM-III; American Psychiatric Association, 1980) has no designation for

ªjuvenile offenders.º However, in place of this, there is a category for youth who demonstrate a basic disregard for rules, law, and authority. This would be the diagnosis of ªconduct disorder.º According to DSM-III and DSM-IV (American Psychiatric Association, 1994), a youth under the age of 18 may be diagnosed as having a conduct disorder if he has demonstrated ªa repetitive and persistent pattern of behavior in which the basic rights of others or major ageappropriate societal rules or norms are violatedº (p. 85). Three such behaviors must have been present for the last 12 months with at least one being present in the last six months, and the disturbance must significantly affect social, academic, or occupational functioning. The behaviors that may lead to a diagnosis of conduct disorder are grouped under four designations: (i) Aggression to people and animals: (a) often bullies, threatens, or intimidates others, (b) often initiates physical fights, (c) has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun), (d) has been physically cruel to people, (e) has been physically cruel to animals, (f) has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery), or (g) has forced someone into sexual activity. (ii) Destruction of property: (a) has deliberately engaged in fire setting with the intention of causing serious damage, or (b) has deliberately destroyed others' property (other than by fire setting). (iii) Deceitfulness or theft: (a) has broken into someone else's house, building, or car, (b) often lies to obtain goods or favors or to avoid obligations (i.e., ªconsº others), or (c) has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery). (iv) Serious violations of rules: (a) often stays out at night despite parental prohibitions, beginning before age 13 years, (b) has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period), or (c) is often truant from school, beginning before age 13 years. Based on these criteria, a youth could stay out past curfew, skip school, and shoplift, and be

Phenomenology diagnosed with a conduct disorder. By the same token, a juvenile could commit rape, armed robbery, and assault with a deadly weapon, and also be diagnosed with a conduct disorder. Just from the standpoint of the levels of aggression involved, common sense suggests that these two youth are most likely very different from each other in regard to the development of these behaviors and contributing circumstances. In an attempt to better understand youth with a conduct disorder, several attempts have been made to subclassify these juveniles. Historically, these classification systems are based on descriptive criteria which imply little about the underlying etiology or natural course of the disorder. In DSM-III, conduct disordered youth are placed in four categories based upon two dimensions of behavior; the presence or absence of aggression and whether behaviors are socialized or undersocialized. The designation of ªaggressiveº or ªnonaggressiveº is self-evident. An aggressive act would be one in which there is direct or indirect confrontation of the victim with harm to the victim. This would include physical and sexual assaults, rape, and murder. Nonaggressive acts would include those offenses whereby there is either no direct contact with the victim (e.g., shoplifting, breaking and entering), there is contact with the victim but no harm is done, or those crimes that are considered ªvictimless.º This would include criminal offenses and status offenses. Criminal offenses would be any act that is considered illegal regardless of the age of the perpetrator. Whether you are 14, 44, or 84 years old, assault, destruction of property, and vandalism are considered crimes. Status offenses would be any act that is considered illegal for a minor but not so for an adult. Examples of status offenses would include under age use of alcohol, truancy, staying out past curfew, and running away from home. The concepts of ªsocializedº vs. ªundersocializedº need explanation. The ªsocializedº types of conduct disordered youth ªshow evidence of social attachment to others, but may be similarly callous or manipulative toward persons to whom they are not attached and lack guilt when these ªoutsiders' are made to suffer.º In contrast, the ªundersocializedº types of conduct disordered youths are ªcharacterized by a failure to establish a normal degree of affection, empathy, or bond with others. Peer relationships are generally lacking, although the youngster may have superficial relationships with other youngsters. Characteristically, the child does not extend himself or herself for others unless there is an obvious immediate advantage. Egocentrism is shown by readiness to manipulate others for favors without any effort to reciprocate. There is generally a lack of

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concern for the feelings, wishes, and well-being of others, as shown by callous behavior. Appropriate feelings of guilt or remorse are generally absent. Such a child may readily inform on his or her companions and try to place blame on themº (American Psychiatric Association, 1980, p. 45). With this two-dimensional scheme, four subcategories of conduct disorder are designated. A youth may be socialized and aggressive. This suggests that the youth's disruptive behavior tends to be violent in nature and usually occurs within the context of a group of similar juveniles to whom the offender expresses loyalty. In colloquial terms, these youth are often considered members of ªgangs.º By the same token, a juvenile may be undersocialized and aggressive. This means that the juvenile's conduct disordered behaviors are violent, and that the youth is a loner who fails to demonstrate remorse for his or her behavior or empathy or affection towards others. In the vernacular, these offenders are often referred to as ªsociopaths.º A third designation is socialized and nonaggressive. These youth exhibit nonviolent behavior consisting primarily of rules violations, status offenses, and minor illegal activities such as property crimes within the context of a group. The overwhelming majority of youth who meet the criteria for a conduct disorder fall into this category. In fact, it is estimated that over 90% of adults have engaged in similar, delinquent behaviors at some point during adolescence. Therefore, the severity and chronicity of these behaviors, plus the degree to which the behaviors impact on the functioning of the youth and his or her family seem to be the most critical factors in this group as far as designating the presence or absence of pathology. Last, a conduct disordered youth may be labeled as nonaggressive and undersocialized. This category of youth are practically nonexistent as it seems that juveniles who are undersocialized are invariably violent in their conduct disordered behaviors. In addition, with youth who meet these behavioral criteria, a more appropriate diagnosis suggesting either pathology in the schizophrenia spectrum of illnesses or Cluster A personality disorders (i.e., paranoid, schizoid, and schizotypal) often is more appropriate in describing the underlying disorder. DSM-III-R (American Psychiatric Association, 1987) attempts to eradicate the problems of the previous nomenclature by suggesting three new subcategories for conduct disorder. The essential feature for youth designated as having a ªgroup typeº of conduct disorder is a ªpredominance of conduct problems occurring mainly as a group activity with peers. Aggressive physical behavior may or may not be

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presentº (p. 56). This tends to encompass the prior categories of socialized conduct disorder, whether the behavior be aggressive or nonaggressive. A juvenile described as having a ªsolitary aggressive typeº of conduct disorder demonstrates a ªpredominance of aggressive physical behavior, usually toward both adults and peers, initiated by the person (not as a group activity)º (p. 56). This, in essence, is a mere renaming of the ªundersocialized, aggressiveº conduct disorder. Last, a youth may be designated as having an ªundifferentiatedº conduct disorder, which represents the designation for those juveniles who do not fit into one of the other two categories. DSM-III-R nomenclature presents a new set of problems. First, the clustering of youth under the description of ªgroup typeº clearly creates an extremely heterogenous association. Included in this designation would be the extremes of violent gang members who may commit heinous crimes to those youth who fraternize with antisocial or counterculture peers and engage in status offenses, but who are not serious offenders. Such a radically heterogenous grouping presents insurmountable obstacles to research about the etiology of such behaviors. Second, this classification runs counter to epidemiological evidence suggesting a developmental schema for conduct disorder related to the age of onset rather than clustering based on group or nongroup affiliation. In order to address these problems, DSM-IV presents a new designation for the subtypes of conduct disorder based on age of onset. If the disruptive behaviors start before the age of 10 years, the child is given the diagnosis of ªchildhood-onset conduct disorder.º Signs of the disorder beginning at the age of 10 or thereafter are designated as ªadolescent-onset conduct disorder.º This subclassification suggests that there are differences in the developmental trajectory for conduct disorder related to age of onset. It also lends itself well to an understanding of serious and violent offenders as chronic; habitual, violent offenders are greatly over-represented in the childhood-onset group. The vast majority of serious and violent offenders demonstrate the onset of aggressive behavior at a very early age with a decrement in violence in late adolescence and early adulthood (Elliot et al., 1986). Therefore, a focus on the epidemiology and etiology of the subtypes of conduct disorder that best encompasses the characteristics of serious and violent offenders is most prudent. Based on DSM-III, DSM-III-R, and DSM-IV, this includes a review of undersocialized-aggressive, solitary aggressive, and childhood-onset conduct disorders.

9.07.3 EPIDEMIOLOGY AND ETIOLOGY Considering that multiple systems are involved in the development of serious and violent offenders, one approach to understanding these youth is to start with the most internal structures, namely the psychobiology of these juveniles, and then work outward to the most external structures. Is it possible that a child may be ªborn bad?º Are some individuals genetically predisposed to be violent? In the animal literature, two types of aggressive behavior are described. ªPredatory aggressionº involves such activities as stalking other animals for a kill, the violence that ensues when one animal infringes upon the marked territory of another, or the posturing and attacks exhibited by nursing mothers when any animal, even the mate, approaches the nest. In contrast, ªaffective aggressionº refers to the violent response of an animal to an emotional state. Affective aggression is characterized by ªautonomic arousal, threatening or defensive postures and vocalizations, and, often, frenzied attacksº (Flynn, Vanegas, & Foote, 1970). In vitro measures of affective aggression are obtained by shocking the floor of a mouse or rat's cage while at the same time introducing a foreign object, such as a brush, a pencil, or another animal. In response to the shock, the animal will viciously attack the foreign object. This is more clearly the classic fight-or-flight response. The animal literature clearly indicates that mammals may be bred to have higher and lower thresholds for both predatory and affective aggression. This results in a broad spectrum of behaviors to include animals who will attack with minimal stimulation to those who freeze and cower even in the presence of a clearly threatening situation (Petitto, Lysle, Gariety, & Lewis, 1994). Furthermore, it is clear that environmental circumstances may alter the degree and types of violence exhibited. For example, rodents, who at the age of weaning are raised in solitary isolation exhibit much higher levels of predatory and affective aggression than their litter mates who are raised in a group (Schneider-Stock & Epplen, 1995). Are there similar findings in humans? Quite clearly, humans demonstrate both predatory and affective aggression. Predatory aggression is most evident in the violent activities of gang members who often mark their territories by spray painting buildings, fences, and walls in lieu of using urine or other scents deployed by ªlowerº mammals. Also, humans demonstrate affective aggression with outbursts of rage in response to frustration or the lack of immediate gratification of needs.

Epidemiology and Etiology However, is there a genetic basis for such behaviors in man? The simplest genetic study that may be done on aggression and conduct disorder is to examine the incidence and prevalence of these behaviors in boys and girls. Aggressive conduct disorder is overwhelmingly and universally manifested in boys at a significantly higher rate than in girls (Hinshaw, Lahey, & Hart, 1993). This suggests some type of genetic vulnerability to conduct disorder in boys that is not evident in girls, highly differential environmental experiences based on gender, or a significant influence of hormones. To further explore the contribution of genetics, it seems expedient to examine data regarding the incidence of conduct disorder in the first-degree relatives of children who are chronically violent. Family studies of children with conduct disorder demonstrate a significantly higher rate of this diagnosis in siblings, particularly brothers, and a higher rate of antisocial personality disorder in parents, fathers much more so than mothers. In addition, there is an extremely high prevalence of attention deficit hyperactivity disorder, alcoholism, aggressive behavior, and criminality in fathers and brothers, and depression, somatization disorder, and substance abuse in mothers and sisters of male probands with an aggressive conduct disorder (August & Stewart, 1983; Biederman, Munir, & Knee, 1987; Hamdan-Allen, Stewart, & Breghly, 1989; Lahey et al., 1987). This suggests a clustering of these diagnoses within families of boys who have an aggressive, earlyonset conduct disorder. Yet, these data still do not clearly answer the question of the relative contribution of genetic and environmental factors. This is best addressed by examining twin and adoption studies. Twin studies involve the use of monozygotic and dizygotic twin pairs. Monozygotic twins are formed from the splitting of one ovum that has been fertilized by one sperm. Subsequently, these twins share 100% of their genetic material. Dizygotic twins result from two ova being fertilized by two separate sperm. The genetic material of these twins is no more related than that of one of the twins and a brother or sister and would be estimated as 50%. Thus, if a disorder is genetically based, when it appears in one twin, the concordance rate (i.e., the likelihood of the disorder occurring in the other twin) should be significantly higher in monozygotic than dizygotic sibling pairs. Several studies have substantiated this finding. The relative concordance rate for criminality in monozygotic twins is 51%, whereas the rate in dizygotic twins is 22% (Christiansen, 1976; Cloniger & Gottesman, 1987; Dalgaard &

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Kringlen, 1976). This again suggests that there is a genetic contribution to the development of this disorder. However, it does not rule out the effect of environment as it has been argued that monozygotic twins, by virtue of being identical, are much more likely to elicit the same reactions from caretakers than dizygotic twins. Therefore, it would be anticipated that the environmental experiences of monozygotic twins would be more homogenous than that of dizygotics. To assess this issue, it becomes necessary to examine adoption studies. The adopted-away offspring of criminal fathers are twice as likely to be antisocial as the adopted-away offspring of noncriminal fathers. Furthermore, the highest criminality rate has been noted in adoptees of criminal fathers who are adopted away to antisocial fathers (Mednick, Gabrielli, & Hutchings, 1984). Studies of Swedish adoptees who are criminals reveal a much higher rate of criminality in their biological fathers than in adoptees who were not antisocial. Given this information, what is inherited that could lead to conduct disordered behavior? Studies on the neurobiological basis of conduct disorder provide some clues. There are a number of studies on the role of the catecholamines in conduct disorder. Those involving the enzyme dopamine-beta-hydroxylase (DBH) are of most interest considering the evidence to suggest a genetic basis or predisposition for this disorder. DBH is the enzyme responsible for converting dopamine to norepinephrine in the catecholamine synthetic pathway. The activity of this enzyme is almost entirely determined by genetic factors. A number of studies demonstrate that boys with an undersocialized-aggressive conduct disorder have significantly lower DBH activity than girls with this type of conduct disorder, children of either gender who have a socialized conduct disorder, and unaffected children. Furthermore, the vast majority of boys with an undersocialized-aggressive conduct disorder have near-zero activity of the enzyme. The anticipated increase in dopamine and decrease in norepinephrine are not found (Rogeness, Jovros, Maas, & Macedo, 1990). This is understandable to a certain degree considering the biochemistry of the catecholamine cascade. All of the catecholamines (i.e., dopamine, norepinephrine, and epinephrine) are formed from the amino acid tyrosine. The rate-limiting step in the formation of the catecholamines is the conversion of tyrosine to dihydroxyphenylalanine (DOPA) by the enzyme tyrosine hydroxylase. The activity of tyrosine hydroxylase is determined by three factors: the amount of the precursor, tyrosine, that is

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available for metabolism; the availability of a cofactor, tetrahydrobiopterin; and feedback inhibition by dopamine. Therefore, when a certain amount of dopamine has been formed, it will shut down further conversion of the precursors to this catecholamine. As a result, it would not be anticipated that there would be excessive dopamine if there is low or near-zero activity of DBH. The failure to find a decrease in norepinephrine is more difficult to explain except it is known that in most individuals, sufficient stores of norepinephrine are synthesized regardless of the activity of DBH. Regardless, this information suggests that the low or near-zero activity of DBH in undersocialized, aggressive, conduct disordered boys does not explain the etiology of this disorder. Rather, it is more likely that low DBH activity is a genetic marker for the type of conduct disorder which yields serious and violent offenders. This also makes sense in that for all of the psychiatric disorders for which a strong genetic predilection is being determined, multiple genetic factors, that is polygenetic inheritance, is being found in association with them rather than a single genetic locus. Several studies also indicate that boys with an undersocialized-aggressive conduct disorder have lower levels of autonomic arousal as per cardiovascular measures and Galvanic skin conductance than unaffected boys or boys with a socialized conduct disorder (Zahn & Kruesi, 1993). The reasons for this underarousal are unknown. In the normal population, studies have indicated the presence of a ªsensation seeking geneº in a limited number of individuals. These individuals do not seem to get the normal autonomic or endorphin rush that most people experience from usual events such as a scary movie, a ride on a roller coaster, or a highly emotionally charged situation. In order to feel aroused, individuals with the sensation seeking gene seem to require more extreme forms of stimulation such as bungee jumping or parachuting. The presence or absence of the sensation seeking gene has not been studied in chronic, violently offending youth. From a theoretical standpoint, it has been postulated that autonomic underarousal may be the basis for the development of a defective conscience. In the typical developing toddler and preschooler, activation of the sympathetic nervous system serves as an internal stimulus signaling the fight or flight response. It is accompanied by heightened emotional arousal and physical changes which are normally associated with anxiety including an increase in heart and respiratory rate and blood pressure, pupillary dilatation, a shunting of the blood away from internal structures such as the gut

and to the muscles, and a general state of ªdiseaseº or ªdispleasure.º In the typical preschooler and toddler, this autonomic response serves to teach the youth about dangers in the environment. When a harmful situation is encountered, the unpleasant sympathetic arousal allows for learning to avoid similar circumstances in the future. As parents intervene to teach young children about what is dangerous or safe and what is ªrightº or ªwrong,º again, arousal of the sympathetic nervous system is called upon to serve as the reinforcer for these ideas. Eventually, the goal is to have a healthy conscience which will elicit sympathetic arousal and displeasure at the thought of doing something wrong before the act even commences. As boys with an undersocialed, aggressive conduct disorder do not experience the normal types of autonomic, physical reactions to anxiety-provoking situations, it is hypothesized that they do not adequately internalize norms related to what is ªrightº or ªwrong.º Furthermore, this lack of activation of the autonomic nervous system seems to play an integral role in the baseline emotional states of these boys and their subsequent behaviors (Quay, 1993). The majority of the boys, particularly once they are adolescents, when asked to describe their mood will respond with ªbored.º It is not unusual to hear them recount an act of criminal behavior as being exciting with an accompanying increase in emotional arousal. This often explains the crimes these youth engage in which to the outside observer seems pointless, such as when one or several of these youth rob a home just to give or throw away the articles that are stolen. The monoamine serotonin is also implicated as a correlate of aggression. Studies of peripheral and central serotonin activity demonstrate correlations between levels of serotonin and aggression, with the most violent youth having the lowest levels of serotonin. These results have been reinforced by studies examining the platelet binding of imipramine which indirectly reflects serotonin levels. Again, in aggressive, conduct disordered boys, there is decreased binding suggesting low peripheral concentrations of the neurotransmitter serotonin. Within the central nervous system, serotonin is found in high concentrations in the raphe nucleus within the brainstem. From there, serotonergic neurons emanate to all areas of the cortex, diencephalon, brainstem, cerebellum, and spinal cord where they are known to play a neuromodulatory role. Specifically, serotonin tends to play a role as a behavioral suppressant. It is known that adequate levels of serotonin serve an integral role in the regulation of mood, prevention of unnecessary anxiety, and in maintaining baseline attention (as opposed to

Epidemiology and Etiology phasic shifts of attention in response to internal or external stimuli) (Bear, Connors, & Paradiso, 1996). Regardless, current studies suggest a genetic predilection to the development of a childhood-onset conduct disorder, and accompanying abnormalities in neurotransmitter levels. Social epidemiologic data on children who will become chronic, violent offenders suggest several defining characteristics. First, these children typically come from poor, urban centers characterized by overcrowded, insufficient public housing. This is not to say that chronic, violent offenders do not exist in the rural environment. In fact, there are data to support the appearance of such behaviors, often in the context of a gang with racial or religious ties, in many rural environments. However, the typical youth with a childhood-onset conduct disorder will evolve within a poor, urban center. Prenatal care, if there is any, is complicated by improper nutrition and substance abuse including the abuse of crack cocaine and alcohol. As would be expected, there is an increased risk of perinatal difficulties in these youth including premature birth, low birth weight for gestational age, and low APGAR scores at the time of birth (Kazdin, 1995). Families of origin tend to be large relative to the general population. As there are more individuals of ethnic minority represented in the poor, urban population, it is not unusual to see that youth who will be labeled as having a childhood-onset conduct disorder will also be from the racially under-represented parts of the population. Here, the debate on nature vs. nurture becomes heated. Overall, the consensus seems to suggest that these life circumstances are integral in the development of conduct disorder as opposed to there being a higher incidence of chronic and violent behavior in children from ethnic minorities (Kazdin, 1995). There are often different birth fathers for the children born to the mothers of these children, and a lack of availability of a paternal figure for emotional or financial support of the mother or children. Mothers of these children often begin child bearing at an early age and the maternal and paternal grandparents, grandmothers in particular, are often the nucleus of these families. The propensity towards violence and substance abuse in the fathers of these youth results in a high rate of domestic violence in the families of chronic and violent offenders (Kazdin, 1995). There have been variable results of studies about the temperaments of these babies. Chess and Thomas (1991) described three basic types of temperaments in infants. Easy babies tend to be extremely flexible in response to the internal and

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external environments. They settle and accommodate very readily to new experiences. On the opposite extreme, difficult babies are overly responsive to change in their worlds. They are frequently described as colicky, cranky babies that are not easily soothed and are overwhelmed with minimal fluctuations in the internal and external environment. In between are the slowto-warm-up infants. These babies often respond like difficult infants during novel situations, but settle much more readily in adjustment to the change, appearing like their counterparts, the easy babies. Some studies have suggested that youth who will evolve into chronic, violent offenders are more likely to have a difficult temperament, however, this has been disputed by other researchers (Lewis, 1991). In summary, youth who tend to be chronic and violent offenders are most often boys who demonstrate a genetic propensity to these types of behaviors. With this, there are abnormalities in neurochemical functioning associated with an increase in aggressive behavior. The intrauterine environment is often subjected to toxins such as illicit drugs and the absence of appropriate nutrition in the mothers. Perinatal insults are common and further compromise the integrity of the developing nervous system. These infants are raised in poor, urban, single parent families where domestic violence is common. There is some evidence to suggest that these infants tends to have a difficult temperament. Their mothers are ill-prepared to nurture them. There are usually multiple siblings and the absence of a father figure to provide support. The mothers tend to be burdened by problems with substance abuse, depression, and somatization disorder. The foundation for appropriate development is absent. As preschoolers and toddlers, these youth typically present with extremes of oppositionality and defiance, far beyond what would be considered as a normal component of development (Achenbach, 1993). Limited skills at parenting, previous experiences of abuse, and the presence of pathology in the parents often lead to neglect and corporal punishment as primary means of dealing with behavior problems in these children. Physical abuse is rampant. The head is the most common part of the body struck, usually with the hand, fist, or a blunt object. Although a history of loss of consciousness secondary to this is unusual, the impact of repeated trauma on the developing central nervous system must be considered (Wood, 1996). From an early age, these boys exhibit aggressive behavior. They tend to push, hit, bite, scratch, etc. in preschool environments. In

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fact, the appearance and persistence of aggressive behavior is the most distinguishing characteristic of this population of youth (Loeber & Stouthamer-Loeber, 1998). It is not unusual to get a history of dismissal from preschools as a result of aggressive behavior. By the same token, these boys are often referred to their primary care physician or a mental health professional at an early age due to these difficulties. Typically, these boys begin to exhibit problems with inattention, distractibility, impulsivity, and hyperactivity at a very early age. However, it is not unusual that these go unnoticed or untreated until the child is in a public school setting. There, the inability to sit still, participate in group activities, follow the rules, and play cooperatively will usually result in the child being referred for medical/psychiatric evaluation. A number of studies have demonstrated the appearance of attention deficit hyperactivity disorder (ADHD) as a comorbid condition in these boys. Studies have indicated that three groups of boys may be identified with conduct disorder and ADHD. The first two groups have only conduct disorder or ADHD, but not both. There is no increase in aggressive or chronic, violent behaviors in either of these groups. A third group has comorbid conduct disorder and ADHD (Biederman, Newcorn, & Sprich, 1990). This group has been identified as having the neurochemical disorders delineated earlier in the chapter. They are also the group that develops into the childhood-onset conduct disorder with eventual evolution into the chronic and violent offender. In elementary school, these boys are often started on stimulant medication to assist them with behavioral control. This will often lead to an improvement in the ADHD, but no real change in the conduct disorder symptoms (Lewis, 1991). The only difference here may be in terms of youth who tend to lash out aggressively in response to the environment. However, there is little change in predatory aggression. School is further compounded by specific developmental disorders, namely problems related to learning reading and math (Moffitt, 1993). As a result, these youth are identified early on as requiring special education services. The combination of ADHD, conduct disorder, learning problems, baseline sense of boredom, and lack of respect for rules and authority make these boys a ªteacher's nightmare.º They are difficult to keep in the classroom, easily distracted and bored, resistant to the teacher's authority, and perpetually involved in physical struggles with their peers. Academic failure and school drop out are common.

Overall, these boys tend to score in the low average to borderline range on tests of intelligence. Of interest is the difference in scores on the verbal and performance sections of intelligence tests (Moffitt, 1993). The verbal part of the intelligence test tends to measure ªcrystallized intelligence,º that is, what a person has learned, primarily through school. The performance section of the intelligence test measures ªfluid intelligenceº or the ability of an individual to think through a novel situation and arrive at an appropriate conclusion. Typically, these boys score well within the normal range in tests of fluid intelligence, but fall below the average on the verbal section (Pennington & Bennetto, 1993). This is often attributed to poor school attendance (truancy is common), learning disabilities that interfere with the means of traditionally acquiring scholastic material, and cultural bias. Although these boys usually do not come to the attention of the law at an early age, it is common to find that actual criminal behavior begins as a preschooler or in early elementary school. During this time, these boys will frequently report that they began shoplifting or engaged in other petty offenses that are illegal. As they grow older, the frequency and the severity of offenses worsens. Often there will be a progression from ªvictimlessº crimes to those involving an actual human target. Shoplifting and petty offenses give way to destruction of property, breaking and entering, and assault with eventual evolution into the most violent types of infractions (Wood, 1996). Concomitant with the onset of adolescence is usually the beginnings of sexual promiscuity and substance abuse. Overall, there seems to be little regard for the human condition or the rights of others. The cessation of boredom and the instant gratification of needs seems to be the basic rule for all behaviors. Although youth with a childhood-onset conduct disorder only make up about 3±5% of all minors with a conduct disorder, it is estimated that they are responsible for well over half of the violent offenses committed by youthful offenders (Elliot, Huizinga, & Ageton, 1985). Concomitantly, a disproportionate amount of public funding is spent on these youth from the time they are very young. This includes funding for educational and mental health services, and later, for legal interventions including detainment. The likelihood of violent behavior occurring has also been shown to be related to additional environmental factors. The availability of firearms, and community laws and norms favorable toward drug use, firearms and crime have been associated with a higher incidence of violence.

Intervention Media portrayal of violence, low neighborhood attachment and community organization, and favorable parental attitudes and involvement in problematic behaviors negatively influences these youth (Hawkins, & Catalano, 1995; Howell, 1995).

9.07.4 INTERVENTION The Coordinating Council on Juvenile Justice and Delinquency Prevention of the Office of Juvenile Justice has developed a national juvenile justice action plan to combat violence and delinquency. The plan consists of eight objectives aimed at a combative effort to address violent and chronic juvenile offenders. The following is a summary of the objectives derived directly from Combating Violence and Delinquency: The National Juvenile Justice Action Plan (1996). (i) Provide immediate intervention and appropriate sanctions and treatment for delinquent juveniles. This is seen as a two-step measure. First, those factors most prevalent in communities which are associated with violent and delinquent behavior must be identified in order to establish effective programs to prevent or control delinquent behavior. ªRisk factors, such as community disorganization, availability of drugs and firearms, and persistent poverty, make children more prone to involvement in delinquent behavior that if those factors were not present. Additionally, when a child's family life is filled with violence, problem behaviors, poor parental monitoring, and inconsistent disciplinary practices or maltreatment, a child's risk of delinquency increasesº (Combating Violence and Delinquency, 1996, p. 7). Second, identifying programs that help youth, families, and communities protect themselves from these risk are paramount. ªThe most effective programs are those that address key areas of risk in the youth's life, those that seek to strengthen the personal and institutional factors that contribute to healthy adolescent development, those that provide adequate support and supervision, and those that offer youth long-term stake in the communityº (Howell, 1995, p. 25). Graduated sanctions that are swift, certain, and consistent are thought to be most effective as a deterrent. It is suggested that immediate intervention for first-time delinquent offenders (misdemeanors and nonviolent felonies) and many nonviolent repeat offenders be offered. Intermediate sanctions should be provided for many first-time serious and repeat offenders and some violent offenders. Finally, secure corrections should be the alternative for many serious, violent, and chronic offenders.

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(ii) Prosecute certain serious, violent, and chronic juvenile offenders in criminal court. It is important to note that the vast majority of juvenile cases can be appropriately handled in the juvenile justice system. However, a slow trend since the late 1980s to remove more serious, violent, and chronic juvenile offenders from the juvenile justice system and turn them over to criminal courts has escalated. It is believed that this is a very effective deterrent to violent crimes and also a method to assure the safety of the public in dealing with this habitually offending youth who seem to have little regard for rules, law, and authority (Hunziker, 1995). (iii) Reduce youth involvement with guns, drugs, and gangs. A trend analysis of juvenile homicide offenses shows that since the mid1970s, the number of homicides in which no firearm was involved has remained fairly constant. However, homicides by juveniles involving a firearm have increased nearly threefold (Snyder & Sickmund, 1995). Drug activity appears to exacerbate juvenile violence in two ways. First, firearms are more prevalent around drug activity. Second, drugs impact the young person's perceptions allowing for an accentuation of the kind of ªhighº many of these youth experience during the commission of a crime. In regard to gangs, this is a significant connection among gang involvement, gang violence, and firearms. Researchers have identified a number of factors that put youth at risk for gang involvement: poverty, school failure, substance abuse, family dysfunction, and domestic and societal violence (Spergel, 1995). Easy access to illicit drugs and the perceived financial rewards of drug dealing pose attractive alternatives for youth with inadequate education and limited educational opportunities, leading them into high-risk behaviors and potential gang involvement. (iv) Provide opportunities for children and youth. Providing children with opportunities to develop positive behaviors is the foundation of most efforts to prevent youth crime and violence. In recent years, the capacity of America's low-income rural and urban communities to provide critical positive activities or environments has declined. Public schools in many areas have deteriorated, and the quality of public education has been compromised. City parks and recreation centers are in disrepair, and financial support for youth facilities and programs has decreased, leaving high-risk environments for youth. Some youth who experience child abuse, neglect, poverty, poor health, or other risk factors do not become juvenile delinquents, school drop outs, or teenage parents. These youth have the benefit of a combination of

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protective factors that help guide them in making healthy choices. A resilient temperament and the development of close relationships with parents and other role models who provide encouragement, healthy beliefs, and clear standards of behavior offer protection from negative environmental influences (Hawkins & Catalano, 1993). (v) Break the cycle of violence by addressing youth victimization, abuse, and neglect. Each year, abuse and neglect leave 1800 children permanentlyÐoften severelyÐdisabled and inflict lifelong psychological damage on thousands of victims, siblings, and family members. Each year an estimated 2000 childrenÐmost under age 4Ðdie at the hands of parents or caretakers, about five children per day (Combating Violence and Delinquency, 1996). Numerous studies demonstrate the connection between child abuse and neglect and later violent delinquent behavior (Thornberry, 1994). A National Institute of Justice funded study found that experiencing childhood abuse and neglect increases the likelihood of arrest as a juvenile by 50%, of arrest as an adult by 38%, and of committing a violent crime by 38% (Combating Violence and Delinquency, 1996). The system of child protective services and dependency courts, which addresses family violence and child abuse and neglect, has reached a crisis point. It is imperative that adequate resources be provided to such agencies to allow for effective and immediate intervention in cases of abuse and neglect with one goal being the cessation of the inherited cycle of violence. (vi) Strengthen and mobilize communities. Communities play the primary role in preventing juvenile delinquency and the criminal victimization of juveniles. All community membersÐbusiness leaders, media representatives, teachers, parents and grandparents, young people, policymakers, clergy, elected officials, and law enforcementÐare responsible for ensuring the health and well-being of children. Community planning teams that include a partnership of agency and lay participants can help create a consensus of priorities and services to be provided. (vii) Support the development of innovative approaches to research and evaluation. A solid knowledge base is necessary to establish effective public policy, laws, and intervention strategies to prevent and reduce juvenile crime and violence. Focused long-term research improves our understanding of the causes and correlates of juvenile crime and strengthen our ability to develop successful prevention, early intervention, and graduated sanction programs. (viii) Implement an aggressive public outreach campaign on effective strategies to combat juvenile violence. Researchers have verified that

long-term public education campaigns on violence prevention, family education, alcohol and other drug prevention, and gun safety curriculums in school are effective strategies to help prevent delinquency (DeJong, 1994). They also concur that involving youth and developing community consensus are essential to an effective public education process. A well-designed public education campaign can make a positive impact on public opinion, target specific audiences, and be a cost-effective way of providing critical information to a large number of people. In summary, the provision of services to this population of youth remains multifaceted, impacting all of the spheres that influence these children and their families. The National Juvenile Justice Action Plan for combating violence and delinquency is to be commended for being comprehensive. However, it must also be commended in that it underscores the need to address the foundations of the problems (i.e., families, communities, schools, etc.) in addition to examining the specific needs of these problematic youth. Finally, it is important to note that the mental health concerns of these children and their parents must be recognized and adequately treated. Providing education, community support, and classes on improved parenting often miss the mark in a family plagued by poverty, substance abuse, and major psychopathology.

9.07.5 CLINICAL APPLICATION Kazdin (1997) has reviewed and identified the various psychosocial approaches that are considered to be promising treatments involved in the intervention with conduct disordered youth. In order for a treatment to be considered as promising, four criteria must have been met. First, there must be clear conceptualization of theoretical basis for the treatment. In other words, there should be some rationale about how the dysfunction leading to conduct disorder develops and then how the intervention will alter that dysfunction. Second, the treatment conceptualization must be supported by basic research. In this regard, basic research refers to the collection of objective data that identify the factors associated with conduct disorder. Third, there should be preliminary outcome evidence indicating that the treatment was effective. Finally, there needs to be a process±outcome connection, namely there is a relationship established between the processes hypothesized to be necessary for therapeutic change and the actual objective evidence of a difference in clinical outcome. Based on these criteria, four treatments were identified as being promising.

Cllinical Application 9.07.5.1 Cognitive Problem-solving Skills Training It has been demonstrated that youth who engage in conduct disordered behaviors often have a distorted or deficient perception of the world around them. This is not to say that their view of reality is skewed. However, they manifest errors of thinking that influence how they react and respond to their environments. This cognitive error results in these youth processing information incorrectly. For example, they may see a malevolent basis for an individual's behavior when nothing of this nature was intended. Disorders of cognitive processing may make it difficult for them to problem solve from an empathetic standpoint or be unable to view realistically the consequences of their behaviors. These thinking errors also serve as a means of justifying underlying antisocial behavior. For example,the womanwho gotherpursestolenwas ªasking for itº because she left her purse out, unattended. Therefore, she is at fault for the crime. Problem-solving skills training involves the development of interpersonal cognitive problem-solving skills. By virtue of this training, children are taught novel ways to approach situations by exploring the thinking processes involved. Step-by-step approaches to problemsolving are emphasized with reinforcement of prosocial responses. The treatment is rendered through structured tasks such as games, stories, and groups with increasing emphasis on real-life situations. Modeling, role-playing, and reinforcement with mild punishment are the media for examining problem-solving skills. There is evidence to suggest that older children fare better with this treatment than younger children, most likely due to their advanced abilities to cognitively process. Children who come from less disturbed family situations and who lack comorbiddiagnoses,learningproblems,andschool delays benefit the least from this treatment modality. Furthermore, there is objective research which indicates that up to a year after treatment, children who receive problem-solving skills training continue to retain the benefits. 9.07.5.2 Parent Management Training This involves procedures geared toward teaching parents to manage their child's behavior in the home. A therapist meets with the parents to teach them techniques to increase prosocial and decrease delinquent behaviors. There is also emphasis on helping parents to recognize when they may be inadvertently reinforcing negative behaviors in their child. The overall purpose of parent management

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training is to change the cyclical pattern of interaction between the youth and parent. Over the source of sessions, parents are taught increasingly more advanced and complicated techniques which build on the successful implementation of more basic interventions. Outcome of parent management training has been well evaluated and these techniques are noted to be extremely effective overall. There is also evidence for generalization of the success of the intervention to the siblings of the identified, conduct disordered youth. It appears that this approach is most successful if carried out over a protracted course of 50±60 hours. Fewest gains are evidences in those families with the highest numbers of risk factors associated with these behavioral disorders (e.g., poor, overcrowded, parental psychopathology). Another advantage of this technique is the ready availability of training manuals that systematically approach how to work with the parents. 9.07.5.3 Functional Family Therapy This therapeutic technique views the family as a system and the behavior of individual members, such as a youth that displays conduct disordered behaviors, as serving a means for some interpersonal functions (e.g., enmeshment, distancing). The goal of treatment then becomes to alter the way in which family members interact such that the cycle of behavior is permanently altered and interpersonal needs are met in such a way as to eliminate problematic behavior. Communication patterns and their different meaning to family members are explored from a sociallearning perspective. The primary focus is within the treatment sessions, where family communication patterns are altered directly. There have been few objection outcome studies of functional family therapy. These studies have illustrated the superiority of functional family therapy over psychodynamicallyoriented family therapy and no treatment control groups. Gains have been noted for up to two and a half years after the completion of treatment. However, a major drawback to this technique is the requirement of a certain level of sophistication on behalf of the family and willingness to objectively examine the comments made by the therapist. 9.07.5.4 Multisystemic Therapy There are multiple systems involved in the development of conduct disordered behaviors. One of the faults of the previous techniques described is that they tend to focus on only one aspect of the complicated systems impacting the

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child (e.g., the child's thinking processes, the ability of the parents to effectively intervene). Multisystemic therapy is a family systems approach which recognizes that the child is influenced by a multiplicity of systems (e.g., immediate and extended family, peers, schools, neighborhoods). Therefore, in order to affect change in the child, the role of these various systems in creating and reinforcing the maladaptive behavior must be understood and altered. For example, in an impoverished neighborhood where the majority of peers for a youth are delinquent, emphasis may need to be placed on development of aspects of the neighborhood that would encourage association with more prosocial peer groups. Therapy is rendered within a family preservation model of service delivery (Henggeler, Schoenwald, & Pickrel, 1995). Services are delivered in the natural environment (e.g., home, school, community). There is a great deal of collaboration between family members and the treatment managers. The strengths of the family and enveloping systems are emphasized and reinforced. Initially, treatment focuses on eliminating the barriers to effective parenting. There have been several outcome studies of multisystemic therapy. It should be noted that the target audience for treatment and study has been a group of extremely antisocial and aggressive youth. Results have shown multisystemic therapy to be superior to ªtraditionalº services offered to these youth in their communities. Guidelines are available to direct the therapist, but they tend to be very general. Thus, in working with a conduct disordered youth who is likely to have multiple risk factors involved in the creation and maintenance of delinquent behaviors, which interventions to use and when may be ambiguous. In summary, there are several promising psychosocial techniques that have been implemented in the treatment of conduct disordered youth. In terms of the dimensions of conduct disorder outlined in this chapter, overall, it has been shown that these interventions are most effective in adolescent-onset rather than childhood-onset conduct disorder (Kazdin, 1997). As a result, the violent and chronic offender, the youth known to have the worst outcome, to a large degree remains an enigma. However, it is hopeful that the combination of intervention techniques may offer a better prognosis for these youth than any single method described.

9.07.6 SUMMARY The numbers of violent crimes committed by youthful offenders is on the rise. The majority of

these crimes may be attributed to a small percentage of the population of conduct disordered youth. Epidemiologic information suggests a developmental pathway for these children and adolescents who will go on to be chronic and violent offenders. There is compelling evidence that there is some type of genetic predilection to the development of these behaviors which occurs predominantly in males. Psychosocial variables such as poverty, overcrowding, and inadequate parenting contribute to the matrix created by nature. As preschoolers, these children exhibit the extremes in oppositional/defiant behavior and manifest the symptoms of ADHD. They also begin to behave aggressively which remains a pervasive theme for them throughout their lives. In school, they show developmental disorders related primarily to reading and arithmetic. Within the structured environment of school these youth's chronic disregard for rules, law, and authority usually first becomes convincingly apparent. Minor illegal activity with no confrontation of a victim gives way to felonious behavior with direct harm to individuals as the child ages. Substance abuse is a frequent comorbid condition in these adolescents. Without intervention, these youth continue on this pathway into adulthood. The US Department of Justice has outlined the objectives for intervention with these youth. There are several psychosocial techniques that show promise. These involve cognitive-behavioral methods and interventions with the multiple systems (e.g., family, school, neighborhood) that impact and contribute to this type of functioning. National strategies such as limiting accessibility to firearms and changing community expectations regarding acceptable and unacceptable behaviors are also important in the prevention and elimination of these types of behaviors. Even with individually and community oriented programs, these youth remain difficult to treat with a relatively low success rate which has typically been measured by looking for the rate of recidivism after intervention. A better understanding of the relative contributions of nature and nurture to this disorder, with an equal assessment of variables allowing for resiliency, opens avenues for continued research. 9.07.7 REFERENCES Achenbach, T. M. (1993). Taxonomy and comorbidity of conduct problems: Evidence from empirically based approaches. Development and Psychopathology, 5,51±64. American Psychiatric Association (1980). Diagnostic and statistical manual of mental disorders (3rd. ed.). Washington, DC: Author. American Psychiatric Association (1987). Diagnostic and statistical manual of mental disorders-Revised (3rd. ed.,

References Rev.). Washington, DC: Author. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th. ed.). Washington, DC: Author. August, G. J., & Stewart, M. A. (1983). Familial subtypes of childhood hyperactivity disorder. The Journal of Nervous and Mental Disease, 171, 362±368. Bear, M. F., Connors, B. W., & Paradiso, M. W. (1996). Neuroscience: Exploring the brain. Baltimore: Williams & Wilkins. Biederman, J., Munir, K., & Knee, D. (1987). Conduct and oppositional disorder in clinically referred children with attention deficit disorder: A controlled study. Journal of the American Academy of Child and Adolescent Psychiatry, 26, 724±727. Biederman, J., Newcorn, J., & Sprich, S. (1991). Comorbidity of attention deficit hyperactivity disorder with conduct, depressive, anxiety and other disorders. American Journal of Psychiatry, 148, 564±577. Chess, S., & Thomas, A. (1991). Temperament. In M. Lewis (Ed.), Child and adolescent psychiatry: A comprehensive textbook (pp. 145±160). Baltimore: Williams and Wilkins. Christiansen, K. O. (1977). A review of studies of criminality among twins. In S. A. Mednick & K. O. Christiansen (Eds.), Biological bases of criminal behavior (pp. 45±88). New York: Gardner Press. Cloniger, C. R., & Gottesman, I. I. (1987). Genetic and environmental factors in antisocial behavior disorders. In S. A. Mednick, T. E. Moffitt, & S. A. Stack (Eds.), The causes of crime: New biological approaches (pp. 92±109). Cambridge, UK: Cambridge University Press. Combating violence and delinquency: The national juvenile justice action plan (1996). Washington, DC: US Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention. Dalgaard, O. S., & Kringlen, E. (1976). A Norwegian twin study of criminality. British Journal of Criminality, 16, 213±232. DeJong, W. (1994). Preventing interpersonal violence among youth: An introduction to school, community and mass media strategies. Washington, DC: National Institute of Justice. Elliot, D. S. (1994). Serious violent offenders: Onset, developmental course, and termination. Criminology, 32, 1±21. Elliot, D. S., Huizinga, D., & Ageton, S.S. (1985). Explaining delinquency and drug use. Newbury Park, CA: Sage. Elliot, D. S., Huizinga, D., & Morse, B. (1986). Selfreported violent offending: A descriptive analysis of juvenile violent offenders and their offending careers. Journal of Interpersonal Violence, 1, 472±514. Flynn, J. P., Vanegas, H., & Foote, W. (1970). Neural mechanisms involved in a cat's attack on a rat. In R. E. W. Whatlen, R. F. Thompson, M. Verzeams, & N. M. Weinberger (Eds.), The neural control of behavior (pp. 35±41). New York: Academic Press. Hamdan-Allen, G., Stewart, M. A., & Breghly, J. H. (1989). Subgrouping conduct disorder by psychiatric family history. Journal of Child Psychology and Psychiatry, 6, 889±897. Hawkins, J. D.,& Catalano, R. F. (1993). Communities that care: Risk-focused approach using the social development strategy. Seattle, WA: Developmental Research and Programs. Hawkins, J. D., & Catalano, R. F. (1995). Risk-focused prevention: Using the social development strategy. Seattle, WA: Developmental Research and Programs.

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Henggeler, S. W., Schoenwald, S. K., & Pickrel, S. G. (1995). Multisystemic therapy: Bridging the gap between university- and community-based treatment. Journal of Consulting and Clinical Psychology, 63, 709±717. Hinshaw, S. P., Lahey B. B., & Hart, E. L. (1993). Issues of taxonomy and comorbidity in the development of conduct disorder. Development and Psychopathology, 5, 31±49. Howell, J. C. (1995). Guide for implementing the comprehensive strategy for serious, violent, and chronic juvenile offenders. Washington, DC: The Office of Juvenile Justice and Delinquency Prevention. Hunziker, D. (1995). Juvenile crime, grown-up time. State Legislatures, 21(5),14±19. Kazdin, A. E. (1995). Conduct disorder in childhood and adolescence (2nd ed.). Thousand Oaks, CA: Sage. Kazdin, A. E. (1997). Psychosocial treatments for conduct disorder in children. Journal of Child Psychology and Psychiatry, 38, 161±178. Lahey, B. B., Piacentini, J. C., McBurnett, K., Stone, P., Hartdagen, S., & Hynd, G. (1988). Psychopathology in the parents of children with conduct disorder and hyperactivity. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 163±170. Lewis, D. O. (1991). Conduct disorder. In M. Lewis (Ed.), Child and adolescent psychiatry: A comprehensive textbook (pp. 561±573). Baltimore: Williams and Wilkins. Loeber, R., & Stouthamer-Loeber, M. (1998). Development of juvenile aggression and violence: Some common misconceptions and controversies. American Psychologist, 53, 242±259. Mednick, S. A., Gabrielli, W. F., & Hutchings, B. (1984). Genetic influences in criminal convictions: Evidence from an adoption cohort. Science, 224, 891±894. Moffitt, T. (1993). The neuropsychology of conduct disorder. Development and Psychopathology, 5, 135±151. Pennington, B. F., & Bennetto, L. (1993). Main effects of transactions in the neuropsychology of conduct disorder? Development and Psychopathology, 5, 153±164. Pettito, J. M., Lysle, D. T., Gariety, J. L., & Lewis, M. H. (1994). Association of genetic differences in social behavior and cellular immune responsiveness: Effects of social experience. Brain, Behavior and Immunity, 8, 111±122. Quay, H. C. (1993). The psychobiology of undersocialized aggressive conduct disorder: A theoretical perspective. Development and Psychopathology, 5, 165±180. Rogeness, G. A., Javors, M. A., Maas, J. W., & Macedo, C. A. (1990). Catecholamines and diagnoses in children. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 234±241. Schneider-Stock, R., & Epplen, J. T. (1995). Congenic AB mice: A novel means for studying the (molecular) genetics of aggression. Behavior Genetics, 25, 475±482. Snyder, H., & Sickmund, M. (1995). Juvenile offenders and victims: A national report. Washington, DC: Office of Juvenile Justice and Delinquency Prevention, US Department of Justice. Spergel, I. (1995). The youth gang problem: A community approach. New York: Oxford University Press. Thornberry, T. P. (1994). Violent families and youth violence. Washington, DC: Office of Juvenile Justice and Delinquency Prevention, US Department of Justice. Wood, I. (1996). Conduct disorder and oppositional defiant disorder. In D. X. Parmelee (Ed.), Child and adolescent psychiatry for the clinician (pp. 83±96). St. Louis, MO: Mosby Press. Zahn, T. P., & Kruesi, M. J. P. (1993). Autonomic activity in boys with disruptive behavior disorders. Psychophysiology, 30, 605±614.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

9.08 Homelessness PAUL A. TORO Wayne State University, Detroit, MI, USA 9.08.1 INTRODUCTION

119

9.08.2 RESEARCH ON HOMELESSNESS: RECENT FINDINGS AND NEW FRONTIERS

120 120 120 121 121 121 122 122 124 125 126 127 127 127 128 128 128

9.08.2.1 Public Opinion and the Prevalence of Homelessness 9.08.2.2 Methodological Issues 9.08.2.2.1 Definition 9.08.2.2.2 Measurement and sampling 9.08.2.2.3 Appropriate comparison groups 9.08.2.3 Describing the Homeless Population 9.08.2.3.1 Psychiatric disorders 9.08.2.3.2 Demographic and other basic characteristics 9.08.2.4 Homeless Families 9.08.2.5 Homeless Adolescents 9.08.2.6 Longitudinal Studies 9.08.2.7 Causes and Consequences 9.08.2.7.1 Deinstitutionalization 9.08.2.7.2 Substance abuse 9.08.2.7.3 Social and demographic trends 9.08.2.7.4 Growing poverty and other economic changes 9.08.3 INTERVENTIONS

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9.08.3.1 The Problem with Emergency Services 9.08.3.2 An Ecological Perspective 9.08.3.3 Preventing Homelessness 9.08.3.4 Intensive Case Management and Related Interventions 9.08.3.5 Tapping Existing Community Resources to Help the Homeless 9.08.3.6 Clinical Issues in Working with the Homeless 9.08.3.6.1 Immediate and long-term needs 9.08.3.6.2 The heterogeneity of the population 9.08.3.6.3 Substance abuse 9.08.3.6.4 Depression 9.08.3.6.5 Compliance with treatment 9.08.3.6.6 Family and other social characteristics 9.08.3.6.7 Competencies and deficits 9.08.3.6.8 Advocacy and traditional services

128 129 129 129 129 129 129 130 130 130 130 130 130 130

9.08.4 SUMMARY

131

9.08.5 REFERENCES

131

(Fournier & Mercier, 1996; Gore, 1990; Lee, Link, & Toro, 1991; Shinn & Weitzman, 1990; Toro & Rojansky, 1990). Responding to this general concern, homelessness has become a major research and clinical focus of many psychologists and other professionals. The number

9.08.1 INTRODUCTION Since the early 1980s, the problem of homelessness has captured the attention of the public, the media, and political leaders in the USA and most other nations of the developed world 119

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Homelessness

of publications on homelessness in psychological and other professional literatures has been steadily rising (Shinn, Burke, & Bedford, 1990; Toro & Warren, 1991) and a wide range of books on the topic have recently appeared (e.g., Baumohl, 1996; Blau, 1992; Burt, 1992; Fournier & Mercier, 1996; Jahiel, 1992; Jencks, 1994; Liebow, 1993; Rossi, 1989; Wright, 1989). A variety of interventions have been initiated and evaluated to cope with the problem (Argeriou & McCarty, 1990; Levine & Rog, 1990; NIAAA, 1991; Shinn, 1992; Shlay & Rossi, 1992). After a brief review on what has been learned about the problem from recent research and discussing areas of additional research that are developing, the chapter will focus on providing suggestions for preventive and treatment interventions and considering a variety of clinical issues that arise in working with homeless populations. The discussion on interventions and clinical issues will be grounded in an ecological perspective on homelessness (Toro, Trickett, Wall, & Salem, 1991). 9.08.2 RESEARCH ON HOMELESSNESS: RECENT FINDINGS AND NEW FRONTIERS 9.08.2.1 Public Opinion and the Prevalence of Homelessness Over 20 opinion surveys and polls on the topic of homelessness have been conducted, mostly in the USA, since the late 1980s (Link et al., 1995). Though some have involved only a handful of questions and/or nonrepresentative samples (e.g., Barbanel, 1989; Benedict, Shaw, & Rivlin, 1988; Media General Research, 1989; ªPoll shows,º 1991), other surveys have used sophisticated sampling methods and have assessed a wide range of attitudes, behaviors, and political beliefs (e.g., Fournier, Toro, Link, Manrique, & Glasser, 1996; Lee, Jones, & Lewis, 1990; Link et al., 1995; Manrique & Toro, 1994, 1995; Toro & McDonell, 1992). As a group, these polls and surveys paint a consistent picture of public opinion on homelessness, one that has remained surprisingly stable throughout the political changes and events since the late 1980s. For example, across the surveys, about two-thirds of the respondents have indicated a willingness to pay more taxes to help people who are homeless. Despite some media reports in recent years on growing ªcompassion fatigueº and the putative backlash against aggressive panhandling and other practices of homeless persons (e.g., Furillo, 1990; ªMany cities,º 1994; ªShift in feelings,º 1991), public support for solving the problem of homelessness has remained strong (Link et al.,

1995; Manrique & Toro, 1994). The average citizen is not only supportive but well-informed about the characteristics of the homeless population and possible remedies, such as more low-cost housing and job-training programs (Toro & McDonell, 1992). Analyses on the predictors of attitudes and knowledge about homelessness show support across the political spectrum, with only age and gender as consistent predictors (women and young people showing generally more positive attitudes). Various estimates on the prevalence of homelessness in the USA have been produced since the mid-1980s by researchers, government officials, and advocates for the homeless. Estimated prevalence rates for the US have varied from as low as 200 000 (HUD, 1984; Barringer, 1991), to 2 million (Hombs & Synder, 1986), to as high as 12±15 million (Link et al., 1994; Manrique & Toro, 1995; Toro & McDonell, 1992). During the 1980s, a heated controversy developed on which were the most accurate rates, with more conservative politicians supporting low rates and advocates for the homeless supporting higher rates (Appelbaum, 1990; Foscarinis, 1991; Kondratas, 1991; Rossi, 1989). In addition to the variation in rates based on political agenda, estimates have also generally increased over time. Though it has been suggested that such increases reflect actual growth in the size of the homeless population over this period (Burt, 1992, 1994), they may also be due to a greater willingness on the part of politicians and policy analysts to accept the problem of homelessness and the use of different estimation methods. Even more important, the rates presented have varied by the time-frame used, that is, whether point, annual, or lifetime prevalence is estimated. The highest estimates come from recent national surveys that have provided lifetime rates suggesting that 7±8% of US citizens have already experienced an episode of homelessness (Link et al., 1994; Manrique & Toro, 1995). Regardless of which rate is chosen, estimation of the prevalence of homelessness is fraught with problems and, no matter which method is used, it is likely to be criticized by someone. It is the author's belief that devoting tremendous resources to further estimate the size of the homeless population may be unnecessary: the problem is clearly of unacceptable proportions by almost anyone's standards and, even with improving economic conditions in the USA and some other nations, the rates do not appear to be dropping. 9.08.2.2 Methodological Issues Perhaps more than anything else, researchers since the 1980s have learned how to study the

Research on Homelessness: Recent Findings and New Frontiers problem of homelessness. An improved understanding of methodological issues has occurred in three basic areas: defining the homeless; sampling and assessment techniques; and selecting appropriate comparison groups. 9.08.2.2.1 Definition Defining who is homeless may seem fairly straightforward but, in fact, the issues involved are as complex as they are in defining mental disorder and other important constructs in clinical psychology. How long must one be without housing to be considered homeless? Should persons living in substandard housing (e.g., shacks in rural areas, rat-infested housing projects in the cities) be considered homeless? What about those living ªdoubled upº with family or friends? Most researchers in the USA and other developed nations have settled these issues by studying the ªliteral homeless,º people staying in shelters for the homeless or sleeping on the streets or other similar settings (e.g., abandoned buildings, underneath bridges). In defining the homeless, it is also important to understand that there are three basic subgroups among the homeless: homeless adults without children (mostly men); homeless families (mostly young women with young children); and homeless adolescents (runaways and throwaways). Largely distinct sets of services and distinct research literatures have developed for each of these three groups. All three of these groups should be considered homeless and of concern to clinical psychologists. 9.08.2.2.2 Measurement and sampling Since the 1980s, researchers have developed and adapted measures appropriate for use with homeless populations, including structured diagnostic tools, measures of social networks and social support, and inventories documenting housing history (e.g., Bates, 1993; Toro & Wall, 1991). In the mid-1980s, toward the beginning of the current new wave of research on homelessness, assessing mental illness became controversial (e.g., Snow, Baker, Anderson, & Martin, 1986; Susser, Conover, & Struening, 1989). Commonly used indicators of mental illness in studies of the homeless have included: (i) a diagnosis generated by a standardized clinical interview; (ii) a score on a symptom checklist; (iii) past history of psychiatric hospitalization; and (iv) global observer assessments (Robertson, 1992). Applied to the homeless, each of these methods has its merits in terms of reliability, validity, and/or practicality. The standardized clinical interview method tends to yield some of the most conservative estimates while the other, less

121

rigorous, methods and combinations of methods yield higher estimates. Given the high rates of substance abuse among the homeless, the inclusion of substance abuse in the definition of ªmental illnessº yields especially high rates of disorder. Of the different methods, only the standardized clinical interview appears to clearly separate substance abuse from mental disorder (Bellavia & Toro, 1998; Toro & Wall, 1991). Researchers have also investigated the impact of different sampling approaches on the nature of the homeless people obtained. For example, relatively few differences have been found in the composition of homeless samples obtained across the seasons and through different sampling methods (Hannappel, Calsyn, & Morse, 1989; Toro & Wall, 1991). Several recent large-scale studies have refined probability sampling procedures for selecting representative groups across large geographical areas from a variety of shelters, food programs, and other types of sites (Burnam & Koegel, 1988; Koegel, Burnam, & Morton, 1996; Robertson, Zlotnick, & Westerfelt, 1994, 1997; Toro et al., 1998). 9.08.2.2.3 Appropriate comparison groups Many of the studies on the homeless done in the early to mid-1980s painted a rather dismal picture of the homeless population. They seemed to have a myriad of deficits, including mental illness, substance abuse, domestic violence, and poor educational attainment. However, it was also known that poor people generally also showed some of these same deficits. A number of more recent studies have selected appropriate comparison groups of persons who are like the homeless in most respects, aside from the condition of homelessness, in order to distinguish the unique characteristics of the homeless from those of the poor (e.g., Bukowski, Wolfe, & Toro, 1998; Goodman, 1991; Laurin, Fournier, Toupin, & Ostoj, 1996; Shinn, Knickman, & Weitzman, 1991; Sosin, 1992; Toro & Bukowski, 1995; Toro, Bellavia et al., 1995; Wood, Valdez, Hayashi, & Shen,1990). Such comparison group designs have now been applied to all three of the major groups of homeless people mentioned earlier (i.e., single adults, adolescents, and families). These studies suggest a number of specific areas that differentiate the poor from the homeless, as well as other areas that are less sensitive in distinguishing these groups. For example, substance abuse has emerged as a frequent predictor of being homeless (rather than poor, but housed), while severe mental illness has not.

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9.08.2.3 Describing the Homeless Population Research since the mid-1980s, primarily conducted in the USA, has now carefully documented the diagnostic and other basic characteristics of homeless adults based on large representative samples from relatively broad geographical areas within various cities. An overview of these characteristics, which are generally consistent from city to city and from study to study, are presented below. Note that most of the relevant studies have not included homeless families and homeless youths but have instead focused on single adults who form the largest segment of the homeless population. In later sections, the findings from the largely separate and more limited research literatures on homeless families and adolescents will be discussed. 9.08.2.3.1 Psychiatric disorders Because it provides the most detailed data on the disorders observed among the homeless and because it separates substance abuse from other disorders, studies using a standardized clinical interview such as the Diagnostic Interview Schedule (DIS) will be emphasized (Eaton & Kessler, 1985; Regier et al., 1988; Robins, Helzer, Croughan, & Ratcliff, 1981). In particular, a set of nine samples of homeless adults from studies that all used the DIS will be focused on (see Fisher, Shapiro, Breakey, Anthony, & Kramer, 1986; Fournier, 1988; Fournier, Mercier, Raynault, Ohayon, & Caulet, 1993; Koegel, Burnam, & Farr, 1988; Koegel, Sullivan, Burnam, Morton, & Wenzel, 1997; North & Smith, 1993; Roberston et al., 1994, Toro et al., 1997; Toro et al., 1998). These studies involved representative samples of homeless adults, generally obtained using similar probability sampling methods, and they were from seven different metropolitan areas in the US and Canada. The studies have produced a fairly consistent diagnostic portrait of the homeless based on DSM-III and DSM-III-R criteria (see Table 1). Because these studies used a common method to operationalize mental disorder and fairly similar sampling approaches, the consistency of diagnostic rates across them suggests that the variability in rates of disorder across various earlier studies on the homeless noted by some reviewers (e.g., Robertson, 1992; Toro & Wall, 1991) was largely due to variability in sampling and measurement methods, rather than to differences in the homeless populations across cities. The nine studies using the DIS have yielded high rates for the major affective disorders among homeless adults (14±30%), with depres-

sion generally accounting for the majority of these disorders (bipolar disorders and mania being much less frequent, usually 5 5% overall). Less severe depression, not meeting all diagnostic criteria, is even more prevalent among homeless adults (Bellavia & Toro, 1998; Toro & Wall, 1991) and post-traumatic stress disorder (PTSD) also appears very common (one recent study using the DIS identified a rate of 40%; North & Smith, 1992). Such high rates of depression and PTSD are consistent with recent views suggesting that homelessness often involves a series of traumatic life events (Goodman, Saxe, & Harvey, 1991). The stresses associated with being homeless have also now been well-documented (e.g., Koegel, Burnam, & Farr, 1990; Toro, Bellavia et al., 1995; Toro et al., 1998). Among the few studies that have included the DIS section on anxiety disorders (including panic and generalized forms), combined lifetime prevalence rates have ranged from 10 to 39% (Fischer et al., 1986; Koegel et al., 1988; North & Smith, 1992). Although the rates for schizophrenic disorders among homeless adults have generally exceeded normative rates by a factor of two to six, such persons are still relatively rare. With the notable exception of the study by Koegel et al. (1988), which was done entirely in the large skid row area of Los Angeles, studies using the DIS have consistently found that under 10% of homeless adults have a schizophrenic disorder meeting diagnostic criteria. These relatively low rates for schizophrenia do not conform with expectations of many professionals and average citizens nor with the extensive research attention given the homeless mentally ill. This inconsistency may be a result of limitations of the DIS and other structured diagnostic measures, which have been criticized as systematically underestimating schizophrenic symptoms, in large part because they involve only a timelimited exposure between interviewer and subject (Arce & Vergare, 1984; Susser et al., 1989). However, the discrepancy between rates obtained in research and public perceptions could also the result of extensive media coverage of the homeless mentally ill and to the fact that such persons, even though they may be relatively rare, are generally very noticeable to the average citizen when observed on the streets. The media and policy analysts often quote the general figure of one-third for mental illness among the homeless. This figure seems to be based on earlier studies that obtained their estimates through self-reported psychiatric hospitalization (see Roberston, 1992, for a review of such studies). It has been suggested that a fair number of such self-reported hospitalizations were likely for substance abuse

Table 1

Lifetime prevalence for severe mental disorders and substance abuse based on representative samples of homeless adults and the DIS. Mental disorders

Fischer et al. (1986) Fournier (1988) Koegel et al. (1988) Koegel et al. (1997) North and Smith (1993) Robertson et al. (1997) Toro et al. (1997) Toro et al. (1998) Toro et al. (1998) Mean rate for homeless Normative rate

Sample size

City

Affective

Schizophrenic

51 299 328 1563 900 564 213 420 297

Baltimore, MD Montreal, Canada Los Angeles, CA Los Angeles, CA St. Louis, MO Oakland, CA Buffalo, NY Buffalo, NY Detroit, MI

13.7 28.1 29.5 21.0 23.0 21.6 18.8 20.2 23.6

Substance abuse Either

Alcohol

Drug

Either

Dual diagnosis

2.0 8.7 13.7 7.0 5.4 4.1 3.3 4.1 6.4

22.3 20.3 22.6 27.3

66.9 62.9 60.0 47.5 52.6 45.5 55.6 55.1

40.4 30.8 49.0 34.2 52.2 37.6 48.9 53.9

70.6 74.2 69.2 71.0 60.1 69.1 57.6 70.0 75.3

19.0 14.2 17.4 23.9

21.4

6.1

23.1

55.8

43.4

68.6

21.3

8.3

1.5

13.3

5.9

16.4

31.8

All disorders are based on DSM-III or DSM-III-R criteria. Major affective disorders generally include bipolar and depressive disorders and dysthymia. Schizophrenic disorders generally include schizophrenia and schizophreniform disorder. Substance abuse disorders include both abuse and dependence. The dually diagnosed have both a severe mental disorder and a substance abuse disorder. The mean rate weights each of the nine samples equally. The national normative rates are based on the five-site Epidemiologic Catchment Area study (N = 18 571; source: Regier et al., 1988).

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(Bellavia & Toro, 1998). Furthermore, having a prior hospitalization, even if for mental illness, does not necessarily assure that all DSM-III-R criteria for a serious mental disorder were met at admission (since rigorous diagnostic methods are not universally used) and prior hospitalization is a poor indicator of current diagnosable mental illness requiring intervention. Thus, the often cited one-third figure is probably an overestimate and planning services for the homeless based on the assumption that a large proportion are actively psychotic is misguided. It is also unclear whether the high rates of mental disorders found can be attributed to homelessness per se, since the rates for the poor are also similarly high (Toro, Bellavia et al., 1995) and, especially in the case of depression, it is not clear to what extent the disorder is a response to the stresses of homelessness and how much it is a precursor to homelessness (Goodman et al., 1991). Alcohol and drug abuse and dependence are very common among homeless adults, with studies using the DIS generally finding 60±75% having a lifetime diagnosis of a substance abuse disorder. A large number of these persons (generally about half) abuse both alcohol and drugs and, among those abusing drugs, often multiple drugs are used (most commonly marijuana, cocaine, and opioids). Though these rates of substance abuse are obviously high and many homeless adults are chronic abusers, a sizeable number (generally 30±50% of those with a lifetime diagnosis of substance abuse) report little or no recent symptoms of substance abuse. Even if such persons ªin recoveryº are being truthful about current use, given their past problems they are still obviously at risk of resuming use and abuse. Most homeless adults with a severe mental disorder have a cooccurring substance abuse disorder. Such ªdually diagnosedº persons have been the focus of extensive recent attention by researchers and program developers and pose special problems for service providers (Blankertz & White, 1990; Dende & Kline, 1995; Dexter, 1990; Drake, Osher, & Wallach, 1991). Several studies have attempted to document the prevalence of organic brain disorders that are often associated with chronic substance abuse (Fischer et al., 1986; Koegel, 1988; North & Smith, 1992; Toro & Wall, 1991). Estimates of cognitive impairment based on the DIS have been as high as 15%. Antisocial personality disorder and criminal histories in general are common among the homeless. Studies that have assessed antisocial personality based on the DIS and DSM-III or DSM-III-R criteria have found lifetime prevalence rates ranging from 16 to 37% (Fischer

et al., 1986; Fournier, 1988; Koegel et al., 1988; North & Smith, 1992; Toro & Wall, 1991). About 25±30% of the homeless report having been convicted of a felony or spent some time in prison and many others (another 35±50%) report having been arrested. However, it has been noted that many arrests of the homeless are for ªvictimlessº crimes such as loitering, disturbing the peace, or public drunkenness (Fischer, 1988). 9.08.2.3.2 Demographic and other basic characteristics Based on recent studies involving representative samples of homeless adults, we now know a great deal about a range of other characteristics of the homeless population. Most homeless adults continue to be men (usually approximately 70% of the total population) and the majority (about two-thirds) are under 40 years of age. Though many homeless appear old, very few are over 60 (usually considerably 510%). This lack of old people among the homeless may be due to early mortality that reduces their presence in the population or to relatively generous benefits available to the elderly in our society that may prevent homelessness (Rossi, 1989). African-Americans are heavily over-represented among all homeless persons in the USA, as they are in the poverty population more generally. In cities with relatively large numbers of African-Americans in the general population (e.g., 20% in metropolitan Detroit), AfricanAmericans often constitute a clear majority of the homeless population (85% in Detroit; see Toro et al., 1998). Other ethnic groups that appear to be over-represented among the homeless, depending the city involved, include Hispanics and Native Americans. Not only are homeless adults currently in severe poverty, but they also generally come from poor socioeconomic backgrounds. For example, in a recent two-city study involving representative samples of homeless adults, the parents of approximately 80% of the homeless in each city held unskilled or blue collar positions and only 3% had parents with professional backgrounds (Toro et al., 1998). The majority of homeless adults have never been married (usually approximately 50%) or are separated or divorced (usually another 40%). Though only a small minority of homeless adults have their children with them while homeless, many more (including both women and men) report having children for whom they feel financially responsible (a recent two-city study found rates of 39±43%; Toro et al., 1998). Often such children are being temporarily cared

Research on Homelessness: Recent Findings and New Frontiers for by relatives or friends or are in foster care after having been removed from the parent's care by protective service agencies. A great deal of recent attention has been paid to other social characteristics of the homeless. It is now well documented that most homeless persons have regular contact with family members (Toro & Wall, 1991; Toro et al., 1998). However, the nature of such contact may not always be positive. In fact, the existence of conflict and violence in social relationships have been identified as risk factors for homelessness among both adults, families, and adolescents. In assessing the childhood histories of both homeless adults and adolescents, out-of-home foster placements, sexual and/or physical abuse, family transience, punitive parenting practices, parental substance abuse and/or mental illness, and other indicators of noxious home environments have been commonly found (Boesky, Toro, & Wright, 1995; Koegel, Melamid, & Burnam, 1995; Susser et al., 1987; Toro, Bellavia et al., 1995; Wolfe, 1994). Violence in romantic relationships has also been identified as a significant risk factor for men as well as women (Toro, Bellavia et al., 1995). For women, such violence often leads to flight from an abusive situation and seeking refuge in a battered women's shelter (women in such shelters are sometimes included in representative samples of homeless adults; e.g., Toro et al., 1998). For men, whether they are perpetrators or victims of the violence (or both), relationships in which violence is prevalent may frequently dissolve and lead to a lack of stable housing. As might be expected, the health status of homeless persons is generally poor (Gelberg, Linn, Usatine, & Smith, 1990; Institute of Medicine, 1988; Lozowski, Rowland, & Toro, 1994; Robertson & Cousineau, 1986; Wright & Weber, 1987). Particularly common among homeless adults are respiratory problems, skin disorders, head and other injuries, and hypertension. Rates of smoking are also high (480%; see Lozowski et al., 1994), which can help partially explain the prevalence of some of these health problems. The homeless also appear to be at heightened risk of HIV and tuberculosis infection (Gelberg, Panarites, Andersen, & Koegel, 1994; Stayanoff, Weber, Wiley, Ford, & Kerndt, 1994; Valencia, Saez, Susser, Conover, & Colson, 1994; Zolopa et al., 1994). Finally, it should be noted that veterans, mainly those who served during the Vietnam era or later, may be another over-represented group, with studies generally finding approximately 25±30% of the total adult homeless population having military experience (Goldstein & Toro, 1995; Rosenheck & Koegel, 1993).

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Why so many veterans are homeless is less clear, although explanations have focused on the stresses associated with military life (including frequent moves and taxing work schedules, as well as combat experience) that may contribute to social and family problems and to high rates of substance abuse. A number of special interventions for homeless veterans, some targeted on a national scale, have also been attempted (e.g., Rosenheck, Gallup, & Frisman, 1993; Seidner, Burling, Fisher, & Blair, 1990). 9.08.2.4 Homeless Families It is widely believed that homeless families are the fastest growing segment of the homeless population (e.g., US Conference of Mayors, 1989). In recent years, the media as well as researchers and service providers have been devoting increasing attention to this important subgroup among the homeless (Lee et al., 1991). Such families consist mostly of young women (generally in their twenties and thirties) who are homeless with their young children. Few families involving men are encountered, perhaps due in part to policies that prohibit men in many shelters for homeless families. Unlike homeless adults as a group (in which males clearly predominate, even when women homeless with their children are included in the samples; e.g., Toro et al., 1997; Toro et al., 1998), homeless children seem equally divided between girls and boys. Among children homeless with their mothers, those of school age (especially those 10 years or older) are relatively rare. Much more common are infants and toddlers. This lack of school-aged children among the homeless could be due to the eventual intervention of protective service workers (leading to the placement of such children) or the willingness of family members to care for such children, who may be seen as less demanding than infants or toddlers. As in the general population, depressive symptoms are even more common among homeless women than homeless men, though women homeless along with their children seem to show levels of depression that are roughly comparable to those seen in homeless single men, suggesting a possible protective effect of motherhood (North & Smith, 1993; Roll, Toro, & Ortola, 1995; Smith & North, 1994). Again paralleling gender differences in the general population, both substance abuse and antisocial behavior among homeless women, especially those homeless with their children, appear to be much less common than among homeless men (Roll et al., 1995; Shinn & Weitzman, 1990; Smith & North, 1994). Children homeless with their mothers have been found to be at elevated risk for a variety of

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problems, including poor health, educational delays, poor school performance, stigmatization by peers, behavioral problems (e.g., aggression, anxiety, and depression), and poor coordination (Bassuk & Gallagher, 1990; Bassuk & Rubin, 1987; Bassuk, Rubin, & Lauriat, 1986; Dail, 1990; Fox & Roth, 1989; Gewirtzman & Fodor, 1987; Molnar, Rath, & Klein, 1990; Passero Rabideau & Toro, 1997; Rafferty & Shinn, 1991; Wagner & Menke, 1990; Wright, 1990). Unfortunately, few of the studies documenting these problems have utilized comparison groups of stably-housed poor children in an attempt to differentiate the effects of homelessness from poverty. Those that have matched homeless children to poor, housed children (e.g., welfare recipients) have generally found that the two groups do not differ from each other, though both differ from the general population (Rafferty & Shinn, 1991). Witnessing domestic violence has been consistently found to relate to a variety of poor outcomes in children (Jaffe, Wolfe, & Wilson, 1990). Given the high rates of domestic violence observed among homeless adults (including those with children), even when compared to comparable housed persons (Bassuk & Rosenberg, 1990; D'Ercole & Struening, 1990; Shinn et al., 1991; Toro, Bellavia et al., 1995), it seems likely that homeless children will often witness violence and be victimized themselves. Such exposure may require special attention from service providers.

9.08.2.5 Homeless Adolescents Most investigators have found that the majority of runaway behavior occurs during mid-adolescence and studies suggest that 9±15% of adolescents have at some time run away from home or been thrown out by their parents (Nye & Edelbrock, 1980; Ringwalt, Greene, & Iachan, 1994; Smart, Adlaf, Walsh, & Zdanowicz, 1994; Windle, 1989). Recent research on homelessness has considered both runaways and throwaways. Some studies have also focused on ªstreet youthº and others have included persons as old as 21 in their samples (e.g., Cauce et al., 1993, 1994). Probability sampling methods are not commonly used and existing studies on homeless adolescents have often obtained their samples from a single youth shelter, mental health or other service agency, or specific inner-city street area where homeless adolescents ªhang out.º The review of the literature suggests that studies that obtain ªstreetº samples (e.g., Cauce et al., 1993, 1994; Robertson, 1990) often find a different profile for the homeless adolescent compared to

studies that obtain their samples from youth shelters or other service settings (e.g., Bukowski et al., 1998; Mundy, Robertson, Greenblatt, & Robertson, 1989; Shaffer & Caton, 1984; Yates, MacKenzie, Pennbridge, & Cohen, 1988). The street samples appear to have higher levels of dysfunction. Studies that identify runaways from among those in much larger school-based or household survey samples (Ringwalt et al., 1994; Smart et al., 1994; Windle, 1989) are likely to be biased toward the less dysfunctional because homeless youth are less likely to be at home or in school. Though the research literature on homeless adolescents is still rudimentary at this point in time (especially when compared to the comparable literature on homeless adults; see Robertson, 1991), a rough profile of the population can still be given. Unlike homeless adults, homeless adolescents seem more equally divided between girls and boys, though studies focusing on street youth and/or including persons aged 18±21 years show higher percentages of males (e.g., Cauce et al., 1993, 1994; Robertson, Koegel, & Ferguson, 1989). Combining this gender profile observed among adolescents with the welldocumented over-representation of men among homeless adults, it has been suggested that the risk of homelessness may drop for women as they get older from adolescence through young adulthood, but rise for men during this period of life (Boesky, Toro, & Bukowski, 1997). Two recent studies have collected probability samples of homeless adolescents and have used the DIS or DIS for Children (DISC; Fisher, Wicks, Shaffer, Piacentini, & Lapkin, 1992; Piacentini et al., 1993; Shaffer et al., 1993), providing diagnostic information based on DSM-III or DSM-III-R criteria. One of these sampled 122 adolescents (ages 12±17) from all six major shelters for homeless youth in the seven-county Detroit metropolitan area (see Boesky et al., 1997; Bukowski et al., 1998; Toro & Bukowski, 1995). The other sampled 97 street youth (ages 13±17) in Hollywood (see Robertson, 1990; Robertson et al., 1989). Both studies found high lifetime rates for affective disorders (44% for depression and mania combined in the Detroit study; 26% for depression only in the Hollywood study), substance abuse/dependence (including both alcohol and drugs; 75% in Hollywood; 34% in Detroit), and disruptive behavior disorders (93% for conduct disorder alone in Hollywood; 48% for conduct, attention deficit, and/or oppositional defiant disorders in Detroit). The Hollywood study also found a high rate for PTSD (38%). The Detroit study included a carefully matched comparison group of housed adolescents and found that both alcohol abuse/dependence and disruptive beha-

Research on Homelessness: Recent Findings and New Frontiers vior disorders were significantly more prevalent among the homeless (Bukowski et al., 1998). 9.08.2.6 Longitudinal Studies Longitudinal research with the homeless represents one of the exciting new frontiers now being explored. Preliminary findings from several ongoing studies, mostly involving homeless adults, are just beginning to emerge (e.g., Cauce et al., 1993, 1994; Cohen et al., 1993; Goldstein & Toro, 1996; Koegel & Burnam, 1994; Robertson et al., 1994; Rowland & Toro, 1996; Shinn, 1996; Toro et al., 1997; Wright, Allen, & Devine, 1993). At this point in time, based on follow-up data of 18 months or more, investigators have identified different patterns in the longitudinal course of homelessness. A sizable chronic group (approximately 25±35% of adults) remains homeless for much of the follow-up period and, at the other extreme, an escapee group (depending on the definition, 15±35%) appears to have made a permanent exit from their homelessness. Others fall in between these two extremes, perhaps experiencing an exit from homelessness followed by another brief return at some later point (such a group could be called the episodic homeless). A few recent studies that followed homeless adults for more than a year have found that, when tracked this long, the homeless show improvements on several outcomes, including physical health, homelessness, and perceived life stress (Rowland & Toro, 1996; Shinn, 1996; Toro et al., 1997). Such results suggest that, when sampled, homeless people may be at a particularly difficult point in their lives and can be expected to show some improvements over time. 9.08.2.7 Causes and Consequences Psychologists are drawn to questions of causality. Unfortunately, they cannot use experimental methods to assess either the causes or consequences of homelessness: They cannot randomly assign people to homelessness nor to the sorts of factors (e.g., poverty, substance abuse, or mental disorder) that might cause it. They must generally rely on various correlational methodologies if they are to understand the important questions they have about homelessness. Creative use of such methodologies represents another research frontier. Longitudinal studies on the homeless can be used to approach some causal questions. Psychologists can explore who among the heterogeneous homeless population has better and worse outcomes. Using structural equation modeling and other sophisticated new statistical

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techniques, they can even begin to understand more complex temporal ordering between various predictors and outcomes, including future homelessness. Such analyses are currently underway for a number of large-scale longitudinal studies of homeless adults (e.g., Wolfe, 1993). Studies following poor people or others at risk of homelessness might suggest answers to other causal questions. Such studies could identify factors that might be responsible for initial episodes of homelessness. They could also investigate the possible causes of homelessness using experimental methods by randomly assigning persons at risk of homelessness to interventions designed to mitigate the impact of risk factors. Unfortunately, such studies would be extremely costly to undertake, since large numbers would need to be tracked over several years in order to observe significant amounts of homelessness prospectively. Designs that compare homeless groups to carefully constructed comparison groups of similar (but not homeless) groups can also help refine our understanding on the causes of homelessness. For example, such studies have been finding that substance abuse differentiates the housed from the homeless, while mental illness is a less sensitive predictor of group differences (Bukowski et al., 1998; Toro, Bellavia et al., 1995). Though by no means conclusive, such findings suggest that substance abuse may be the more important causal factor. International comparisons, a few of which have already been made, could also be useful in the search for the causes of homelessness (e.g., Adams, 1986; Daly, 1990; Fournier et al., 1996; Toro, Alan et al., 1995; Toro & Rojansky, 1990). If comparable rates of homelessness could be produced across various nations, then economic, cultural, and other factors possibly associated with varying rates could be identified. Based on the existing research, a number of plausible causes of homelessness will be briefly presented. These causes involve a variety of socioeconomic factors as well as conditions with which clinical psychologists have expertise. 9.08.2.7.1 Deinstitutionalization The first thought that comes to mind for many when attempting to come to grips with explaining why a wealthy nation such as the USA would have so much homelessness involves the deinstitutionalization of the mentally ill that took place in the 1960s and 1970s. Unfortunately, this explanation does not go very far since most homeless people are not seriously mentally ill and have never been hospitalized. Even using a reasonably loose

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definition of mental illness that includes severe depression in addition to schizophrenia, no more than a third of all homeless people can be considered mentally ill. The deinstitutionalization argument ignores the majority of the homeless population who are not mentally ill. Casting further suspicion on this argument, recent comparison group studies find that rates of severe mental illness are nearly as high among the poor as they are among the homeless (Bukowski et al., 1998; Toro, Bellavia et al., 1995). 9.08.2.7.2 Substance abuse The combination of very high rates observed (see Table 1), the results of comparison group designs which identify greater substance abuse among the homeless vs. the housed, and other research data all point to substance abuse as an important factor in homelessness. One international comparison suggested that the low rates of homelessness observed in certain developed nations (e.g., Japan) may be due to lower rates of substance abuse (Toro & Rojansky, 1990).

ranks of the poor and the wealth of the USA and other developed nations becoming increasingly concentrated in the hands of a smaller percentage of people (Phillips, 1990). Reductions in real welfare benefits observed in recent years, in large part a function of the ªwelfare reformº that has been so politically popular, has also been suggested as a major cause of increased homelessness (Jencks, 1994; Rossi, 1989). Urban revitalization, a well-meant set of social policies that began in the 1960s and has destroyed many viable though poor and ªblightedº neighborhoods having extensive low-income housing in the 1960s, has also been suggested as one factor that may be partially responsible for the recent rise in homelessness (Adams, 1986; Wright & Lam, 1987). In summary, it seems likely that a number of alternative explanations for the recent rise in homelessness have some merit. While we will probably never have definitive answers to the key causal questions on homelessness, we can still proceed with interventions based on a research understanding of the problem, rather than responding solely on the basis of impressionistic beliefs.

9.08.2.7.3 Social and demographic trends The pervasiveness of family conflict and violence seen in the histories of homeless people supports the idea that growing family breakdown might be responsible for the increasing prevalence of homelessness seen in recent years. Nations with apparently lower rates of homelessness also seem to show fewer such trends. Related sociodemographic trends can also be implicated in homelessness. Delayed marriage, more single-parent families, and the associated greater demand for housing units all seem to be reasonable explanations for the increase in homelessness observed in the past decade or two. The impact of the baby boom generation can also be considered. With such a large number of middle-aged persons monopolizing the job and housing markets, many in this age group, as well as younger adults (in their 20s), have recently been competing for scarce employment and housing. 9.08.2.7.4 Growing poverty and other economic changes The loss of well-paying but unskilled jobs, such as those in manufacturing industries, is one obvious explanation for the growing homelessness observed in recent years. The growth in income disparity between the rich and poor can also be suggested as a possible cause of increasing homeless. Homelessness can be seen as a byproduct of more and more persons entering the

9.08.3 INTERVENTIONS Perhaps the most important new frontier in research on the homeless involves the identification and evaluation of effective interventions. Clinical psychologists have much to offer in promoting this research direction. In the rush to deal with the problem of homelessness in the past decade, a great many interventions for the homeless have been implemented, often haphazardly. Few of these interventions have been carefully evaluated. Not only do more interventions need to be developed to prevent and treat homelessness, but such interventions must be carefully evaluated to determine if they are effective. 9.08.3.1 The Problem with Emergency Services The growth in services for the homeless has been occurring at a fast pace in the USA and UK since the late 1980s and has been since the early 1990s in many other developed nations. Most of the services being developed have been oriented toward meeting the immediate needs that homeless people have (e.g., food, shelter, health care) and are provided only on a temporary basis. However, based on existing research, it is known that the homeless have long-term needs. Emergency services also do little to stem the tide of the large numbers of people who continually enter the ranks of the homeless.

Interventions 9.08.3.2 An Ecological Perspective The inadequacy of the sorts of services being developed to address homelessness suggests the need for a broader, ecological perspective. Such a perspective highlights the need to consider both social and other contextual factors, in addition to individual vulnerabilities, when developing interventions (Toro et al., 1991). It also points out that interventions need to be considered at multiple levels of analysis, from individually-focused treatment to large-scale social policy. 9.08.3.3 Preventing Homelessness Since the 1980s, there has been considerable progress in developing effective preventive interventions (see Price, Cowen, Lorion, & Ramos-McKay, 1988). Preventive interventions have now addressed most areas of traditional concern to clinical psychologists, including mental disorders, substance abuse, delinquency, and school drop-out. Interventions oriented toward preventing homelessness have yet to be developed, though some promising approaches for preventing the closely related problem of poverty have begun to emerge (e.g., Head Start; see Zigler & Styfco, 1990). Based on an ecological perspective, a number of potentially effective approaches to preventing homelessness can be proposed. Some involve changing large-scale social policies. For instance, rather than eliminating welfare benefits, such benefits could be expanded and programs designed to reduce domestic violence and substance abuse could be more widely implemented. Of course, such approaches would require large amounts of funds and would need to be politically viable. Given the many risk factors for abnormal development that have been observed among homeless children (Rafferty & Shinn, 1991), preventive interventions, such as Head Start, may be especially warranted for this vulnerable group. 9.08.3.4 Intensive Case Management and Related Interventions Though not oriented toward prevention, a number of other innovative interventions, consistent with an ecological perspective, have been developed in the 1990s to help currently homeless persons escape homelessness. One general category of such interventions involves intensive case management. Such interventions work closely with homeless clients, attempting to meet all of their long- and short-term needs, including permanent housing, job training and placement, and linkages to services in mental

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health, substance abuse, health care, and other relevant areas. Interventions of this type have been adapted and shown some effectiveness in careful research evaluations for a variety of homeless populations, including the homeless mentally ill (Morse, Calsyn, Allen, Tempelhoff, & Smith, 1992), homeless street youth (Cauce et al., 1993, 1994), and more general samples of homeless adults and families (Toro et al., 1997). 9.08.3.5 Tapping Existing Community Resources to Help the Homeless Another promising general approach for assisting those who are currently homeless involves tapping existing community resources in creative ways in order to reduce the incidence of homelessness. The Habitat for Humanity program is an example of this approach. This program taps interested volunteers in the community to develop low-income housing. Interventions can also consider homeless people themselves as valuable resources. Thus, the homeless can be taught to help rehabilitate housing for use by the poor and serve in other public works capacities. In this way, the homeless receive valuable training that can help them reintegrate into the community at the same time that they reduce the potential future risk of homelessness for others and improve the general quality of life in the community. Unfortunately, such approaches have only been developed on a small scale and there have been no systematic attempts to rigorously evaluate them. 9.08.3.6 Clinical Issues in Working with the Homeless In the sorts of innovative programs described above, as well as in more traditional clinical interventions, there are a number of special issues that should be considered when working with the homeless. 9.08.3.6.1 Immediate and long-term needs Most services targeted specifically to homeless persons have focused on their immediate needs. While it is obviously important that these needs be addressed, the long-term needs of the homeless require even more attention. These needs include substance abuse treatment, job training and placement, health care, suitable permanent housing, mental health services, and assistance to repair damaged family and other social relationships. Generally, any particular homeless person or family will show a variety of such needs. Unfortunately, the human service

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system is not designed to address such a multiplicity of long-term needs. Rather, that system is fragmented, with separate agencies able to handle only one or two areas. Intensive case management services are one way to improve on such a system, since these services insert someone who knows the system into the life of the homeless person or family so that the multiplicity of client needs can be readily met. A one stop shopping approach to service delivery for the homeless is recommended, in which all needs can be handled at a single site.

9.08.3.6.2 The heterogeneity of the population In addressing both the short- and long-term needs of the homeless, service providers and planners need to consider the heterogeneous nature of the homeless population. Homeless people come from all age and ethnic groups, include both men and women, and show a variety of other background characteristics that are generally similar to the cities in which they are found. Such heterogeneity suggests that effective interventions need to be individually tailored.

9.08.3.6.3 Substance abuse One of the factors most clearly distinguishing the homeless from other groups in our society is a history of drug and/or alcohol abuse. While many of those with such a history may not currently be abusing, all need long-term help to prevent future resumption of destructive substance abusing behaviors. In serving the homeless, the role of substance abuse cannot be forgotten. As in substance abuse treatment generally, research evaluations should be undertaken to assess both short- and long-term program effectiveness. A number of such evaluations have begun (e.g., Argeriou & McCarty, 1991; NIAAA, 1991).

9.08.3.6.4 Depression The presence of depressive symptoms, of varying severity across homeless individuals, also needs to be considered. Whether such depression is seen as a cause or effect of homelessness, service providers must deal with the sense of hopelessness and despair that is so commonly seen among homeless people. Such negative affect can stymie well-intentioned intervention efforts. It may sometimes be necessary to address the affect itself in order to motivate the homeless to work on their other problems.

9.08.3.6.5 Compliance with treatment Depression, substance abuse, physical and other disabilities, complicated social lives, the lack of financial resources, criminal histories, and the need to cope with immediate crises can all conspire to make serving the homeless less than rewarding. Flexibility of approach and a willingness to deal with whatever problem is of concern to the client can help engage homeless clients in both traditional and more innovative services. 9.08.3.6.6 Family and other social characteristics While a small minority of the homeless fit the stereotype of the social isolate, considerable research has documented that most homeless people have regular contact with family. Unfortunately, this contact is not always positive. Among all segments of the homeless population, domestic violence and conflict are prevalent and often serve to precipitate and prolong episodes of homelessness. If homeless people are to make long-term adjustments in the community, attention needs to be paid to improving family functioning. Conflict resolution strategies, family therapy, and other intervention models can address these needs. 9.08.3.6.7 Competencies and deficits While their deficits clearly need to be addressed if homeless people are to make positive long-term adjustments in the community, their competencies also need to be considered and strengthened. For example, many young homeless men have some employable skills and many women homeless with their children have good parenting abilities. These skills can be honed and put to use. For example, men with appropriate skills could be placed in positions to assist in the construction of more low-income housing and women with effective parenting skills could serve as paraprofessional parent or teacher aides. 9.08.3.6.8 Advocacy and traditional services With their expertise in assessment and behavioral management, and their understanding of the many problems faced by homeless people (e.g., substance abuse, depression), clinical psychologists are in a unique position to provide direct services and supervise the services provided by others to this population. While such services are becoming increasingly funded through special grants and contracts and some psychologists have been providing their

References services to the homeless on a pro bono basis (Freiberg, 1991), fiscal pressures in the health and mental health care fields also operate to limit access to services for the poor and homeless. In addition to providing and developing traditional services, it is recommended that clinical psychologists interested in helping the homeless also consider other, less traditional roles. With their conceptual and research skills, clinical psychologists are well-equipped to assist in effective program evaluation and design and in policy analysis and planning. Also, since they are often respected members of their communities, psychologists can help address the needs of homeless people by educating policy makers and through political advocacy. If the incidence of homelessness is to be reduced, such advocacy as well as many more persons willing to assist homeless people directly are needed. 9.08.4 SUMMARY Homelessness has become a troubling social problem in the USA and most other developed nations. Psychologists and other professionals have become involved with the problem as researchers and service providers. Recent research has shed light on many aspects of homelessness. Public opinion surveys have identified firm support among Americans for solving the problem and the diagnostic and other basic characteristics of the homeless in American cities have been well documented. Researchers have refined sampling and measurement methods and are now increasingly engaged in longitudinal and intervention research. In response to the great perceived need, services for the homeless have been developing at a rapid pace since the early 1980s. Unfortunately, most of the services are targeted only to the immediate needs of homeless people rather than their long-term problems and few of the services are being carefully evaluated. In working to help the homeless, a number of special issues are often encountered. These include dealing with the substance abuse and depression that are so common among these people and expanding traditional clinical approaches to consider the person's entire array of skills and resources and to include program design and evaluation activities and political advocacy. 9.08.5 REFERENCES Adams, C. T. (1986). Homelessness in the post-industrial city: views from London and Philadelphia. Urban Affairs Quarterly, 21, 527±549. Appelbaum, R. P. (1990). Counting the homeless. In J. Momeni (Ed.), Homelessness in the United States: data and issues (pp. 1±16). New York: Praeger. Arce, A. A., & Vergare, M. J. (1984). Identifying and

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characterizing the mentally ill among the homeless. In H. R. Lamb (Ed.), The homeless mentally ill: A task force report of the American Psychiatric Association (pp. 75±90). Washington, DC: American Psychiatric Association. Argeriou, M., & McCarty, D. (Eds.) (1990). Treating alcoholism and drug abuse among homeless men and women: Nine community demonstration grants. New York: Haworth Press. Barbanel, J. (1989, June 29). New Yorkers fault city help for the homeless, poll shows. New York Times, pp. A1, B4. Barringer, F. (1991, April 12). US homeless count is far below estimates. New York Times, p. A11. Bassuk, E., & Gallagher, E. M. (1990). The impact of homelessness on children. Child & Youth Services, 14, 19±33. Bassuk, E. L., & Rosenberg, L. (1990). Psychosocial characteristics of homeless children and children with homes. Pediatrics, 85, 257±261. Bassuk, E. L., & Rubin, L. (1987). Homeless children: A neglected population. American Journal of Orthopsychiatry, 57, 279±286. Bassuk, E. L., Rubin, L., & Lauriat, A. (1986). Characteristics of sheltered homeless families. American Journal of Public Health, 76, 1097±1101. Bates, D. (1993, August). Cross-sectional and longitudinal analyses of social support among the homeless. Paper presented at the 101st Annual Convention, American Psychological Association, Toronto, Canada. Baumohl, J. (Ed.) (1996). Homelessness in America. Phoenix, AZ: Oryx Press. Bellavia, C., & Toro, P. A. (1998). Mental illness among homeless and poor people: A comparison of assessment methods. Community Mental Health Journal. Benedict, A., Shaw, J., & Rivlin, L. (1988). Attitudes toward the homeless in two New York City metropolitan samples. Journal of Voluntary Action Research, 17(3±4), 90±98. Blankertz, L., & White, K. K. (1990). Implementation of rehabilitation program for dually diagnosed homeless. Alcoholism Treatment Quarterly, 7, 149±164. Blau, J. (1992). The visible poor: Homelessness in the United States. New York: Oxford University Press. Boesky, L. M., Toro, P. A., & Bukowski, P. A. (1997). Differences in psychosocial factors among older and younger homeless adolescents found in youth shelters. Journal of Prevention and Intervention in the Community, 15(2), 19±36. Boesky, L. M., Toro, P. A., & Wright, K. (1995, October). Maltreatment in a probability sample of homeless adolescents: A subgroup comparison. Paper presented at the Annual Meeting of the American Public Health Association, San Diego, CA. Bukowski, P. A., Toro, P. A., & Wolfe, S. M. (1998). Homeless and matched housed adolescents: A comparative study of psychopathology. Journal of Clinical Child Psychology, 27(2). Burnam, A., & Koegel, P. (1988). Methodology for obtaining a representative sample of homeless persons: The Los Angeles Skid Row Study. Evaluation Review, 12, 117±152. Burt, M. R. (1992). Over the edge: The growth of homelessness in the 1980s. New York: Russell Sage Foundation. Cauce, A. M., Morgan, C. J., Shantinath, S. D., Wagner, V., Wurzbacher, K., Tomlin, S., & Blanchard, T. (1993). Intensive case management for homeless youth: A description of a study in progress. The Community Psychologist, 26(2), 32±34. Cauce, A. M., Morgan, C. J., Wagner, V., Moore, E., Sy, J., Wurzbacher, K., Weeden, K., Tomlin, S., & Blanchard, T. (1994). Effectiveness of intensive case

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management for homeless adolescents: Results of a 3month follow-up. Journal of Emotional and Behavioral Disorders, 2, 219±227. Cohen, E. H., Mowbray, C., Bybee, D., Yeich, S., Ribisl, K., & Freddolino, P. P. (1993). Tracking and follow-up methods for research on homelessness. Evaluation Review, 17, 331±352. Dail, P. W. (1990). The psychosocial context of homeless mothers with young children: Program and policy implications. Child Welfare, 69, 291±308. Daly, G. (1990). Programs dealing with homelessness in the United States, Canada, and Britain. In J. Momeni (Ed.), Homelessness in the United States: Data and issues (pp. 133±152). New York: Praeger. Dende, J. D., & Kline, J. D. (1995). Overcoming crack, schizophrenia, and homelessness: A comprehensive case management approach. New Directions for Mental Health Services, 65, 53±69. D'Ercole, A., & Struening, E. (1990). Victimization among homeless women: Implications for service delivery. Journal of Community Psychology, 18, 141±152. Dexter, R. A. (1990). Treating homeless and mentally ill substance abusers in Alaska. Alcoholism Treatment Quarterly, 7, 25±30. Drake, R. E., Osher, F. C., & Wallach, M. A. (1991). Homelessness and dual diagnosis. American Psychologist, 46, 1149±1158. Eaton, W. W., & Kessler, L. G. (1985). Epidemiologic field methods in psychiatry: The NIMH Epidemiologic Catchment Area Program. Orlando, FL: Academic Press. Fischer, P. (1988). Criminal activity among the homeless: A study of arrests in Baltimore. Hospital and Community Psychiatry, 39, 46±61. Fischer, P. J., Shapiro, S., Breakey, W. R., Anthony, J. C., & Kramer, M. (1986). Mental health and social characteristics of the homeless: A survey of mission users. American Journal of Public Health, 76, 519±524. Fisher, P., Wicks, J., Shaffer, D., Piacentini, J., & Lapkin, J. (1992). Diagnostic interview schedule for children users' manual. New York: Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute. Foscarinis, M. (1991). The politics of homelessness: A call to action. American Psychologist, 41, 1232±1238. Fournier, L. (1988). Rapport syntheÁse de l'operation d'eÂnumeÂration de la clienteÁle des missions et refuges de MontreÂal [Summary report on a census of the clientele of shelters and soup kitchens in Montreal]. Unite de recherche psychosociale, Centre de recherche de l'hopital Douglas, Verdun, Canada. Fournier, L., & Mercier, C. (Eds.) (1996). Sans domicile fixe: Au-delaÁ du steÂreÂotype [Homelessness: Beyond the stereotype]. Montreal, Canada: MeÂridien. Fournier, L., Mercier, C., Raynault, M., Ohayon, M., & Caulet, M. (1993). Reaching the most destitute of the homeless: When success turns to failure. Contemporary Drug Problems, 19, 415±431. Fournier, L., Toro, P. A., Link, B., Manrique, M., & Glasser, I. (1996, August). A cross-cultural analysis of homelessness: Prevalence and public opinion. Paper presented at the 104th Annual Convention, American Psychological Association, Toronto, Canada. Fox, E. R., & Roth, L. (1989). Homeless children: Philadelphia as a case study. Annals of the American Academy of Political and Social Sciences, 506, 141±151. Freiberg, P. (1991, February). APA pro bono program serves homeless people. APA Monitor, 22(2), 34. Furillo, A. (1990, July 19). Homeless face growing hostility in nation's cities. San Francisco Examiner/Chronicle, pp. A1, A12. Gelberg, L., Linn, L. S., Usatine, R. P., & Smith, M. H. (1990). Health, homelessness, and poverty: A study of clinic users. Archives of Internal Medicine, 150, 2325±2330.

Gelberg, L., Panarites, C. Andersen, R., & Koegel, P. (1994, November). Tuberculosis among the homeless in Los Angeles County. Paper presented at the Annual Meeting, American Public Health Association, Washington, DC. Gewirtzman, R., & Fodor, I. (1987). The homeless child at school: From welfare hotel to classroom. Child Welfare, 66, 237±245. Goldstein, M. N., & Toro, P. A. (1995, November). A comparison of veterans and nonveterans in a representative sample of homeless adults. Presented at the Annual Meeting, American Public Health Association, San Diego, CA. Goldstein, M., & Toro, P. (1996, August). Predicting outcomes among homeless adults: A longitudinal analysis. Paper presented at the 104th Annual Convention, American Psychological Association, Toronto, Canada. Goodman, L. A. (1991). The prevalence of abuse in the lives of homeless and housed poor mothers: A comparison study. American Journal of Orthopsychiatry, 61, 489±500. Goodman, L., Saxe, L., & Harvey, M. (1991). Homelessness as psychological trauma: Broadening perspectives. American Psychologist, 46, 1219±1225. Gore, A. (1990). Public policy and the homeless. American Psychologist, 45, 960±962. Hannappel, M., Calsyn, R. J., & Morse, G. A. (1989). Mental illness in homeless men: A comparison of shelter and street samples. Journal of Community Psychology, 17, 304±310. Hombs, M. E., & Snyder, M. (1986). Homelessness in America: A forced march to nowhere. Washington, DC: The Community for Creative Non-Violence. HUD (1984). A report to the Secretary on the homeless and emergency shelters. Washington, DC: US Department of Housing and Urban Development. Institute of Medicine (1988). Homelessness, health, and human needs. Washington, DC: National Academy Press. Jaffe, P. G., Wolfe, D. A., & Wilson, S. K. (1990). Children of battered women. Newbury Park, CA: Sage. Jahiel, R. I. (Ed.) (1992). Homelessness: A preventionoriented approach. Baltimore: Johns Hopkins University Press. Jencks, C. (1994). The homeless. Cambridge, MA: Harvard University Press. Koegel, P., & Burnam, A. (1994, November). The course of homelessness among adults in Los Angeles. Paper presented at the Annual Meeting, American Public Health Association, Washington, DC. Koegel, P., Burnam, A., & Farr, R. K. (1988). The prevalence of specific psychiatric disorders among homeless individuals in the inner city of Los Angeles. Archives of General Psychiatry, 45, 1085±1092. Koegel, P., Burnam, A., & Farr, R. K. (1990). Subsistence adaptation among homeless adults in the inner city of Los Angeles. Journal of Social Issues, 46, 83±108. Koegel, P., Burnam, A., & Morton, S. C. (1996). Enumerating homeless people: Alternative strategies and their consequences. Evaluation Review, 20, 378±403. Koegel, P., Melamid, E., & Burnam, A. (1995). Childhood risk factors for homelessness among homeless adults. American Journal of Public Health, 85, 1642±1649. Koegel, P., Sullivan, G., Burnam, A., Morton, S. C., & Wenzel, S. (1997). Utilization of mental health and substance abuse services among homeless adults. Unpublished manuscript, RAND Corporation, Santa Monica, CA. Kondratas, A. (1991). Housing policy and homelessness in the United States. American Psychologist, 46, 1226±1231. Laurin, I., Fournier, L., Toupin, J., & Ostoj, M. (1996, August). Homeless and housed men: A study of risk factors. Paper presented at the 104th Annual Convention, American Psychological Association, Toronto, Canada.

References Lee, B., Jones, S. H. & Lewis, D. W. (1990). Public beliefs about the causes of homelessness. Social Forces, 69, 253±265. Lee, B. A., Link, B. G., Toro, P. A. (1991). Images of the homeless: Public views and media messages. Housing Policy Debate, 2, 649±682. Levine, I. S., & Rog, D. J. (1990). Mental health services for homeless mentally ill persons: Federal initiatives and current service trends. American Psychologist, 45, 963±968. Liebow, E. (1993). Tell them who I am: The lives of homeless women. New York: Penguin. Link, B. G., Schwarz, S., Moore, R., Phelan, J., Struening, E., Stueve, A., & Colten, M. E. (1995). Public knowledge, attitudes, and beliefs about homeless people. Evidence for compassion fatigue? American Journal of Community Psychology, 23, 533±555. Link, B. G., Susser, E., Stueve, A., Phelan, J., Moore, R., Struening, E., & Colten, M. E. (1994). Lifetime and fiveyear prevalence of homelessness in the United States. American Journal of Public Health, 84, 1907±1912. Lozowski, S., Rowland, L. L., & Toro, P. A. (1994, November). Self-reported health in a probability sample of homeless adults. Presented at the Annual Meeting, American Public Health Association, Washington, DC. Manrique, M. A., & Toro, P. A. (1994, November). National public opinion on homelessness: Is there compassion fatigue? Paper presented at the Annual Meeting, American Public Health Association, Washington, DC. Manrique, M. A., & Toro, P. A. (1995, August). Life-time prevalence of homelessness in the United States. Paper presented at the 103rd Annual Convention of the American Psychological Association, New York. Many cities in crackdown on homeless. (1994, December 14). New York Times, p. 8. Media General Research (1989). Codebook: Media General/Associated Press National Poll 23 (November, 1988). Richmond, VA: Author. Molnar, J. M., Rath, W. R., & Klein, T. P. (1990). Constantly compromised: The impact of homelessness on children. Journal of Social Issues, 46, 109±124. Morse, G., Calsyn, R. J., Allen, G., Tempelhoff, B., & Smith, R. (1992). Experimental comparison of the effects of three treatment programs for homeless mentally ill people. Hospital and Community Psychiatry, 43, 1005±1010. Mundy, P., Robertson, J., Greenblatt, M., & Robertson, M. (1989). Residential instability in adolescent inpatients. Journal of the American Academy of Child and Adolescent Psychiatry, 28, 176±181. NIAAA (1991). Synopses of cooperative agreements for research demonstration projects on alcohol and other drug abuse treatment for homeless persons. Rockville, MD: US Department of Health and Human Services, National Institute on Alcohol Abuse and Alcoholism. North, C. S., & Smith, E. M. (1992). Posttraumatic stress disorder among homeless men and women. Hospital and Community Psychiatry, 43, 1010±1016. North, C. S., & Smith, E. M. (1993). A comparison of homeless men and women: Different populations, different needs. Community Mental Health Journal, 29, 423±431. Nye, I. F., & Edelbrock, C. (1980). Some social characteristics of runaways. Journal of Family Issues, 1, 147±150. Passero Rabideau, J. M., & Toro, P. A. (1997). Social and environmental predictors of adjustment in homeless children. Journal of Prevention and Intervention in the Community, 15(2), 1±17. Phillips, K. (1990). The politics of rich and poor: Wealth and the American electorate in the Reagan aftermath. New York: Random House. Piacentini, J., Shaffer, D., Fisher, P., Schwab-Stone, M., Davies, M., & Gioia, P. (1993). The Diagnostic Interview

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Schedule for Children-Revised Version (DISC-R): III. Concurrent Validity. Journal of The American Academy of Child and Adolescent Psychiatry, 32, 658±665. Poll shows majority don't oppose shelters. (1991, March 6). Washington Post, p. B2. Price, R. M., Cowen, E. L., Lorion, R. P., & RamosMcKay, J. (1988). Fourteen ounces of prevention: A casebook for practitioners. Washington, DC: American Psychological Association. Rafferty, Y., & Shinn, M. (1991). The impact of homelessness of children. American Psychologist, 46, 1170±1179. Regier, D. A, Boyd, J. H., Burke, J. D., Jr., Rae, D. S., Myers, J. K., Kramer, M., Robins, L. N., George, L. K., Karno, M., & Locke, B. Z. (1988). One-month prevalence of mental disorders in the United States: Based on five epidemiologic catchment area sites. Archives of General Psychiatry, 45, 977±986. Ringwalt, C. L., Greene, J. M., & Iachan, R. (1994, November). Prevalence and characteristics of youth in households with runaway and homeless experience. Paper presented at the meeting of the American Public Health Association, Washington, DC. Robertson, M. J. (1990, August). Characteristics and circumstances of homeless adolescents in Hollywood. Paper presented at the Annual Convention of the American Psychological Association, Boston, MA. Robertson, M. J. (1991). Homeless youth: An overview of the recent literature. In J. H. Dryder-Coe, L. M. Salamon, & J. M. Molnar (Eds.), Homeless children and youth: A new American dilemna (pp. 33±68). Baltimore: Johns Hopkins University Press. Robertson, M. J. (1991). The prevalence of mental disorder among homeless people. In R. I. Jahiel (Ed.), Homelessness: A prevention-oriented approach (pp. 57±86). Baltimore: Johns Hopkins University Press. Robertson, M. J., & Cousineau, M. R. (1986). Health status and access to health services among the urban homeless. American Journal of Public Health, 76, 561±563. Robertson, M. J., Koegel, P., & Ferguson, L. (1989). Alcohol use and abuse among homeless adolescents in Hollywood. Contemporary Drug Problems, 16, 415±452. Robertson, M. J., Zlotnick, C., & Westerfelt, A. (1994, November). The course of homelessness among adults and families in Alameda County. Paper presented at the Annual Meeting, American Public Health Association, Washington, DC. Robertson, M. J., Zlotnick, C., & Westerfelt, A. (1997). Drug disorders and treatment contact among homeless men and women in Alemeda County. American Journal of Public Health, 87, 221±228. Robins, L. N., Helzer, J. E., Croughan, J., & Ratcliff, K. S. (1981). National Institute of Mental Health Diagnostic Interview Schedule: Its history, characteristics, and validity. Archives of General Psychiatry, 38, 381±389. Roll, C. N., Toro, P. A., & Ortola, G. L. (1995, November). Characteristics and experiences of homeless adults: A comparison of single men, single women, and women with children. Paper presented at the Annual Meeting, American Public Health Association, San Diego, CA. Rosenheck, R., Gallup, P., & Frisman, L. K. (1993). Health care utilization and costs after entry into an outreach program for homeless mentally ill veterans. Hospital and Community Psychiatry, 44, 1166±1171. Rosenheck, R., & Koegel, P. (1993). Characteristics of veterans and nonveterans in three samples of homeless men. Hospital and Community Psychiatry, 44, 858±863. Rossi, P. H. (1989). Down and out in America: The origins of homelessness. Chicago: University of Chicago Press. Rowland, L. L., & Toro, P. A. (1996, August). Predicting health outcomes among the homeless: An 18-month

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longitudinal study. Paper presented at the 104th Annual Convention, American Psychological Association, Toronto, Canada. Seidner, A. L., Burling, T. A., Fisher, L. M., & Blair, T. R. (1990). Characteristics of telephone applicants to a residential rehabilitation program for homeless veterans. Journal of Consulting and Clinical Psychology, 58, 825±831. Shaffer, D., & Caton, C. L. M. (1984). Runaway and homeless youth in New York City: A report to the Ittleson Foundation. New York: New York State Psychiatric Institute and Columbia University. Shaffer, D., Schwab-Stone, M., Fisher, P. C., Piacentini, J., Davies, M., Conners, C. K., & Regier, D. (1993). The Diagnostic Interview Schedule for Children-Revised version (DISC-R): Preparation, field testing, interrater reliability, and acceptability. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 643±650. Shift in feelings on the homeless: Empathy turns to frustration. (1991, September 2) New York Times, p. 1. Shinn, M. (1992). Homelessness: What is a psychologist to do? American Journal of Community Psychology, 20, 1±24. Shinn, M. (1996, August). Family homelessness: State or trait. Paper presented at the 104th Annual Convention, American Psychological Association, Toronto, Canada. Shinn, M., Burke, P. D., & Bedford, S. (1990). Homelessness: Abstracts of the psychological and behavioral literature, 1967±1990. Bibliographies in Psychology Series, 7. Washington, DC: American Psychological Association. Shinn, M., Knickman, J., & Weitzman, B. C. (1991). Social relationships and vulnerability to becoming homeless among poor families. American Psychologist, 46, 1180±1187. Shinn, M., & Weitzman, B. C. (1990). Research on homelessness: An introduction. Journal of Social Issues, 46, 1±11. Shlay, A. B., & Rossi, P. H. (1992). Social science research and contemporary studies of homelessness. Annual Review of Sociology, 18, 129±160. Smart, R. G., Adlaf, E. M., Walsh, G. W., & Zdanowicz, Y. (1994). Similarities in drug use and depression among runaway students and street youth. Canadian Journal of Public Health, 85, 17±18. Smith, E. M., & North, C. S. (1994). Not all homeless women are alike: Effects of motherhood and the presence of children. Community Mental Health Journal, 30, 601±610. Snow, D. A., Baker, S. G., Anderson, L., & Martin, M. (1986). The myth of pervasive mental illness among the homeless. Social Problems, 33, 407±423. Sosin, M. R. (1992). Homeless and vulnerable meal program users: A comparison study. Social Problems, 39, 170±188. Stayanoff, S. R., Weber, M. D., Wiley, D., Ford, W. L., & Kerndt, P. R. (1994, November). HIV prevalence and associated risk factors among homeless patients in an inner city clinic in Los Angeles. Paper presented at the Annual Meeting, American Public Health Association, Washington, DC. Susser, E., Conover, S., & Struening, E. L. (1989). Problems of epidemiologic method in assessing the type and extent of mental illness among homeless adults. Hospital and Community Psychiatry, 40, 261±265. Susser, E., Struening, E. L., & Conover, S. (1987). Childhood experiences of homeless men. American Journal of Psychiatry, 144, 1599±1601. Toro, P. A., Alan, K., Saccarelli, T., Saccarelli, E. G., Lombardo, S. A., & Pienkowski, J. (1995, June). A crosscultural comparison of homelessness across developed

nations. Presented at the Fifth Biennial Conference on Community Research & Action, Chicago. Toro, P. A., Bellavia, C., Daeschler, C., Owens, B., Wall, D. D., Passero, J. M., & Thomas, D. M. (1995). Distinguishing homelessness from poverty: A comparative study. Journal of Consulting and Clinical Psychology, 63, 280±289. Toro, P. A., & Bukowski, P. A. (1995). Homeless adolescents: What we know and what can be done. NMHA Prevention Update, 6(1), 6±7. Toro, P. A., & McDonell, D. M. (1992). Beliefs, attitudes, and knowledge about homelessness: A survey of the general public. American Journal of Community Psychology, 20, 53±80. Toro, P. A., Rabideau, J. M. P., Bellavia, C., Daeschler, C., Wall, D. D., Thomas, D. M., & Smith, S. J. (1997). Evaluating an intervention for homeless persons: Results of a field experiment. Journal of Consulting and Clinical Psychology, 65, 476±484. Toro, P. A., & Rojansky, A. (1990). Homelessness: Some thoughts from an international perspective. Community Psychologist, 23(4), 8±11. Toro, P. A., Trickett, E. J., Wall, D. D., & Salem, D. A. (1991). Homelessness in the United States: An ecological perspective. American Psychologist, 46, 1208±1218. Toro, P. A., & Wall, D. D. (1991). Research on homeless persons: Diagnostic comparisons and practice implications. Professional Psychology: Research and Practice, 22, 479±488. Toro, P. A., & Warren, M. G. (1991). Homelessness, psychology, and public policy: Introduction to section three of the special issue on homelessness. American Psychologist, 46, 1205±1207. Toro, P. A., Wolfe, S. M., Bellavia, C., Thomas, D. M., Rowland, L. L., Daeschler, C. V., & Bukowski, P. A. (1998). Obtaining representative samples of homeless persons: A two-city study. Unpublished manuscript, Department of Psychology, Wayne State University. US Conference of Mayors (1989). A status report on hunger and homelessness in America's cities: A 27-city survey. Washington, DC: US Conference of Mayors. Valencia, E., Saez, H., Susser, E., Conover, S., & Colson, P. (1994, November). HIV and TB prevalence among mentally ill men in NYC shelter. Paper presented at the Annual Meeting, American Public Health Association, Washington, DC. Wagner, J., & Menke, E. (1990, November). The mental health of homeless children. Paper presented at the meeting of the American Public Health Association, New York. Washington Post (1991). Poll shows majority don't oppose shelters. Washington Post, 6 March, B2. Windle, M. (1989). Substance use and abuse among adolescent runaways: A four-year follow-up study. Journal of Youth and Adolescence, 18, 331±344. Wood, D., Valdez, R. B., Hayashi, T., & Shen, A. (1990). Families in Los Angeles: A study comparing demographic, economic, and family function characteristics. American Journal of Public Health, 80, 1049±1052. Wolfe, S. M. (1993, August). Structural equation modeling among homeless adults: Stress, support, and self-esteem. Paper presented at the 101st Annual Convention, American Psychological Association, Toronto, Canada. Wolfe, S. M. (1994, August). A comparative study of housed and homeless adolescents. Paper presented at the 102nd Annual Convention, American Psychological Association, Los Angeles. Wright, J. D. (1989). Address unknown: The homeless in America. New York: Aldine de Gruyter. Wright, J. D. (1990). Homelessness is not healthy for children and other living things. Child & Youth Services, 14, 65±88. Wright, J. D., Allen, T. L., & Devine, J. A. (1993, August).

References Tracking non-traditional populations in longitudinal studies. Paper presented at the 101st Annual Convention, American Psychological Association, Toronto, Canada. Wright, J. D., & Lam, J. A. (1987). Homelessness and the low-income housing supply. Social Policy, 17(4), 49±53. Wright, J. D., & Weber, E. (1987). Homelessness and health. New York: McGraw-Hill. Yates, G., MacKenzie, R., Pennbridge, J., & Cohen, E. (1988). A risk profile comparison of runaway and non-

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runaway youth. American Journal of Public Health, 78, 820±821. Zigier, E., & Styfco, S. J. (1990). Head Start: Criticism in a constructive context. American Psychologist, 49, 127±132. Zolopa, A. R., Hahn, J. A., Gorter, R., Miranda, J., Wlodarczyk, D., Peterson, J., Pilote, L., & Moss, A. R. (1994). HIV and tuberculosis infection in San Francisco's homeless adults: Prevalence and risk factors in a representative sample. Journal of the American Medical Association, 272, 455±461.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

9.09 Individuals with Traumatic Brain Injury STEPHEN R. HOOPER University of North Carolina, Chapel Hill, NC, USA 9.09.1 INTRODUCTION

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9.09.2 DEFINITIONAL ISSUES

138 138 138 139

9.09.2.1 Alteration in Level of Consciousness 9.09.2.2 Degree of Post-traumatic Amnesia 9.09.2.3 Presence of Physical Damage 9.09.3 EPIDEMIOLOGICAL CHARACTERISTICS

139 139 140 140

9.09.3.1 Incidence Rates and Related Factors 9.09.3.2 Major Causes of Traumatic Brain Injury 9.09.3.3 Related Factors 9.09.4 NEUROPATHOLOGICAL MECHANISMS

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9.09.4.1 Acceleration-dependent Injuries 9.09.5 TYPES OF INJURIES

141 141 141 142 142 142 142 143 143

9.09.5.1 Penetrating Head Injuries 9.09.5.2 Nonpenetrating Head Injuries 9.09.5.3 Medical Complications 9.09.5.3.1 Hypoxia/ischemia 9.09.5.3.2 Cerebral edema 9.09.5.3.3 Hemorrhages 9.09.5.3.4 Cerebral atrophy 9.09.5.3.5 Post-traumatic epilepsy 9.09.6 NEUROCOGNITIVE AND PSYCHOSOCIAL OUTCOMES

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9.09.6.1 Neurocognitive Outcomes in Penetrating Head Injuries 9.09.6.2 Neurocognitive Outcomes in Nonpenetrating Head Injuries 9.09.6.2.1 Intellectual 9.09.6.2.2 Motor/visual±motor 9.09.6.2.3 Attention 9.09.6.2.4 Language 9.09.6.2.5 Memory 9.09.6.2.6 Academic 9.09.6.3 Psychosocial Outcomes 9.09.6.3.1 Impact on the family

143 144 144 145 145 145 145 146 146 147

9.09.7 ISSUES RELATED TO OUTCOMES

147 147 148 148

9.09.7.1 Age at Time of Injury 9.09.7.2 Recovery Rates 9.09.7.3 Premorbid Functioning 9.09.8 INTERVENTION

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9.09.8.1 Cognitive Rehabilitation 9.09.8.2 Educational Programming

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9.09.9 SUMMARY

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9.09.10 REFERENCES

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9.09.1 INTRODUCTION Neurological involvement of any kind can have a significant impact on the overall functioning of an individual. This is especially possible in the case of traumatic brain injury (TBI) where the sudden nature of the injury and its severity can alter the developmental progression, expectations, and environmental arena of an individual forever. Recognizing the possible impacts of a TBI can assist the clinical psychologist and other practitioners in developing assessment, treatment, and tracking programs for these individuals; however, most professionals, particularly clinical child psychologists, are ill-prepared to manage such cases (Cooley & Singer, 1991). This chapter discusses issues pertinent to TBI, including definitional issues, epidemiology, specific causes of TBI, associated risk factors, and outcomes. Selected intervention issues are also presented. Although a lifespan approach to TBI is put forth, this chapter focuses much of its discussion on children and adolescents.

9.09.2 DEFINITIONAL ISSUES The National Head Injury Foundation (NHIF, 1985) defines a TBI as ªan insult to the brain, not of a degenerative or congenital nature, but caused by an external force, that may produce a diminished or altered state of consciousness.º This definition addresses most of the core issues pertinent to TBI. First, the definition states that this is an acquired problem, and consideration should be given to the many dynamics that can surround such an injury, as opposed to one of a degenerative or congenital nature (e.g., a specific learning disability). Second, it states that a TBI must be caused by an external force. Although a brain insult can occur via any number of neurological mechanisms (e.g., a cerebrovascular accident, tumors, epileptogenic brain activity), it is important to recognize that a TBI arises only in the case where an external force is involved. This external force does not necessarily have to be a direct blow to the head. The effects of acceleration± deceleration forces, as can be the case in a shaken infant or in a motor vehicle accident, may be the external force which creates the brain injury without actual physical contact (Jennett, 1986). Finally, the definition addresses the issue of change in functioning when compared to preinjury status. This is an extremely important

issue with respect to the assessment and treatment course following a TBI. Despite the inclusion of these core issues, the NHIF definition remains simplistic with respect to addressing the myriad of issues invoked in defining TBI. Indeed, Levin, Benton, and Grossman (1982) reviewed several systematic attempts to classify different types of traumatic injuries, but each one has been challenged on its ability to reflect actual brain injury, particularly in mild cases. At present, there are at least three key variables that appear pertinent to the definition of TBI: an alteration in the level of consciousness, the degree of post-traumatic amnesia (PTA), and the presence of neurophysiological, neuroanatomical damage, and/or some other type of physical damage (Bigler, 1990). 9.09.2.1 Alteration in Level of Consciousness As noted in the NHIF definition, an altered state of consciousness is one of the key features of TBI. Although it is recognized that such changes can be common sequelae of most TBIs, variants to this corollary are quite common. For example, such alterations do not always appear with some brain injuries (Jennett, 1986; Levin et al., 1982), as can be the case with selected types of focal injuries. In other cases, the appearance of the alterations may be temporally delayed (e.g., edema, hematoma). Conversely, a brief alteration in the state of consciousness with quick and total recovery of functioning, as might be seen in a concussion (Bakay & Glasauer, 1980), may not be sufficient to invoke the inference of a TBI. Consequently, care should be taken when making a direct linkage between the presence/absence of an altered state of consciousness and a possible brain injury. 9.09.2.2 Degree of Post-traumatic Amnesia The degree of PTA has also been invoked as a useful variable for defining the severity of a TBI. PTA is the amount of time following a brain injury that an individual experiences difficulties in learning and retaining new information. It is the time following an injury when the individual is alert and functioning (i.e., not comatose), and capable of responding in a relatively reliable manner. PTA ends when the individual is oriented and continuous memories are restored (Rosen & Gerring, 1986). Although there may also be significant retrograde amnesia (i.e., lack

Epidemiological Characteristics of recall for events prior to the accident), PTA has been deemed useful for defining the severity of a TBI. Brooks (1983) noted that a severe PTA of at least one week or more has been related to poorer cognitive and psychosocial outcomes. 9.09.2.3 Presence of Physical Damage A final variable that must be included in conceptualizing a definition of TBI is whether there is any actual physical damage that can be identified in the brain. This physical damage can be in the form of: neurophysiological evidence, as can be uncovered with electroencephalographic assessment strategies; neuroanatomical evidence, as depicted with a variety of neuroimaging procedures such as computerized axial tomography (CT scan), magnetic resonance imaging (MRI), or functional magnetic resonance imaging (fMRI); and/or in the form of direct physical examination (e.g., specific neuropsychological deficits, speech/language deficits, hemiparesis, cortical blindness). Findings from these procedures, when used in tandem with the presence of PTA and the degree of consciousness, offer a powerful multidimensional approach to defining TBI. 9.09.3 EPIDEMIOLOGICAL CHARACTERISTICS The complexity of the definitional issues relevant to TBI also contributes to what is known about the epidemiology of TBI. In fact, Kraus (1987) cited the lack of consistency across studies in the definition of a head injury and how this hindered the ascertainment of an accurate estimate of TBI cases. Further, Goldstein and Levin (1987) noted that many potential brain injuries have been diagnosed by the cause (e.g., fall, motor vehicle accident) rather than by the nature of the injury. These investigators also cited the pitfalls attached to developing incidence estimates based on hospital admission records and telephone surveys. These methodological issues contribute to the difficulties in gaining an accurate estimate of the incidence and prevalence of traumatic brain injury across the life span. Despite these obstacles, it has been estimated that TBIs represent the most frequent neurological conditions that result in hospitalization of children and adolescents under 19 years of age, and are a major contribution to mortality and morbidity in children and adolescents (Frankowski, 1985). In general, TBI represents a major health problem because it is the leading cause of death or permanent disability in children and adolescents (Guyer & Ellers, 1990).

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9.09.3.1 Incidence Rates and Related Factors There have been a number of well-conducted epidemiological studies to examine issues pertinent to TBI (Annegers, 1983; Guyer & Ellers, 1990; Hahn et al., 1988; Ivan, Choo, & Ventureya, 1983; Kraus, Fife, Cox, Ramstein, & Conroy, 1986). Annegers, Grabow, Kurland, and Laws (1980) conducted one of the first epidemiological studies which employed clear diagnostic criteria to ascertain incidence rates in Olmsted County, MN. They obtained an overall incidence rate of 386 per 100 000, with males (270/100 000) showing over a 2:1 ratio when compared to females (116/100 000). In addition to the gender differences, specific age trends also were observed in the data. Specifically, Annegers et al. found that the incidence of TBI increased significantly in the 15±24 years age range, particularly for males. More specifically, males showed a heightened rate from ages 5±25 years, whereas females demonstrated a decline from age 3 years through to age 15 years. There were also second peaks which occurred during infancy and at the age of 70 years and older. Similar trends were obtained by Kraus et al. (1984) in their study of medical records of patients who died or who were admitted to San Diego County Hospital in 1981. When taken together, Goldstein and Levin (1987) and Frankowski (1985) reported incidence rates of: 150/100 000 for ages birth to 4 years; 550/100 000 for ages 15±19; 160/ 100 000 around age 50; and 200/100 000 for age 65 and beyond. Kraus, Rock, and Hemyari (1990) also reported different incidence rates for different degrees of TBI severity for individuals ranging in age from birth to age 15 years. These rates indicated that about 5% of TBIs are fatal, whereas 6%, 8%, and 81% were described as severe, moderate, and mild, respectively. In addition to differences reported in the age, gender, and severity of the TBI, information has begun to emerge with respect to the impact of race and socioeconomic status on the incidence rates of TBI. Studies conducted by Kraus (1987), Rivara and Mueller (1986), and Cooper et al. (1983) revealed a higher rate of TBI in minority populations when compared to Whites. As Fennell and Mickle (1992) noted, however, these studies generally failed to take into account the effects of socioeconomic status on the incidence rates of TBI. In fact, Kraus (1987) reported that the highest rates of TBI were observed in sociocultural groups with the lowest median income, suggesting that socioeconomic factors should be considered when examining incidence rates of TBI.

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Selected risk factors have also been discussed which might increase the chance of a TBI in selected populations. For example, Rutter, Chadwick, Shaffer, and Brown (1980) noted that these individuals may not represent a random cut of the general population. They noted that their mildly injured group of children showed a higher rate of psychosocial problems, that probably preceded the TBI. Similarly, Craft, Shaw, and Cartlidge (1972) found an increased rate of teacher-reported problems including hyperactivity, depression, and antisocial behaviors that predated the brain injury. Premorbid developmental difficulties and specific learning problems (Klonoff & Paris, 1974), language problems (Mahoney et al., 1983), and lower academic achievement (Chadwick, Rutter, Brown, Shaffer, & Traub, 1981) have also been reported for pediatric TBI samples. Finally, recent evidence does suggest that an individual who sustains a TBI is at increased risk, perhaps because of the sequelae incurred from the first TBI, for sustaining a second brain injury. Annegers et al. (1980) reported that this risk was age-related, with risk being increased twofold under age 14 years, threefold between the ages of 15 and 24 years, and fivefold after age 25 years. Males also had twice the likelihood of sustaining a second TBI as females.

9.09.3.2 Major Causes of Traumatic Brain Injury Along with factors related to gender, race, socioeconomic status, and chronological age, specific causes of TBIs have been charted. For adults, motor vehicle accidents account for nearly half of all injuries, with motorcycle accidents tending to be about four times more common than other types of motor vehicle accidents. Falls are the second leading cause of TBI (Kalsbeek, McLaurin, Harris, & Miller, 1980). For children and adolescents, accidents in the home account for the major number of head injuries in preschool children, although child abuse is rapidly gaining in this age band (Christoffel, 1990). Rivara (1984) observed that infants and preschoolers may be at risk for head vs. trunk and extremity injuries, due to the disproportionate size of the child's head at these ages and the associated higher center of gravity. Falls, pedestrian±motor vehicle accidents, bicycle±motor vehicle accidents, and sporting activities comprise the majority of mild TBIs in school-age children (Frankowski, 1985). Similar to adult epidemiological findings, motor vehicle accidents constitute the majority of severe TBI cases for older adolescents (Rutter et al., 1980).

9.09.3.3 Related Factors In general, the causes of TBI tend to change with age and may contribute to the actual pathophysiology of the TBI. For example, more severe brain injuries tend to be incurred by older adolescents and adults secondary to high-speed motor vehicle accidents. In contrast, Kalsbeek et al. (1980) reported that a similar level of severity in a TBI incurred from a fall may be created by compression of cortical and subcortical regions secondary to intracerebral hematoma, as opposed to frank brain damage. Similarly, a TBI resulting from a fall may develop intracranial hematomas (DiRocco & Velardi, 1986), whereas a TBI resulting from a motor vehicle accident usually results in concussion. Temporal fluctuations have also been reported with respect to the specific causes of TBI. These fluctuations have been seen with respect to specific times of the day (Levin et al., 1982), specific days (Edna, 1987), and specific seasons of the year depending on region of the country (Klauber et al., 1981). For example, the likelihood of a child or adolescent incurring a TBI increases from the time that school ends to the time they go to bed (Levin et al., 1982). Falls are most likely to occur between noon and 6.00 p.m., and motor vehicle accidents between 6.00 p.m. and 9.00 p.m. (Jagger, Levine, Jane, & Rimel, 1984). TBIs tend to occur with a higher frequency on weekends, with peak days being Friday and Saturday (Edna, 1987). Geographically, where weather patterns are more stable, stable rates of TBI are observed (Klauber et al., 1981); however, in regions of the country where more variable weather patterns are observed, an increased rate of TBIs are observed during the spring and summer months (Edna, 1987). 9.09.4 NEUROPATHOLOGICAL MECHANISMS The mechanisms involved in a TBI occur as a result of three physical forces: tension (i.e., the tearing apart of tissues), compression (i.e., the pushing together of brain tissue), and shearing (i.e., the sliding of one portion of tissue over another). These physical forces combine to describe injuries from acceleration-dependent (i.e., acceleration, deceleration, rotation) and nonacceleration-dependent factors (e.g., many crushing types of injuries). The latter types of injuries are relatively rare, with much of the energy being evenly distributed and typically causing skull fractures, but relatively little brain damage in many instances. In these cases, the amount of damage is largely dependent upon the degree of skull deformation. Given the relative rarity of these types of injuries,

Types of Injuries acceleration-dependent injuries are the focus of this discussion. 9.09.4.1 Acceleration-dependent Injuries Denny-Brown and Russell (1941) demonstrated that a moderate blow to a movable head could produce severe brain damage, but a blow with 20 times the strength could be sustained by a rigidly fixed head with relatively little brain damage being incurred. Although clinical situations involving a rigidly fixed head are infrequent, acceleration forces typically have been viewed as the dominant factors involved in TBI, particularly closed head injuries (Pang, 1985). Acceleration injuries occur when the slower moving brain tissue is damaged or rendered dysfunctional by a sudden external force (e.g., from a punch, baseball, or rock). The brain tissue is of a different density than bone, and consequently it will accelerate at a slower rate than bone. As the external force hits the head, the skull moves in a direction opposite the impact, whereas the brain tissue initially moves in the direction of the impact and then follows the direction of the skull. In contrast to pure accelerating forces, where an object strikes a stationary head, deceleration forces occur when the moving head strikes a stationary object. In these instances, such as in motor vehicle accidents, the head is suddenly stopped with resultant damage occurring at the impact site (i.e., coup) as well as at the opposite site (i.e., contrecoup). Rotational injuries occur as a result of hyperflexion, hyperextension, lateral flexion, and turning movements of the head on the neck and brainstem. These rotational or torquing forces can produce shearing and tearing of cerebral tissue, with some investigators attributing most contrecoup injuries to these forces (Ommaya, Grubbs, & Naumann, 1971). All of these mechanisms can result in the rupturing of superficial and deep blood vessels, and the subsequent development of different kinds of hemorrhages. 9.09.5 TYPES OF INJURIES A trauma to the head does not always lead to a brain injury. To be of significance to the neurologist, psychologist, or other child or adult practitioner, a head trauma sufficient to produce a disruption of the central nervous system must have been incurred. There are several types of brain injuries that can be seen, with two broad classes generally being accepted: penetrating wounds and nonpenetrating injuries. A possible third category, skull fractures, will be subsumed under these two broad classes.

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9.09.5.1 Penetrating Head Injuries These kinds of injuries occur when an external object strikes the head with sufficient force to cause a depressed skull fracture, whereby skull fragments either tear the dura or cause a brain laceration. About 30% of all skull fractures reportedly are of a depressed nature, with compound fractures being present in about 20% of individuals with severe head trauma (Reitan & Wolfson, 1985) A second kind of penetrating head injury occurs when a missile penetrates the skull. Such a penetration can lead to the missile being lodged in the brain tissue or passing through it. Some individuals may show an immediate loss of consciousness, whereas others may not lose consciousness at the time of injury, but gradually progress into a coma over several hours. If the injury is severe enough, then increased intracranial pressure and decreased blood pressure may be seen which may create a medical emergency. Brainstem dysfunctions (e.g., poor arousal modulation) also can be observed, and are intimately related to coma states. In penetrating types of brain injuries, both focal and diffuse effects can be observed. Tearing of the dura, and subsequent damage to the underlying vasculature of the dura and meninges, along with focal contusions, can be observed in such cases. Further, the depressed skull fragments can cause tearing of the brain tissue directly underlying the depression (Dacey, Alves, Rimel, Winn, & Jane, 1986; Shapiro, 1987). Diffuse effects, such as stretching and shearing of the brain tissue, as well as contrecoup contusion, may also occur with penetrating types of brain injuries (Fennell & Mickle, 1992). Brain contusions (i.e., bruising), are most often seen in depressed skull fractures (Shapiro, 1987). 9.09.5.2 Nonpenetrating Head Injuries In contrast to the penetrating types of injuries, nonpenetrating head injuries do not involve any actual penetration of foreign material into the brain. These types of injuries can occur when the trauma to the head does not produce a skull fracture, or it generates a nondepressed or linear skull fracture. This type of involvement includes the closed head injuries and concussions and, in general, accounts for over 90% major pediatric head injuries (Menkes, 1990). Although a head injury can occur at any time in life, infants and young children are at particular risk for nonpenetrating closed head injuries because of specific skull±brain interface factors. For example, at birth there are six spaces, or fontanelles, between the neonatal skull bones. These remain unfused in order to

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accommodate the increasing size of the brain. Five of these fontanelles fuse by the age of 6 weeks, but the most anterior one does not fuse until about 9±16 months of age. As one might suspect, the infant brain is particularly susceptible to damage during this time period, although the flexibility of the immature skull can absorb a greater degree of deformation before resulting in a fracture (Menkes, 1990). This absorption factor, however, also can contribute to an increased amount of generalized shearing damage to the brain. The actual interface between the skull and the brain also contributes to the different kinds of brain damage that can be seen. The brain tends to be more tightly packed in the posterior regions of the brain and more loosely packed in anterior regions. In addition, because the brain is more tightly packed in posterior regions, the internal surface of the skull tends to be smoother, whereas an increased number of bony protuberances can be found in the anterior regions. Consequently, the frontal and temporal lobes, particularly anterior temporal regions, are the cortical areas most likely to be damaged, regardless of the site or direction of the initial impact. Given this skull±brain interface, frontotemporal lacerations and contusions are frequently seen in all types of brain injuries, particularly nonpenetrating head injuries (Bigler, 1990). These injuries can result in memory disorders, executive functioning deficits, and a variety of emotional changes (Levin et al., 1982; Salazar et al., 1986). Another primary finding in head trauma of all types is diffuse axonal injuries. Much neuropathological evidence suggests that the predominant impact of TBI is of a diffuse, nonspecific nature (Adams, Graham, & Gennarelli, 1985; Jennett, 1986). This is especially evident in cases of closed head injury. Even when focal deficits are evidenced, they are typically present in the face of more diffuse damage or dysfunction. These diffuse findings have been related to the effects of neuronal shearing and tearing (Auerbach, 1986). The diffuse damage that occurs results from the twisting, tearing, or breaking of the axonal fibers, damage to the connective supportive cells of the brain, or neuronal degeneration, these processes are referred to as diffuse axonal injury. Diffuse axonal injury can occur anywhere in the brain, but typically occurs in the brainstem, deep white matter structures, and in the frontotemporal regions. 9.09.5.3 Medical Complications In addition to the above types of TBI, there are a number of medical complications that can ensue. Although many of these concerns are

addressed prior to an individual leaving the hospital, it is important to be familiar with these complications as they may affect an individual's physical, neurocognitive, and general adaptive behavior functioning. These include ischemia/ hypoxia, cerebral edema, hemorrhage, cerebral atrophy, ventricular enlargement, and posttraumatic epilepsy. 9.09.5.3.1 Hypoxia/ischemia In addition to diffuse axonal injury, neuronal damage can also occur via obstructed blood flow (i.e., ischemia) and/or poorly oxygenated blood (i.e., hypoxia). Frequently, a loss of blood pressure to the brain can be seen, perhaps secondary to a significant loss of blood, and when this pressure falls to a certain critical point, ischemic hypoxia can occur. This process can contribute to brain tissue damage or destruction, particularly in the small vessels of the brain. In addition to the diffuse effects that can be seen with ischemic hypoxia, anoxic-type damage may disrupt specific structures as well (e.g., the hippocampus). 9.09.5.3.2 Cerebral edema This is the most common secondary effect of TBI. Cerebral edema, or brain swelling, can create focal findings, such as with a lateralized contusion, or it can produce more generalized findings (Yoshino, Yamaki, Higuchi, Horikawa, & Hirakawa, 1985). Prolonged cerebral edema can compress blood vessels feeding the brain and lead to an infarction. It also can compress actual brain tissue which may lead to cell dysfunction or destruction (Ito, Tomita, Yamazaki, Takada, & Inaba, 1986). Children are at a greater risk than adults to develop diffuse cerebral swelling following a TBI. Shapiro (1987) estimated that about 30% of conscious head-injured children, and about 40% of comatose children, show diffuse cerebral edema CT Scan. With the possibility of tissue damage and destruction, concomitant neuropsychological sequelae typically can be seen. 9.09.5.3.3 Hemorrhages Hemorrhages are bleeds that can occur in nearly any place. An extradural hematoma is a collection of blood between the skull and the dura which develops at the site of the trauma. It occurs in about 1% of children hospitalized for TBI and typically is unilateral in its appearance. The severity of the symptoms is associated, in part, with the size of the hematoma and the speed of its evolution. In children, there is typically a period of disorientation or loss of

Neurocognitive and Psychosocial Outcomes consciousness, but neurologic signs appear and a progressive loss of consciousness ensues minutes to days after evolution of the hematoma (Mealey, 1987). In general, the younger the child, the longer the latency. A subdural hematoma is a localized collection of blood between the dura and the cerebral mantle, and typically has neurosurgical implications due to increased intracranial pressure. It typically is unilateral in its appearance (Menkes, 1990) and is responsible for death and physical injury in a significant number of battered or shaken babies (Caffey, 1974). It is important to note that a hematoma may form at the time of the injury, or sometime thereafter, so it might not be an immediate complication from TBI (Bucci, Phillips, & McGillicuddy, 1986; Soloniuk, Pitts, Lovely, & Bartkowski, 1986). In addition, the presence of any type of hematoma, regardless of location, may exacerbate underlying cerebral dysfunction or damage, and might be related to increased risk for neurocognitive deficits (Cullum & Bigler, 1986). 9.09.5.3.4 Cerebral atrophy A TBI can cause cerebral atrophy, which typically corresponds to enlargement of the ventricular system and subsequent hydrocephalus (Cullum & Bigler, 1986; Lipper et al., 1985). Cullum and Bigler (1986) noted that this atrophy tends to be seen more in the frontotemporal regions, although it can also present in a diffuse fashion, with the greatest atrophy being associated with areas of contusion and/or prior hematoma. White matter degeneration has been described in a variety of age groups, and typically results from retraction of axonal pathways following injury (Graham, Adams, & Gennarelli, 1987). Results from neuroimaging procedures have suggested that changes in ventricular size may be more sensitive to structural deficits than the actual presence of cortical atrophy (Bigler, 1994). 9.09.5.3.5 Post-traumatic epilepsy Seizures that are associated with TBI have been classified as to their time of onset. Immediate types of seizures occur within a few seconds of the head trauma. Menkes (1990) suggested that these types of seizures are the result of direct mechanical stimulation of brain tissue having a low seizure threshold. Early types of seizures typically appear during the first 24±48 hours following a brain injury. In general, these are due to cerebral edema, intracranial hemorrhage, contusion, laceration, or actual tissue necrosis. Children are more prone to developing seizures in the immediate and early postinjury

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period than adults, even after a minor TBI, although the overall incidence of early posttraumatic seizures is about 7% (Jennett, 1975). Late post-traumatic seizures tend to emerge within the first two years following the injury, with about 50% of these occurring within the first year. These seizures typically have an origin in cerebromeningeal scarring. Further, there was a 5±10% incidence of post-traumatic epilepsy in children who experienced a loss of consciousness for at least one hour following their TBI, compared to a 2% occurrence when there was not a significant loss of consciousness. This incidence rate increased to 30% when a brain laceration was sustained, and doubled when the child experienced a post-traumatic amnesia of more than 24 hours. The topography of these seizures can take any form but, as a rule, generally is not manifested in absence form. It has been estimated that these seizures become less frequent after the third year following the injury in about 20±50% of patients, but that the individual will remain prone to a seizure disorder (Jennett, 1975). Finally, it must be remembered that many of the anticonvulsant medications also maintain their own liabilities with respect to their impact on neurocognitive functioning (e.g., phenytoin and phenobarbital can both cause and/or contribute to deficits on neuropsychological testing). 9.09.6 NEUROCOGNITIVE AND PSYCHOSOCIAL OUTCOMES The range of neurocognitive and psychosocial outcomes for any particular TBI will be highly varied. In addition, there may be any number of medical outcomes that will interfere with the accurate assessment of an individual's functioning (e.g., post-traumatic seizures, spasticity, ataxia). This section focuses on the neurocognitive and psychosocial outcomes that might be seen in children and adolescents who have sustained a TBI. 9.09.6.1 Neurocognitive Outcomes in Penetrating Head Injuries When the brain is damaged, deficits stem from injury to those areas of the brain that govern the involved functions. In penetrating head injuries, such as in an open head injury from a missile, discrete brain areas in the path of injury typically will be affected with largely predictable deficits. For example, if a bullet passes through the right motor strip, then disruption of functions on the left side of the body will result (e.g., hemiparesis, paralysis). In general, although the incidence of penetrating head injuries is difficult to ascertain, it has been estimated that only about 2±5% of all

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head injuries brought to medical attention are penetrating types of injuries (Kampen & Grafman, 1989), and this figure is usually less for children and adolescents. Penetrating head injuries typically occur as a result of military combat, suicide attempts, crime, or miscellaneous accidents that occur during work or leisure activities. The amount and kind of tissue damage incurred from a penetrating head injury depends on a number of factors including the type of object, the location of entry to the brain, and the velocity of the object. For example, studies investigating the effects of high-velocity missile injuries have evidenced microscopic changes in brain regions far from the actual missile track, whereas the changes incurred from low-velocity objects (e.g., a knife) typically show focal damage. Further, a penetrating object can enter the brain at any particular point and then perform a number of actions. It can come to rest along the original missile trajectory, ricochet within the skull cavity, break apart leaving shrapnel and bone fragments scattered along the path and in adjacent and distal brain regions, or it can exit the skull. The penetrating type of injury also can produce hemorrhaging, although contrecoup injures are not typically observed (Kaufman, Makela, Lee, Haid, & Gildenberg, 1986). Given the relatively high variability in these types of injuries, systematic neurobehavioral studies are few. A recent study of four adults and two children with penetrating wounds from gun shots showed focal deficits at one year postinjury (e.g., the patients with left hemisphere injuries exhibited greater verbal difficulties) as opposed to any generalized lowering of neurocognitive abilities. In addition, however, all of the patients experienced some form of memory dysfunction (Kampen & Grafman, 1989). Deficits from a penetrating head injury should directly relate, in large part, to the areas of the brain that were damaged by the object. Other regions of the brain may also be affected, however, given the actions of the object and the response to the object by the brain. Nonetheless, if the entry point of an object can be identified, and perhaps its exit point, then initial functional hypotheses can be established based on what is known about brain±behavior relationships.

9.09.6.2 Neurocognitive Outcomes in Nonpenetrating Head Injuries Nonpenetrating head injuries can result in more diffuse brain damage. Primary damage occurs to structures at the point of impact. Damage may also occur at the point opposite the impact point (i.e., contrecoup injury) as the

brain is pushed against the interior of the skull. Secondary injury results from processes of vasodilation, edema, and increased intracranial pressure that can occur as a result of the primary injury. For example, if the right parietal motor strip is at the point of impact, then an associated left-sided paralysis may also be seen. A rightsided or bilateral paralysis may result as a consequence of the contrecoup injury of the more generalized secondary injury. In its least severe form, a nonpenetrating head injury, or closed head injury, can produce a concussion. A concussion is a brief alteration/ loss of consciousness. This is usually followed by a period of confusion, disorientation, and other neurological signs such as bradycardia, lowering of the blood pressure, and amnesia (Gennarelli, 1987). In children, these symptoms can be delayed for minutes or hours after a TBI, with full recovery typically occurring within 24 hours (Shapiro, 1987). Postconcussion syndrome has also been described and can include headaches, irritability, physical lethargy, emotional lability, memory disruption, and associated academic performance problems (Casey, Ludwig, & McCormick, 1986; Lanser, Jennekens-Schinkel, & Peters, 1988; Levin, Magnusson, Rafto, & Zimmerman, 1989). In addition to the range of symptoms that have been associated with postconcussion syndrome, a variety of other neurocognitive outcomes have been identified in nonpenetrating head injuries. 9.09.6.2.1 Intellectual A review of numerous studies exploring the possibility of a decline in the level of intellectual performance following a TBI reveals a clear trend in that direction. Klonoff, Law, and Clark (1977) showed that initial estimates of intellectual function in a large group of children and adolescents were significantly below a matched group of normal controls. Levin and Eisenberg (1979) reported a low average level of intellectual functioning for many children who were comatose for at least 24 hours. For the most severely involved children (i.e., a PTA 4 7 days), scores on the Wechsler Intelligence Scale for Children-Revised have typically shown lower performance IQs compared to verbal IQs (Chadwick, Rutter, Brown, Shaffer, & Traub, 1981; Levin & Eisenberg, 1979; Winogron, Knights, & Bawden, 1984). This pattern of results is probably due to the dependence of many of the subtests on the verbal scale of old learning, with the exceptions being arithmetic and digit span, whereas subtests from the performance scale are more dependent upon speeded accuracy, problem-solving, and more novel learning (Boll, 1983).

Neurocognitive and Psychosocial Outcomes It is unlikely that IQ scores return to preinjury levels for severely brain-injured children, with evidence indicating that only a partial recovery of intellectual abilities is generally possible (Mayes, Pelco, & Campbell, 1989). This finding has been buttressed by studies showing persistent IQ deficits at one (Berger-Gross & Shackelford, 1985; Chadwick, Rutter, Brown et al., 1981), two and a half (Chadwick, Rutter, Shaffer et al., 1991), three (Filley, Cranbert, Alexander, & Hart, 1987), four (Mahoney et al., 1983), and five (Klonoff et al., 1977) years postinjury. Although these findings appear to be related directly to the severity of the TBI, they seem to be robust across the age span. 9.09.6.2.2 Motor/visual±motor Shapiro (1987) noted that the assessment of motor functions following a TBI has depended upon the procedures used in the neurological examination. Focal signs of motor dysfunction (e.g., hemiparesis, facial weakness) and problems with balance and gait typically have been described. Several studies have attempted to document motor functioning in a more explicit fashion. Levin et al. (1982) described motor slowing during the immediate time period following a mild, moderate, or severe head injury, although the severity of the injury eventually will exert a significant negative influence on the chronicity of these deficits. Gulbrandsen (1984) reported that mildly headinjured children did not differ from normal controls on simple motor speed at six months postinjury. For a severely injured group, however, simple and complex motor speed deficits have been documented (Chaplin, Deitz, & Jaffe, 1993), with these deficits persisting at one-year (Bawden, Knights, & Winogron, 1985) and twoyear follow-up points (Klonoff et al., 1977). Visual±motor deficits also have been reported, particularly in copying and visual construction abilities (Bawden et al., 1985).

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(Bawden et al., 1985; Winogron et al., 1984), although these findings have not been universally supported (Chadwick, Rutter, Shaffer, & Shrout, 1981). Obviously, how attention and its various components are operationally defined and measured will influence these types of findings, and these issues continue to require refinement for study in TBI populations (Fennell & Mickle, 1992). 9.09.6.2.4 Language In general, the incidence of speech and language deficits following a TBI increases proportionately with the degree of severity (Levin & Eisenberg, 1979). More pervasive deficits, such as mutism and frank aphasias, can be seen in many individuals, particularly those with severe head injuries (Ylvisaker, 1986). These types of global deficits tend to occur in younger children (i.e., less than age five years), although many of these deficits can resolve over the process of recovery. Estimates of aphasictype disorders secondary to a TBI have ranged from about one-third of pediatric closed headinjury patients (Kaiser & Pfenninger, 1984) to nearly two-thirds of severely brain-injured individuals (Gilchrist & Wilkinson, 1979). From a developmental perspective, Ewing-Cobbs, Fletcher, Levin, and Landry (1985) speculated that the type of speech/language impairment incurred from a TBI would be related to the language abilities that are in primary ascendancy at the time of the injury. In addition to these global speech/language deficits, specific deficits have also been uncovered. Specific deficits have been reported in object naming (Jordan, Ozanne, & Murdoch, 1990), verbal fluency (Slater & Bassett, 1988), word and sentence repetition (Levin & Eisenberg, 1979), speech (Filley et al., 1987), narrative discourse (Biddle, McCabe, & Bliss, 1996), and written output (Ewing-Cobbs & Fletcher, 1987). 9.09.6.2.5 Memory

9.09.6.2.3 Attention Attentional problems for children and adolescents following a TBI have been described across several studies, with these problems surfacing largely for more severely injured groups (Bruce, Schut, Bruno, Woods, & Sutton, 1978). Hyperactivity and poor attention have been reported by parents at follow-up intervals, with some evidence suggesting that these deficits can persist in a younger age group for up to five years postinjury (Klonoff et al., 1977). Deficits in concentration and speeded performance have been documented up through one year postinjury for individuals at all levels of severity

Despite the high degree of interaction between memory functions and attentional efficiency, a variety of memory deficits typically can be seen following TBI, particularly in children suffering closed head injuries (Fennell & Mickle, 1992), with deficits continuing to be present through one year postinjury. Similar to other functional domains, the presence of memory deficits secondary to mild and moderate brain injuries is less clear, especially over the long term. Bassett and Slater (1990) showed deficits in immediate and delayed recall of story passages and in visual reproduction in their sample of severely involved adolescents; how-

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ever, these deficits were not manifested in their mildly injured or age-matched normal controls. Deficits in visual recall (Berger-Gross & Shackelford, 1985) and spatial memory (Winogron et al., 1984) have been reported in severe TBI groups at one year postinjury, but these deficits tended not to be present in milder injuries beyond a 6±12 month period of time. Verbally based memory deficits have also been reported (Chadwick, Rutter, Shaffer, & Shrout, 1981), particularly for verbal retrieval of newly learned materials, although some investigations have uncovered these findings regardless of injury severity (Donders, 1993).

even in cases where mild injuries have been sustained. Difficulties learning new or novel materials, problems with higher-order cognition (e.g., generalization, abstraction, organization, planning, strategy generation), slowed information processing speed, and overall independent work efforts all can impact upon an individual's classroom or vocational performance in a negative fashion. These difficulties should be taken into account when evaluating a TBI survivor's return to the formal academic or vocational setting.

9.09.6.3 Psychosocial Outcomes 9.09.6.2.6 Academic Few systematic studies have been conducted examining academic morbidity following a TBI. This is surprising given that a child spends nearly the equivalent of a work week in the school setting. One crucial distinction needs to be made with respect to understanding the academic functioning of children and adolescents with a TBI. This is the distinction between skill-based deficits and performance-based deficits. Skill-based deficits reflect a lack of knowledge regarding a specific academic domain (i.e., the skills have never been present and/or have deteriorated secondary to a TBI), whereas performance-based deficits reflect the poor deployment of skills and abilities that may be present. It is speculated that clinicians should expect to see skill and, perhaps, performancebased deficits at younger ages, but more performance-based deficiencies at older ages. Academic problems following TBI at all severity levels have covered the gamut, although these findings have typically been reported for children and adolescents suffering moderate to severe injuries. In addition to specific problems in reading (Shaffer, Bijur, Chadwick, & Rutter, 1980), writing (Berger-Gross & Shackleford, 1985), and arithmetic (Levin & Benton, 1986), several investigators have documented the inreased need for special education programs, failure to return to school, and a tendency to return to a lower grade placement (Brink, Garrett, Hale, Woo-Sam, & Nickel, 1970; Fuld & Fisher, 1977; Klonoff et al., 1977). For example, Massagli, Michaud, and Rivara (1996) and Donders (1994) demonstrated that about 50±75% of their samples required some form of special education services postinjury. These rates reflect significant academic morbidity in this population. The variety of deficits that can be manifested in individuals with TBI truly is impressive, and the impact of these deficits will undoubtedly affect school and vocational performanceÐ

From all available evidence, it is clear that a TBI can be associated with increased vulnerability for emergence of a psychiatric disorder, and it may contribute to some of the most devastating outcomes following an injury (Voogt & Voogt, 1994). In the 1970s, Klonoff and Paris (1974) found that for their younger age group (i.e., ages 2±8 years), denial of the injury and lack of concern for the injury were the most common reactions. For their older group (i.e., ages 9 through 15), however, they noted a significant deterioration in self-concept. Some examinations have suggested that behavior problems may emerge in the initial time period following even a mild TBI (Casey et al., 1986). In this regard, although studies of children with mild to moderate brain injuries have shown changes in temperament and other transient behavioral symptoms (e.g., increased irritability) immediately following an injury, mild TBI does not appear to be associated with an increased risk for psychiatric disturbance. The same cannot be said with respect to more severe TBI. Probably one of the best controlled examination of this topic comes from the prospective studies of head-injured children by Rutter and his colleagues (Brown, Chadwick, Shaffer, Rutter, & Traub, 1981; Chadwick, Rutter, Brown et al. 1981; Chadwick, Rutter, Shaffer, & Shrout, 1981; Rutter et al., 1980). Children ranging from 5 to 14 years of age who had experienced closed head injuries of sufficient severity to result in a PTA of seven days or more were compared with a group of children having less severe head injuries (i.e., those with a PTA of less than seven days, but a duration of at least one hour). In addition, these groups were compared with a matched control group of hospital-treated children also suffering severe accidents, but with orthopedic rather than cranial injuries. All children were studied prospectively at 4 months, 1 year, and 2.5 years after their injuries. An important feature of this study was the care taken to determine the

Issues Related to Outcomes children's behavior before their accidents. This was done in an unbiased fashion by interviewing parents immediately after their child's injury, but before the child's postinjury psychiatric condition could have been known. The children with severe head injuries did not differ from controls in their preinjury behavior, but they showed more than double the rate of psychiatric disorder at four months postinjury, and at each subsequent follow-up point. This was true even when children who had psychiatric disorders before their accidents were eliminated from the study, thereby focusing specifically on the comparative rate of new psychiatric disorders arising over the course of the follow-up period. There was a rather high threshold for an effect, however, because definite cognitive or psychiatric sequelae were found only in head-injured children having a PTA of at least one week. Whereas persistent psychiatric sequelae were quite common once this range of severity was reached, cognitive impairment lasting for more than two years generally required a PTA of at least three weeks. Head-injured children tended to show greater impairment on timed visual±spatial and visual± motor tests than on verbal tests but, apart from this, no pattern of cognitive deficits specific to head injury was identified. Likewise, the types of psychiatric disorder among the head-injured children were very similar to those found in controls. The only exception to this was in the case of grossly disinhibited social behavior, which was present only in children with very severe head injuries and may have been linked directly to frontal lobe damage or dysfunction. In general, children with severe TBI showed an increased risk for psychiatric disorder regardless of the age, sex, or social class of the childÐfactors that ordinarily show a striking mediating effect in the general population. The risk was greater among children with histories of preaccident behavior disorders as well as those experiencing various psychosocial adversities within their homes, but the effects were additive rather than interactive. Thus, although psychiatric disorders in childhood have a multifactorial etiology, evidence from this series of studies indicated that severe brain injury can play a major independent role in the development and/or exacerbation of psychosocial difficulties, whereas this does not seem to be the case with milder injuries. 9.09.6.3.1 Impact on the family Given the psychosocial as well as the neurocognitive changes that can be observed in individuals who have sustained a TBI, it stands to reason that the larger family system will be

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vulnerable as well. Martin (1990) reported that variables such as family support systems, family communication, extracurricular involvement of the family system (e.g., church), and availability of appropriate services and trained personnel were crucial to assisting families in their coping with the injured individual. Issues pertinent to increased dependency, financial difficulties secondary to costs of rehabilitation and medical needs, and increased family stress, perhaps related to parental or spousal guilt following an injury, all serve to disrupt the family system. Bragg, Klockars, and Berninger (1992) found that families with adolescents who had sustained a mild or moderate head injury experienced less autonomy and more dysfunction. Further, the adolescents themselves also described an increased amount of stress and more maladaptive behaviors. Families may respond to this stress in a variety of ways. For example, Livingston and McCabe (1990) observed that families may try to cope with the injured individual by becoming overprotective and overindulgent at the expense of other family needs (e.g., siblings, marriage). In fact, Martin (1990) reported that these families seem to progress through the same stages as those who have experienced a significant loss and are grieving: shock, denial, anger, sorrow, and acceptance. Preinjury family status on such variables as communication, problem-solving, role flexibility, and stress also have been deemed predictive of family functioning postinjury (Rivara et al., 1997). 9.09.7 ISSUES RELATED TO OUTCOMES In addition to rehabilitation efforts, there are a variety of factors that influence rate of recovery of functions and ultimate outcome. Many of these factors have been mentioned already, such as types of injuries, medical complications, and injury severity. In particular, the severity of the injury appears to hold the most weight with respect to prognosis for recovery. Several additional factors also require mention: chronological age at the time of injury, rate of recovery, and premorbid functioning of the child and/or family. 9.09.7.1 Age at Time of Injury It is clear that a TBI may disrupt new learning, along with a variety of related neurocognitive functions. Given this, it has been speculated that younger children may be at greater risk for learning difficulties in that most of their learning will be new. In general, these difficulties are likely to be related to the

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physiological maturity of the developing brain and to the functional status of the brain at the time of the injury. Consequently, age-dependent differences might be seen not only in the loss or change in functional status, but in the recovery of functions and subsequent developmental trajectories of these functions (Fletcher, Miner, & Ewing-Cobbs, 1987; Thompson et al., 1994). For example, studies employing children aged five years or older have noted that age at the time of injury was unrelated to either the severity of the neurocognitive sequelae or the rate of recovery (Chadwick, Rutter, Brown et al., 1981; Levin & Eisenberg, 1979). Studies including infants and preschoolers, however, have reported more severe long-term neurocognitive deficiencies in these children (LangeCosack, Wider, Schlesner, Grumme, & Kubicki, 1979; Shaffer et al., 1980).

9.09.7.2 Recovery Rates The rate of recovery appears to be dependent, at least in part, upon the severity of the TBI. In general, individuals incurring more severe injuries tend to show a slower rate of recovery than individuals who sustained mild or, in some instances, moderate TBI. Further, it has been suggested that the more rapidly that a specific function emerges following an injury, the better the prognosis for that function. For adults and children, it seems that the major portion of recovery occurs during the first year following injury (Jaffe, Polissar, Fay, & Liao, 1995; Klonoff et al., 1977), perhaps due to spontaneous remission and/or the specific interventions employed. Chadwick, Rutter, Shaffer, and Shrout (1981) demonstrated that most of the recovery of intellectual functions tended to occur for more severely injured children. There was relatively little improvement in IQ for the controls and mildly injured individuals at oneyear and 30 month follow-up points. In contrast, however, there was significant improvement in IQ by the severely injured group at the one-year follow-up point, with some modest improvements continuing at the 30 month point. Klonoff et al. (1977) have even shown that neuropsychological improvement can be demonstrated over a five-year period. Fletcher and Levin (1988) and Taylor (1984) offered three different positions for age effects in a TBI and subsequent recovery of function: (i) children show an increased vulnerability to damage, but less recovery of function than adults; (ii) that children show greater behavioral sparing and recovery of function than adults; and (iii) the effects of a TBI will depend upon the age of the child/adolescent, and recovery will be

dependent upon the capacity of the developing brain to evolve alternate coping/behavioral strategies. Although the field has not yet arrived at clear answers with respect to these positions, it is clear that the increased precision in how TBIs are evaluated will contribute to increasing our understanding of how age at the time of injury will affect ultimate outcome. 9.09.7.3 Premorbid Functioning Despite the epidemiological features discussed earlier (e.g., more boys than girls sustaining TBI; more injuries occurring in lower socioeconomic status homes) and, in contrast to the similar gender differences typically found in clinical samples of learning and psychiatric disorders, the gender of a child does not appear to affect the ultimate outcome (Chadwick, Rutter, Brown et al., 1981; Shaffer et al., 1980). Likewise, social class seems to exert little influence on outcome (Chadwick, Rutter, Brown et al., 1981), although clinical intuition persists in suggesting that children from more affluent backgrounds tend to show better improvement following an injury. Despite these findings, preinjury difficulties, particularly in the psychiatric domain, have proved to be predictive of later problems (Brown et al., 1981). These findings suggest the importance of gaining a comprehensive preinjury history when working with individuals who have sustained a TBI. It remains unclear, however, how these factors interact to influence outcome from a TBI. Although individuals with severe injuries generally tend to have poorer prognoses, those sustaining milder types of head injury can show neurocognitive residualsÐeven if only for several months after the injury. This is important in that these transient changes in neurobehavioral functioning can affect an individual's daily functioning within the home, school, and vocational settings. Further, given the timing of the injury (e.g., most injuries occur during the spring and summer months in seasonal regions), it is likely that these few months could stretch over two school years and disrupt an individual's academic progress quite significantly. 9.09.8 INTERVENTION Interventions for individuals with TBI should be tailored to their specific strengths and weaknesses. Although this may seem a bit trite, this adage becomes extremely critical when working with these individuals. In particular, individuals in an acute phase of recovery may be

Intervention showing frequent changes, and assessment± treatment linkages will need to be dynamic and reviewed on a regular basis. The range of interventions for individuals with TBI is quite wide, with many different kinds of strategies being applicable to this population. These have included pharmacological treatments, psychotherapies, behavioral strategies, family interventions, cognitive rehabilitation, and educational programming. This section will provide a brief overview of two treatments, cognitive rehabilitation and educational programming. The interested reader is referred to other, more comprehensive sources to gain more details pertaining to treatment strategies for individuals with TBI (e.g., Ylvisaker, Szekeres, & Hartwick, 1992).

9.09.8.1 Cognitive Rehabilitation The term cognitive rehabilitation is extremely broad and, consequently, can include many different kinds of intervention delivered by many different disciplines. In general, the primary goal of cognitive rehabilitation is to promote recovery and to help individuals overcome barriers posed by their cognitive impediments (Ylvisaker et al., 1992). Over two decades ago the work of Diller and Weinberg (1977) illustrated the possible benefits of training individuals to increase their hemifield attention. Using individuals who sustained right hemisphere cerebral vascular accidents, these investigators employed specific training procedures to facilitate attentional adaptation. In a similar fashion, Ben-Yishay, Diller, and Rattok (1978) described the effectiveness of a cognitive retraining program, orientation remedial module, for improving basic deficits in attention. At the same time, these investigators were careful to note that these cognitive retraining strategies facilitated the use of spared abilities, perhaps more so than retraining damaged neurologic systems. The work of Ylvisaker and colleagues has clearly exemplified the importance of developing spared strengths to facilitate the improvement of other neurocognitive systems (e.g., memory, executive functions) following a TBI (Ylvisaker et al., 1992). The specific strategy or strategies chosen for intervention and the extent of its deployment will depend on the severity of the injury, resulting spared and impaired abilities, the surrounding milieu and general psychosocial supports, and the skills of the interventionist. These variables not withstanding, however, Prigatano, O'Brien, and Klonoff (1993) have provided several pragmatic guidelines when considering any type of cognitive retraining:

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(i) Never underestimate the severity of the cognitive deficits. (ii) Assume initially that an individual does not fully recognize the severity or impact of a cognitive and/or personality deficit. (iii) Approach any cognitive retraining task with a collaborative learning and problem solving attitude. (iv) Allow the individual to record and observe their own behaviors, and then encourage the individual to examine the interventionist in the same fashion. (v) Do not lecture the individual as to the deficits or the need for change. (vi) Carefully record training activities and measure behavioral outcome on a regular basis. (vii) Do not limit cognitive retraining activities to one-on-one sessionsÐin vivo situations are likely to prove more ecologically valid. (viii) Watch the individual for an emotional reaction during the retraining activities. (ix) Provide ample opportunities for practice in and out of the therapy setting. (x) Focus on cognitive retraining as well as social±behavioral considerations. These 10 general axioms should serve any interventionist regardless of the specific cognitive retraining strategies being utilized.

9.09.8.2 Educational Programming Telzrow (1991) asserted that the process of educational consultation and programming should begin prior to the return of the student to the formal educational setting. In fact, Pieper (1991) stated that this process should begin at the time of the injury so as to promote communications between the family and the school, and to facilitate the planning for the student's reentry. The initial consultation might not only entail performing a comprehensive assessment to determine current neurobehavioral residuals from the injury, but it will also require understanding the nature of the individual's injuries and the current medical status of the student as the school reentry preparations begin. This will increase the need for clear communications between the hospital or rehabilitation facility, the family, and the school (Blosser & DePompei, 1991; Savage, 1991). Furthermore, placement decisions should consider the full range of services available in a school system in order to address the student's pending educational needs. This planning should also extend into the summer months in order to address the issues of maintenance and generalization of information (Ylvisaker, Hartwick, & Stevens, 1991). Relatedly, it will be important for the practitioner to become familiar with specific

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teaching strategies that might be helpful with these students. Although many of these strategies may not appear to be very different from what is used in regular and special education settings, their use with individuals with TBI may be crucial with respect to learning, prevocational adaptation, and general school readjustment. For example, Cohen (1991) stated that direct instruction techniques, repetition and practice, cueing, modeling, instructional pacing, decreased use of time limits, and providing immediate feedback regarding the individual's performance will be important components of instruction. Further, Savage (1991) suggested that individual education plans should be written for shorter periods of time due to the rapid changes that can be seen during recovery, and parents should be encouraged to request regular meetings regarding progress and changes in functioning. 9.09.9 SUMMARY There is much information to be learned and incorporated into the role of the professional working with individuals who have sustained a TBI. This chapter endeavors to provide an overview of this information including a discussion of definitional issues, epidemiological characteristics, and neuropathological mechanisms. Recognizing the differences in types of TBIs and the various kinds of outcomes that can occur are also essential knowledge for professionals working with this population. The recognition of factors that can influence outcomes is also important. Although not covered in this overview, some foundation in the neurological bases of behavior will also be necessary. Treatment strategies represent a wide array of activities, including the use of traditional intervention strategies (i.e., teaching, pharmacology, strategy development); however, their application to individuals with TBI will require a recognition of the spared and impaired abilities as well as the nature of the presenting brain injury. Finally, it is critical to note that one strategy for addressing TBI is via prevention. By advocating for primary prevention venues, such as those addressing bicycle and motorcycle helmets, child restraint systems, child abuse, and drinking-and-driving laws, perhaps some of these injuries could be prevented. 9.09.10 REFERENCES Adams, J. H., Graham, D. L., & Gennarelli, T. A. (1985). Contemporary neuropathological considerations regarding brain damage in head injury. In D. P. Becker & J. T. Polviishack (Eds.), Central nervous system trauma status reportÐ1985. Washington, DC: National Institute for

Neurological and Communicative Disorders and Stroke, National Institutes of Health. Annegers, J. F. (1983). The epidemiology of head trauma in children. In K. Shapiro (Ed.), Pediatric head trauma (pp. 1±10). Mount Kisco, NY: Futura. Annegers, J. F., Grabow, J. D., Kurland, L. T., & Laws, E. R., Jr. (1980). The incidence, causes, and secular trends of head trauma in Olmsted County, Minnesota, 1935±1974. Neurology, 30, 910±919. Auerbach, S. H. (1986). Neuroanatomical correlates of attention and memory disorders in traumatic brain injury: An application of neurobehavioral subtypes. Journal of Head Trauma Rehabilitation, 1, 1±12. Bakay, L., & Glasauer, F. E. (1980). Head injury. Boston: Little, Brown. Bassett, S. S., & Slater, E. J. (1990). Neuropsychological function in adolescents sustaining mild closed head injury. Journal of Pediatric Psychology, 15, 225±236. Bawden, H. N., Knights, R. M., & Winogron, H. W. (1985). Speeded performance following head injury in children. Journal of Clinical and Experimental Neuropsychology, 7, 39±54. Ben-Yishay, Y., Diller, L., & Rattok, J. (1978). A modular approach to optimizing orientation, psychomotor alertness, and purposive behavior in severe head trauma patients. In Working approaches to cognitive deficits in brain damage (Rehabilitation Monograph No. 59). New York: New York University Medical Center, Institute of Rehabilitation Medicine. Berger-Gross, P., & Shackelford, M. (1985). Closed head injury in children: Neuropsychological and scholastic outcomes. Perceptual and Motor Skills, 61, 254. Biddle, K. R., McCabe, A., & Bliss, L. S. (1996). Narrative skills following traumatic brain injury in children and adults. Journal of Communication Disorders, 29, 446±469. Bigler, E. D. (1990). Neuropathology of traumatic brain injury. In E. D. Bigler (Ed.), Traumatic brain injury: Mechanisms of damage, assessment, intervention and outcome (pp. 13±49). Austin, TX: Pro-ed. Bigler, E. D. (1994). Advances in brain imaging with children and adolescents. In M. G. Tramontana & S. R. Hooper (Eds.), Advances in child neuropsychology (pp. 48±83). New York: Springer. Blosser, R., & DePompei, J. (1991). Preparing education professionals for meeting the needs of students with traumatic brain injury. Journal of Head Trauma Rehabilitation, 6, 73±82. Boll, T. J. (1983). Minor head injury in childrenÐOut of sight but not out of mind. Journal of Clinical Child Psychology, 12, 74±80. Bragg, R. M., Klockars, A. J., Berninger, V. W. (1992). Comparison of families with and without adolescents with traumatic brain injury. Journal of Head Trauma, 6, 94±108. Brink, J. D., Garrett, A. L., Hale, W. R., Woo-Sam, J., & Nickel, V. L. (1970). Recovery of motor and intellectual function in children sustaining severe head injuries. Developmental Medicine and Child Neurology, 12, 565±571. Brooks, D. N. (1983). Disorders of memory. In M. Rosenthal, E. R. Griffith, M. R. Bond, & J. D. Miller (Eds.), Rehabilitation of head injured adults (pp. 185±196). Philadelphia: F. A. Davis. Brown, G., Chadwick, O., Shaffer, D., Rutter, M., & Traub, M. (1981). A prospective study of children with head injuries: III. Psychiatric sequelae. Psychological Medicine, 11, 63±78. Bruce, P., Schut, L., Bruno, L. A., Woods, J. H., & Sutton, L. N. (1978). Outcome following severe head injury in children. Journal of Neurosurgery, 48, 679±688. Bucci, M. N., Phillips, T. W., & McGillicuddy, J. E. (1986). Delayed epidural hemorrhage in hypotensive multiple trauma patients. Neurosurgery, 19, 65±68.

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Mechanisms of damage, assessment, intervention, and outcome (pp. 381±394). Austin, TX: Pro-ed. Massagli, T. L., Michaud, L. J., & Rivara, F. P. (1996). Association between injury indices and outcome after severe traumatic brain injury in children. Archives of Physical Medicine and Rehabilitation, 77, 125±132. Mayes, S. D., Pelco, L. E., & Campbell, C. J. (1989). Relationships among pre- and post injury intelligence, length of coma, and age in individuals with severe closed head injuries. Brain Injury, 3, 301±313. Mealey, J. (1968). Pediatric head injuries. Springfield, IL: Charles C. Thomas. Menkes, J. H. (1990). Textbook of child neurology (4th ed.). Philadelphia: Lea & Febiger. National Head Injury Foundation (1985). An educator's manual: What educators need to know about students with traumatic brain injury. Framingham, MA: Author. Ommaya, A. K., Grubbs, R. L., & Naumann, R. (1971). Coup and contrecoup injury: Observations on the mechanics of visible injuries in the rhesus monkey. Journal of Neurosurgery, 35, 503±516. Pang, D. (1985). Pathophysiologic correlates of neurobehavioral syndromes following closed head injury. In M. Ylvisaker (Ed.), Head injury rehabilitation: Children and adolescents (pp. 3±70). San Diego, CA: College-Hill Press. Pieper, B. (1991). Traumatic brain injury: What the teacher needs to know. Washington, DC: National Institute of Disability and Rehabilitation Research. Prigatano, G. P., O'Brien, K. P., & Klonoff, P. S. (1993). Neuropsychological rehabilitation of young adults who suffer brain injury in childhood: Clinical observations. Neuropsychological Rehabilitation, 3, 411±421. Reitan, R. M., & Wolfson, D. (1985). Neuroanatomy and neuropathology. A clinical guide for neuropsychologists. Tucson, AZ: Neuropsychology Press. Rivara, F. P. (1984). Childhood injuries. III. Epidemiology of non-motor vehicle head trauma. Developmental Medicine and Child Neurology, 26, 81±87. Rivara, J. M., Jaffe, K. M., Polissar, N. L., Fay, G. C., Liao, S., & Martin, K. M. (1997). Predictors of family functioning and change three years after traumatic brain injury in children. Archives of Physical Medicine and Rehabilitation, 77, 754±764. Rivara, F. P., & Mueller, B. A. (1986). The epidemiology and prevention of pediatric head injury. Journal of Head Trauma Rehabilitation, 1, 7±15. Rosen, C. D., & Gerring, J. P. (1986). Head trauma: Educational reintegration. San Diego, CA: College-Hill Press. Rutter, M., Chadwick, O., Shaffer, D., & Brown, G. (1980). A prospective study of children with head injuries: 1. Design and methods. Psychological Medicine, 10, 633±645. Salazar, A. M., Grafman, J., Schlesselman, S., Vance, S. C., Mohr, J. P., Carpenter, M., Pevsner, P., Ludlow, C., & Weingartner, H. (1986). Penetrating war injuries of the basal forebrain: Neurology and cognition. Neurology, 36, 459±465. Savage, R. C. (1991). Identification, classification, and placement issues for students with traumatic brain injuries. Journal of Head Trauma Rehabilitation, 6, 1±9. Shaffer, D., Bijur, P., Chadwick, O. F. D., & Rutter, M. L. (1980). Head injury and later reading disability. Journal of the American Academy of Child Psychiatry, 19, 592±610. Shapiro, K. (1987). Special considerations for the pediatric age group. In P. R. Cooper (Ed.), Head injury (pp. 367±389). Baltimore: Williams & Wilkins. Slater, E. J., & Bassett, S. S. (1988). Adolescents with closed head injuries. American Journal of Diseases of Children, 142, 1048±1051. Soloniuk, D., Pitts, L. H., Lovely, M., & Bartkowski, H.

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Copyright © 1998 Elsevier Science Ltd. All rights reserved.

9.10 Street Gangs DAVID W. THOMPSON Clinical Psychology Associates, Burlington, WI, USA 9.10.1 INTRODUCTION

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9.10.2 NATURE

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9.10.2.1 Definition 9.10.2.2 Theories of Youth Gang Involvement 9.10.2.2.1 Subcultural theories 9.10.2.2.2 Opportunity theory 9.10.2.2.3 Social development theory 9.10.3 PREVALENCE

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9.10.3.1 Methodological Issues 9.10.3.2 Estimates 9.10.4 ASSESSMENT

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9.10.4.1 Macrolevel 9.10.4.2 Microlevel

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9.10.5 TREATMENT

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9.10.5.1 9.10.5.2 9.10.5.3 9.10.5.4 9.10.5.5

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Street Worker Approaches Group Cohesiveness Approaches Prevention Approaches Gang Suppression Approaches Comprehensive Approaches

9.10.6 FUTURE DIRECTIONS FOR RESEARCH AND PRACTICE

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9.10.7 SUMMARY

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9.10.8 REFERENCES

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prevention efforts are crucial. This chapter seeks to identify the special issues which must be considered when working with youth street gangs. By providing a critical overview of the theoretical, practical, and empirical considerations related to youth street gangs, this chapter will equip others to more effectively intervene with this special population.

9.10.1 INTRODUCTION Youth street gangs have long been a serious problem in the USA and elsewhere. Gang behavior is costly to the community. Not only are there direct costs to individual victims of assaults, vandalism, and robberies, but the entire community pays significantly for gangrelated law enforcement, judicial proceedings, and imprisonment of gang offenders. Indirect costs including loss of life, physical and emotional suffering, and the loss of productivity are inestimable. Given the severe impact of street gangs on society, effective and timely intervention and

9.10.2 NATURE 9.10.2.1 Definition Simply defining a gang is difficult. Thrasher (1927) described a gang as 155

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an interstitial group originally formed spontaneously, and then integrated through conflict. It is characterized by the following types of behavior: meeting face to face, milling, movement through space as a unit, conflict, and planning. The result of this collective behavior is the development of tradition, unreflective internal structure, esprit de corps, solidarity, morale, group awareness, and attachment to a local territory. (p. 57)

9.10.2.2 Theories of Youth Gang Involvement One of the more puzzling and controversial questions facing researchers investigating youth street gangs is the reason for gang existence. Why do street gangs form in the first place, and what factors contribute to their longevity? 9.10.2.2.1 Subcultural theories

Thrasher also defined various subtypes of gangs, including the diffuse type (i.e., those without lasting solidarity), the solidified type (the opposite of the diffuse type), the conventional type (a social or athletic club), and the criminal type (those which habitually engage in delinquent and criminal behavior). Fagan (1989) proposed four types of gangs, including party gangs (i.e., those involved in drinking, drug use, and drug sales), social gangs (those which use drugs and commit crimes), delinquent gangs (those which seek to control ªturfº), and young organizations (those which are well organized and exist for the purpose of making money). Differences exist between gangs and delinquent groups. For example, Cohen (1969) compared the behavior of known gang groups with that of nongang groups, and concluded that (i) gang offenders were more homogenous with respect to age, race, sex, and residence patterns than their nongang counterparts; (ii) the victims of gang offenders were more homogenous in their characteristics than the victims of nongang offenders; and (iii) the gang offenders had more extensive prior records and were charged with more serious offenses. Klein (1971) proposed a useful definition of youth street gangs which will be used in this chapter. He used the term gang to refer to groups of adolescents that ª(a) are generally perceived as a distinct aggregation by others in their neighborhood; (b) recognize themselves as a denoteable group (almost invariably with a group name); and (c) have been involved in a sufficient number of delinquent incidents to call forth a consistent negative response from neighborhood residents or law enforcement agenciesº (p. 13). The gangs described by Thrasher (1927) were usually formed along racial or ethnic lines, comprised of younger members, and used fists and sticks to settle arguments. Today, youth street gangs transcend racial and ethnic boundaries and routinely use lethal weapons such as knives and guns to settle disputes. This chapter is limited to a discussion of street gangs. Other types of gangs exist (e.g., prisonbased extensions of street gangs or organized crime), but these are fundamentally different from street gangs and will not be addressed.

Cohen (1955) suggested that gangs arise from a delinquent subculture, namely . . . a way of life that has somehow become traditional among certain groups in American society (p. 13). He proposed that the important difference between delinquent and nondelinquent children is their degree of exposure to delinquent conduct and values. Subcultural theory essentially suggests that gang delinquency is the result of learned behavior based on subcultural values which differ from those of society at large or which are only perceived by a narrow segment of the middle class to be different values but are in reality not deviant but normal. Although subcultural theories of street gang involvement have been examined empirically by a number of researchers, little evidence has been found to support them. For example, Rivera and Short (1967) conducted interviews of 458 lower-class Chicago youth, and found neither a rejection of middle-class concerns with occupational mobility nor the formulation of subcultural delinquency in reaction to actual or anticipated conventional failure. Spergel (1967) found some support for Cohen's (1955) subcultural theory, although the data were not conclusive. He interviewed 131 boys aged 8±12 years from three Chicago neighborhoods and rated their responses on a 72-item interview schedule. About two-thirds of his sample were classified as deviant, while the remainder were categorized as conformist. He concluded that the delinquent behavior of his sample tended to be relatively independent of behavior patterns developed by older teenagers and adults. Short, Tennyson, and Howard (1963) attempted to assess behavior patterns characteristic of the gangs studied to determine their significance to the subcultural theory of delinquency. Street workers rated 598 members of 16 delinquent gangs in Chicago on 37 different behavioral categories (e.g., joy riding, truancy, assault, arson, auto theft, homicide). Using factor analysis, the authors derived five factors: (i) conflict (e.g., fighting, use of weapons), (ii) stable corner activities (e.g., team sports, gambling), (iii) stable sex (e.g., statutory rape, petting), (iv) retreatist (e.g., narcotics use, deviant sexual behavior, suicide), and (v)

Nature authority-protest (e.g., auto theft, truancy, public nuisance). They reported that criminal behaviors were scattered across all five categories, and that no clearly criminal subculture pattern could be identified. 9.10.2.2.2 Opportunity theory Opportunity theory is based both on the work of Emile Durkheim and Robert Merton which focused on the sources of social pressure which may lead to deviance, and on the work of Clifford Shaw, Henry McKay, and Edwin Sutherland which examined the ways in which features of social structure regulate the selection and evolution of deviant solutions (Cloward & Ohlin, 1960). Klein (1971) summarized five concepts central to Cloward and Ohlin's theory. Society has generally accepted cultural goals (such as material gain). Not all persons have equal access to these goals or to the accepted means of achieving them, and individuals may therefore turn to illegitimate means of attaining these goals. Communities differ in the availability of both legitimate and illegitimate means to access these goals, and the nature of the community's integration of legitimate and illegitimate means will determine the nature of the subcultural (delinquent) accommodation to goal achievement. Cloward and Ohlin made three predictions based on these concepts: (i) A criminal subculture, and criminal gangs, will develop where there is cross-age integration of offenders plus close relations between the ªcarriers of criminal and conventional values.º (ii) A conflict subculture, and conflict gangs, will develop in neighborhoods not integrated as above, where social controls are relatively absent, and there is an absence of available systematic illegitimate means to material goals. The use of violence becomes in this setting an alternate means to an alternate goal (status rather than material goals). (iii) A retreatist subculture, and retreatist gangs, will develop among boys locked out of the previous two subcultural adaptations because of the lack of means integration and because of ªinternalized prohibitionsº or ªsocially structured barriersº to the use of violence. This ªdouble failureº leaves only retreat, through drugs and alcohol most specifically (Klein, 1971, pp. 29±30). Rivera and Short (1967) reported that gang membership seems to be related to lower occupational goals. This would appear to argue against Cloward and Ohlin's theory, which predicts that delinquents would develop higher aspirations to achieve status than nondelinquents, turning to delinquent behavior when

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they become frustrated by the lack of opportunity to achieve their goals. However, Spergel (1964) found that delinquents did indeed aspire to higher status than nondelinquent youth when indicators such as anticipated income were used, providing some support for opportunity theory. Kobrin, Puntil, and Peluso (1967) tested the opportunity theory postulate that styles of delinquency in lower-class communities are a function of the relative availability of illegitimate opportunity. They investigated a network of six street groups, four of which were delinquent. Their data indicated that the delinquent groups could be individually categorized as sophisticated, conspicuous, occupational, and versatile. They concluded that their data supported the implications of opportunity theory that adolescent street gangs' prestige would be highest for groups whose norms were closest to those of adult criminals. Other aspects of opportunity theory have not received overwhelming empirical support. Elliott (1962) found that delinquents and nondelinquents evaluated the importance for success of school positions, education, and occupational positions similarly. Nondelinquents perceived greater opportunity to become representatives on the student council, but no significant differences existed between the two groups with respect to their perceived opportunity to achieve other school offices, although delinquents perceived lower opportunities to achieve successful educational and occupational positions than nondelinquents. Elliot concluded that the relationship between educational or occupational opportunity and social class was significant, but both middle- and lower-class delinquents perceived lower opportunities than nondelinquents. Although opportunity theory focuses on the discrepancy between success goals and the legitimate attainment of these goals as a source of delinquent behavior, Elliott's data suggest that this perceived discrepancy may be a result of the delinquent behavior itself, that is, the delinquents realize that their delinquent behavior may result in the loss of various opportunities. 9.10.2.2.3 Social development theory In a comprehensive and systematic review of delinquency theories and research, several US government-funded studies have attempted to provide an empirically based model of delinquency which integrates the most valid parts of various theoretical perspectives (Weis & Hawkins, 1981; Weis, Sederstrom, Worsley, & Zeiss, 1980). The researchers drew upon the two major theoretical perspectives of

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delinquency: control theory (Briar & Piliavin, 1965; Hirschi, 1969) and cultural deviance theory (Akers, 1977; Akers, Krohn, LanzaKaduce, & Radosevich, 1979). Control theory states that juvenile delinquency is the result of weak, absent, or ineffective social controls (Weis & Hawkins, 1981). Although numerous variations of control theory are found in the literature, Hirschi (1969) offered a version which specifies that a youngster's bond to society will be composed of four elements (i.e., attachment, commitment, involvement, and belief), and that significant units of social control include the family, school, and the law. Delinquency becomes possible when there is inadequate attachment to parents or school, inadequate commitment to educational or occupational success, and inadequate belief in the legitimacy and validity of the law. Thus, a delinquent child is the unsocialized product of his or her environment. Hirschi's theory does not address the issue of why youth become delinquent, but instead questions why persons refrain from crime. He proposed that the four elements of a youngster's bond to society are important because of the following reasons. Attachment is important because it contains a moral dimension that dissuades persons from engaging in delinquency. He argued that although various subcultures do not exist, variance in a person's belief in society's norms does exist. He proposed that the less one's belief, the more prone one is to engage in delinquent behavior. Commitment to conventional activity dissuades persons from delinquency because they have invested time and energy into a conventional activity which therefore causes the person to weigh the risk of losing their investment against the benefits of engaging in delinquent behavior. Finally, he indicated that involvement reduces delinquency by limiting one's time to contemplate and commit delinquent acts. Cultural deviance theory states that delinquency results from youths conforming to deviant cultural norms. In essence, cultural deviance theory is identical to the subcultural theories discussed above. Akers (1977) used a social learning model and proposed that the delinquent behavior is learned when the consequences of that behavior are rewarding to the youth engaging in delinquent acts. Thus, to prevent delinquency, delinquent behavior should be extinguished or punished. Perhaps the most widely cited and investigated cultural deviance theory is Sutherland's theory of differential association (Sutherland & Cressey, 1970). This theory includes seven propositions which address specific causal factors of unlawful behavior. The concept of

association with lawbreakers is seen as central to the origin of delinquency, and organized crime and criminal behavior could be overcome if we, as a society, organized ourselves better to fight it. Sutherland's theory of differential association continues to be quite influential. Control and cultural deviance theories are easily integrated with each other. Although they are both socialization theories, they also have individual inadequacies. In combination, the two theories complement each other by compensating for each others' deficienciesÐcontrol theory specifies units and elements of socialization which result in a well-socialized individual, whereas cultural deviance theory focuses on the learning of deviant behavior, suggesting how individuals might be socialized to conventional norms. Weis and Hawkins (1981) offered a model of delinquency, relevant to prevention and intervention efforts with street gangs, based upon this integration of control and cultural deviance theories. They further suggested that a dynamic multivariate causal model, which is responsive to the direct and interaction effects among variables over time, is appropriate. They postulated that the different causes of delinquency have different effects at different points in a youngster's life. Further, they suggested the existence of four stages of a youngster's life during which different units of socialization exert primary influence. They described these stages as parallel to those of the educational systemÐpreschool, primary school, junior high school, and high schoolÐand as having as their most salient units the family, the school, and peers, respectively. Based on this integrated social development model of delinquency, they described the general process and strategies of delinquency prevention as follows. Opportunities for involvement in conventional activities and for interaction with appropriate role models are necessary for nondelinquent socialization. In order for these experiences to produce social bonds, participants must have certain basic skills, the application of which makes participation rewarding. It should be emphasized that skills must be possessed by both youthful participants and by others (such as parents and teachers) with whom youths are involved. For example, for involvement in school to be rewarding, students must develop cognitive skills, but teachers must also be skilled in recognizing and reinforcing students' progress. Furthermore, different actors in youths' social environments must be consistent in their expectations for and responses to behavior if conforming behavior is to be continually reinforced and deviant behavior prevented or extinguished.

Nature Based on this model, gang intervention programs must strive to facilitate the formation of bonds between the youth and the appropriate institution (family, school, or peers, depending upon the youth's age). To accomplish this, programs must teach requisite social and educational skills when they are absent, and then facilitate their use and subsequent reinforcement in appropriate manners. Despite the fact that social development theory is a relatively young theory, research evidence exists both for and against it. Jensen (1972) reanalyzed Hirschi's (1969) data in an attempt to answer two questions. First, he asked if parental control affected delinquency directly (as predicted by control theory) or indirectly by influencing the youth's exposure to delinquent behavior patterns (as asserted by differential association theory). Second, he asked if delinquent peers fostered delinquency directly (control theory) or indirectly through exposure to delinquent behavior patterns (differential association theory). Jensen used school delinquency rates, perceptions of trouble in the neighborhood, and the number of delinquent friends reported by youth as variables for his analyses. In addition, he utilized self-reported delinquency (SRD) as his outcome variable. He found that when differential association variables were held constant, parental control variables (father's supervision and father's support) still decreased delinquency. He concluded that control theory was supported over differential association theory, and that the number of delinquent friends affected youths' SRD scores independently of the effect of delinquent definitions, and determined that group-process and situationalmotive theories of delinquency were empirically superior to differential association theory. Matsueda (1982) compared Hirschi's control theory against Sutherland's theory of differential association. Using the data upon which Hirschi's (1969) and Jensen's (1972) work was based, he applied mathematical modeling to test specific hypotheses derived from both the theories. Based on both control and differential association theories, Matsueda constructed structural models which specified the causal pathways between background variables (such as age, socioeconomic status, and broken vs. intact families), and youths' perceptions of neighborhood disturbance and other variables (such as parental control, peer relationships, and definitions of delinquent behavior patterns). He concluded that delinquent behavior was reduced in boys by parental supervision which had the effect of reducing their exposure to delinquent definitions of behavior. He further concluded that youths' association with delinquent friends

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mediated delinquency only by regulating exposure to delinquent definitions of behavior. He concluded that the data supported Sutherland's differential association theory. Roff and Wirt (1984) followed 2453 three- to six-grade children into adulthood. They identified 127 low peer-status subjects and examined these youth in relation to subsequent delinquency. Using a multivariate design, they assessed the effects of social class, family disturbance, and childhood behavior problems as antecedents of delinquency. They found that childhood aggression was the best predictor of delinquency for males and, that although social class and family disturbance were associated with aggression, these variables exerted no direct effects on delinquency itself. Suzuki, Nishimura, and Takahashi (1982), however, offered evidence in support of social development theory. Japanese high school students completed a self-report delinquency questionnaire as well as one examining their attitudes towards home and school. The delinquent group of students reported more feelings of maladjustment and discontent about families and schools, and tended to not believe in or adhere to school rules than the nondelinquent students. In addition, this group reported less positive perceptions of families and teachers, studied less, and felt more alienated than the nondelinquent youth. Suzuki et al. (1982) concluded that delinquent students tended to have weaker family and school bonds than nondelinquent students. In conclusion, little empirical support exists for subcultural theory. Cloward and Ohlin's opportunity theory has received considerable research attention but, although the results of these investigations have been mixed, sufficient support for their theory has been reported to justify further investigation. Social development theory seems promising, but more data are needed before an adequate assessment of that model can be made. As Short (1967) has noted, gang behavior appears to be composed of mixtures of the various patterns as opposed to one pattern exclusively. It is clear that modifications in theory will be necessary in order to explain the current data. Indeed, most of the studies cited above provide partial evidence for practically any of the theories, while questioning portions of others. The reasons for the current paucity of knowledge in this area stem in large part from methodological difficulties. It is clear from our review of the literature that gang behavior is more complex than Cohen or Cloward and Ohlin postulated. The formulation of more complex (e.g., multivariate) models of gang behavior requires experimental design and data

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collection techniques significantly more sophisticated than those reflected by the current literature. There are those, however, who disagree with this formulation. Covey, Menard, and Franzese (1997), for example, assert that we currently possess adequate theoretical knowledge for the formulation of a comprehensive, integrated theory of juvenile gang behavior. They offer a series of 30 theoretical propositions which may account for juvenile gang formation, gang persistence or disintegration, gang structure, gang behavior, and the development of various types of juvenile gangs (Covey et al., 1997, pp. 212±250). Although available space does not allow for a comprehensive description of this theoretical formulation, these authors have attempted in a unique and provocative manner to integrate elements of numerous theories of gang formation and delinquent behavior to explain the origin and behavior of street gangs. Their 30 propositions derived from this approach appear to lend themselves readily to empirical study, perhaps providing a formulation for the multivariate study of street gang phenomena. To the extent that yet-to-becollected data support these propositions, this comprehensive theoretical approach may suggest specific intervention strategies as well. 9.10.3 PREVALENCE 9.10.3.1 Methodological Issues A variety of methodological difficulties preclude an accurate estimate of the magnitude of the gang problem. For example, few youth street gangs willingly share membership information with researchers or law enforcement agencies, and many youth who are not gang members may inaccurately identify themselves to peers and adults as gang members. It is clear, however, that the problem of youth street gangs continues to grow tremendously. Although law enforcement estimates of gang crime in specific locales are available, reliance on such data does not allow for the systematic assessment of the scope of gang problems nationwide. Uniform Crime Report (UCR) data are not available on gang crimes, and the National Incident Based Reporting System (NIBRS) does not include information on gang-related crimes. Difficulties in defining gangs and gang-related crime continue to be problematic, particularly since various jurisdictions define and report data differently (Ball & Curry, 1995). The development of methods for the systematic and consistent reporting of gang crimes is a fundamental requirement for accurate research in this area.

9.10.3.2 Estimates Curry, Ball, and Decker (1996) described efforts to accurately estimate the scope of gang activity in the USA. They provided two sets of estimates of the nation's gang problem, one described as extremely conservative and the other as reasonably larger. Based on police reports, they conservatively estimated gang problems in approximately 57% of all US cities with populations over 25 000, with gang problems in 87.8% of cities with populations over 150 000. Using statistical procedures to estimate data from jurisdictions which did not formally produce annual statistics, they offered a larger estimate of the nation's gang problem based on 1994 National Institute of Justice extended survey data. Using this approach, they estimated the number of gang members as 555 181 and the number of gangs as 16 643. Their estimate of the national total gang crimes for 1993 was 580 331 (Curry et al., 1996). If the prevalence of gangs, gang membership, and gang crimes is disturbing, the proliferation of gangs and gang-related crime in the USA is alarming. Klein (1995) described the spread of street gangs as ªa seriously accelerating problem,º citing a 74% growth in gang-involved cities between 1961 and 1970, 83% by 1980, and 345% by 1992. 9.10.4 ASSESSMENT The assessment of street gangs is a complex endeavor fraught with problems. Given the problems associated with even the definition of a street gang, how does one approach the empirical assessment of gangs? Unlike many other groups or phenomena, street gangs often have no desire to be assessed, and have the potential for becoming uncooperative with or even dangerous toward those who attempt to quantify gangs or their activities. These issues pose significant challenges for the researcher or clinician seeking to assess the effectiveness of a given street gang intervention. 9.10.4.1 Macrolevel One approach to the assessment of street gangs involves approaching them on a macrolevel. For example, one could collect data on the number of cities reporting street gang activity (Klein, 1995; Spergel & Curry, 1993). Data regarding emerging trends in gang membership and behavior also contribute to the large-scale understanding of street gangs (Chesney-Lind, Shelden, & Joe, 1996; Chin, 1996). Although these data may prove useful in describing and assessing changes in the national

Treatment scope of the street gang problem, a variety of political factors and the general lack of standardized reporting of gang crimes continue to decrease the reliability of these data. Curry et al. (1996) document many of these factors, and call for a more organized and comprehensive federal effort to collect national data on the US gang crime problem. 9.10.4.2 Microlevel An alternative approach to the assessment of street gangs involves approaching them on a smaller, microlevel. Studying the individual members of a specific street gang, for example, can provide useful data relating to trends in gang membership (Thompson & Jason, 1988), the specific activities of individual members, and contribute to the assessment of gang cohesiveness. Difficulties are also present with this microlevel approach to street gang assessment. How many gangs maintain formal membership rosters which they will openly share with interested researchers? If one adopts a more behavioral approach to assessing gang membership (e.g., classifying members based on their manner of dress, self-report, and peer affiliations), how does one classify ªwannabeº or copy-cat individuals? At what point do we consider them real street gang members? Although there are no definitive answers to these complicated assessment issues, several solutions seem reasonable. Macrolevel assessment of street gangs may be useful for tracking trends and changes in street gang behavior as a whole (e.g., increases in violent behavior). Such data may also prove beneficial when comparing gang problems in the same cities over time or when conducting larger-scale comparisons of various intervention approaches. These data must be tempered, however, with the realization that they have significant limitations. Caution must be exercised when utilizing data which may, on the surface, appear to be uniform but upon closer examination may reflect vastly diverse origins or regional idiosyncrasies. In a similar vein, microlevel assessment of street gangs may prove beneficial when evaluating the effects of specific intervention or gang suppression efforts. The development of uniform definitions, data collection, and reporting for gang crimes and related behaviors is fundamental to the systematic study of street gangs and effective gang intervention programs. Until coordinated efforts result in improvements in these areas, the development and implementation of effective street gang intervention programs will remain severely handicapped.

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9.10.5 TREATMENT Treatment approaches to street gangs can generally be grouped into one of several categories. Traditional street worker model programs have attempted to intervene directly with street gangs on their turf through the use of gang intervention workers. Other programs have targeted the variables which allow street gangs to continue, such as group cohesiveness. Some treatment approaches have adopted a prevention approach, seeking to intervene with at-risk youth before they become gang members, whereas other programs are aimed at gang suppression. Finally, some intervention programs have attempted to adopt a more comprehensive approach to gang intervention by selectively drawing upon various promising components of all intervention categories. 9.10.5.1 Street Worker Approaches Gang intervention programs utilizing street workers (also referred to as detached workers) are based on the proposition that because gang members do not respond well to agency-based (in-house) programs, the programs must be taken to the youth in order to be effective (Klein, 1971). Spergel (1996) defined street work as a systematic effort by an agency worker to help a group of young people, described as delinquent or potentially delinquent, to achieve a conventional adaptation through use of social work or social treatment techniques within distinct neighborhood contexts. Street work further requires work with, or manipulation of, those persons or agency representatives who interact critically with the members of delinquent groups (p. 44).

Unfortunately, few street worker programs have been carefully evaluated. For example, the New York City Youth Board established a project using street workers known as the Council of Social and Athletic Clubs. Gannon (1967) reported the results of questionnaires and interviews with agency street workers, but the results did not evaluate the overall program effectiveness, and instead were largely confined to general characteristics of the youth gangs serviced by the project. When detached worker programs have been systematically evaluated, the results have been less than encouraging. Miller (1962) reported the results of the Roxbury project, a three-year detached worker program targeting about 400 members of 21 street gangs. Evaluation using a variety of data found no significant effects, and matched control-group gangs evidenced almost identical trends in court appearance rates.

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The effectiveness of a joint detached worker project of the Chicago Boys Clubs and the Institute for Social Research of the University of Michigan was evaluated in a series of studies (Caplan, Deshaies, Suttles, & Mattick, 1967). Although the program successfully established relationships with various gangs and street youth, overall delinquency was not reduced (Klein, 1971). Indeed, Caplan (1968) reported that the project youth who received the most intensive services actually reported an increase in delinquency rates. Klein (1969) described the Los Angeles Group Guidance Project, a program targeting lower- and lower-middle-class urban youth. Using a pre±post design, with gangs as their unit of observation, the intervention ªhad the overall effect of increasing the number of recorded offenses committed by the gangs included in its programº (Klein, 1969, p. 157). The evaluation suggested that the intervention actually tended to strengthen gangs, particularly those with initially lower levels of group cohesiveness. 9.10.5.2 Group Cohesiveness Approaches The Ladino Hills Project attempted to reduce delinquency and direct gang members into more positive channels by breaking the bonds of gang cohesiveness (Klein, 1971). Rather than viewing group cohesiveness in gangs as a positive dynamic, the youth were conceptualized as being driven to gang membership by environmental influences. Intervention included arranging individual relationships with adults for targeted youth, de-emphasizing external threats, and varying the assignment of workers to the gang so that the continuity of a given worker's presence did not foster cohesiveness. Klein reported a reduction in gang cohesiveness ranging from 11% to 40%, depending upon the indicator used. Individual gang member offense rates did not change, but the entry of new members to the gang was completely halted, resulting in an overall 35% decrease in the number of offenses committed. Klein concluded that higher levels of group programming for gangs leads to increased gang cohesiveness, and a focus on younger gang members increases cohesiveness through recruitment. He also concluded that the transfer of street workers between gangs eliminates a major contributing factor to gang cohesiveness. 9.10.5.3 Prevention Approaches Few approaches to street gangs have sought to prevent youth identified as at-risk from joining gangs. This may stem from the extensive past emphasis on detached worker programs,

political climates which affect the availability of funding, or the methodological difficulties inherent in measuring something which has not occurred (Jason, Thompson, & Rose, 1986). Given the proliferation of street gangs, prevention must be considered. The costs of an effective prevention program are likely to be substantially less than the direct and indirect costs of gang membership, and the work of Klein (1971) strongly suggests that preventing new members from joining gangs is a highly effective strategy for the elimination of a gang altogether. A sound theoretical basis for prevention efforts exists. Weis (1977) suggested several specific implications for delinquency prevention based on control theory and directed toward the family, the schools, and the law. First, he suggested that delinquency prevention efforts work toward enhancing the family's ability to develop self-control among its children. Second, prevention efforts should assist youth in developing and maintaining an attachment to school and education. Third, prevention efforts should be directed at desocialization of the juvenile court system so as to strengthen the youths' belief in the law. Finally, he suggested that all delinquency prevention efforts directed at these institutions should also attempt to enhance the self-concept of youth. Weis (1977) conceptualized a community organizational approach to delinquency prevention under cultural deviance theory, and enumerated several points to be considered when implementing such interventions. First, a community must organize itself against delinquent behavior. Second, community control of delinquency prevention and other youth services should be encouraged. Third, both youth and adult participation in delinquency prevention should be effected. Finally, delinquent groups should be coopted or disbanded, and ties to conventional groups should be encouraged and developed. Broader Urban Involvement and Leadership Development (BUILD) is a Chicago nonprofit agency which focuses entirely on the problem of youth street gangs. A school-based gang membership prevention program operated by BUILD provided a series of 12 classroom sessions to eighth-grade public school students in areas where active gang recruiting in the schools was reported. Following conclusion of the classroom sessions, participants who had been identified as being at risk for gang recruitment were invited to participate in an after-school athletic program conducted in their neighborhood by BUILD staff. This program consisted of organized sports clinics and competition and encouraged intragroup

Treatment cooperation. The after-school program also facilitated the travel of these youth out of their neighborhood to participate in events and activities with similar groups from other locations. Finally, targeted youth were provided with job skills training workshops, social/ recreational opportunities, and educational assistance programs sponsored by BUILD. The effectiveness of the prevention program was evaluated using a quasi-experimental design, and the results were reported by Thompson and Jason (1988). The dependent variable of gang membership was determined pre- and postintervention by comparing targeted youth names with gang rosters provided by gang members involved with other BUILD programs. The BUILD program evaluation showed that one experimental group youth and four control group youth joined gangs during the year. None of the youth who participated in the after-school program had subsequently joined street gangs during the year. Although these results were not statistically significant, this strong trend suggested that the prevention program may have been beneficial despite methodological difficulties found in the evaluation of a multifaceted program's effects on a transient and often poorly identified population. The BUILD program data also suggested that viable alternatives to detached worker interventions may exist, and that they should certainly receive additional research and evaluation attention. Cahill (1996) has explored empirical factors related to gang membership and serious delinquent behavior. She reported a relationship between psychopathy ratings and active gang membership, again suggesting that factors relevant to the identification of youth at risk for street gang membership can be isolated. This in turn suggests that further efforts aimed at preventing youth from joining street gangs may be developed with some degree of success. 9.10.5.4 Gang Suppression Approaches Usually operated by police departments or law enforcement agencies, gang suppression efforts are designed to apply pressure to gang members. Efforts in this arena may include street sweeps where the police focus on a given area and attempt to arrest as many gang members as possible during the sweep. Other gang suppression efforts include harassment of gang members by police, increased police presence, and generally any get-tough approach tolerated by the community or the legal system. Klein (1995) described the Los Angeles Police Department's Operation Hammer as a ªmassive, antigang police sweep.º A special force of 1000 police officers swept through the targeted

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area arresting everyone available on the basis of outstanding warrants, observed criminal activities, and gang-related behavior. Klein indicated that of a total of 1453 arrests during the two day sweep, 1350 were released without charges, almost half were not gang members, and there were only 60 felony arrests, with 32 of these leading to charges (Klein, 1995). Project HICOP (High Intensity Community Oriented Policing) developed out of the Aurora, Colorado volunteer Aurora Gang Task Force. Atkinson (1996) described the project as including police sweeps through targeted areas, mass arrests in an attempt to control gangrelated drug activity, and assigning police officers to assist citizens in keeping crime out of their neighborhoods. Project HICOP was only one facet of an often-discussed and praised community antigang effort in Aurora. Nonetheless, Atkinson (1996, p. 262) reported that, despite six years of intervention efforts, ªgangrelated statistics from the Aurora police department portray mixed results.º Gang suppression efforts are generally based on deterrence theory. Klein (1995) capsulized this approach as follows: (i) low priority is given to prevention and treatment efforts; (ii) high priority is given to visible crime which frightens the public; (iii) a policy of deterrence of gang crime through the use of harassments, surveillance, and penalties is adopted; (iv) it is assumed that gang members will respond to these efforts by engaging in less crime. Special prosecution efforts have been effective in addressing some areas of organized crime (e.g., federal RICO statutes and special prosecution teams). Similar efforts have been directed towards street gangs in an attempt to deter gang-related crime. For example, Klein (1995) described the efforts of the Los Angeles District Attorney to hold all gang members responsible for the actions of other members. As part of a graffiti-removal effort, the district attorney obtained a court order declaring gangs to be a form of corporate structure, allowing the city to force gang members to participate in cleanup efforts even if they had not placed the graffiti themselves. The Institute for Law and Justice (1993) reported other statutory mechanisms for prosecution-based gang-suppression efforts, including provisions for waiver from juvenile court to adult court, various penalty enhancers for gang-related crime, efforts to hold parents financially responsible for the behavior of their children, and enhanced provisions for the confiscation of property or money related to gang crimes.

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Are gang suppression efforts effective? Klein (1995) has argued that many facets of these efforts may actually increase gang cohesiveness, thus inadvertently strengthening the very gangs the programs seek to destroy. By increasing opposing forces, gangs become stronger. When efforts at gang suppression are shown to be ineffective, communities do not abandon them but instead intensify efforts, thus intensifying gang cohesiveness. Some antigang units can be effective, however. Klein (1995) contrasted the efforts of two Los Angeles area gang suppression programs, the Los Angeles Police Department's Community Resources Against Street Hoodlums (CRASH) units and the Los Angeles Sheriff Department's Operation Safe Streets (OSS). The CRASH units consist of uniformed officers and standard patrol cars which cruise gang areas and harass gang members. They are not assigned to the project over the long term, and are rotated out of the program after several years. The OSS officers wear plain clothes (not uniforms) and drive unmarked cars, and often remain assigned to a particular community for many years. Klein reported that the less suppressive approach of the OSS allows them to be more effective in their communities. He cited news reports (Los Angeles Times, 1986) claiming that the OSS program is more effective with fewer resources than the CRASH program. Other less publicized gang suppression efforts are described by Klein (1995). These include techniques such as the cul-de-sac operation, where police blockade an area of known drug distribution and control access to it for a long period of time. Although no formal evaluations of this technique have been reported, it is likely that the drug dealing operations simply change locations, and although some relief to the immediate neighborhood may be obtained, no true impact on crime results from this technique. Shaming, or the use of public apologies or public appearances, has been attempted in some communities, as have local crackdowns on activities by specific individuals. No outcome data have been reported for these techniques. Education efforts directed toward citizens, groups, and law enforcement coalitions have been provided by metropolitan gang crime units and even the federal authorities, such as the FBI, the Drug Enforcement Agency (DEA), and the Bureau of Alcohol, Tobacco, and Firearms (ATF) have become involved in suppression efforts. Unfortunately, these agencies do not appear to effectively generalize their expertise in the area of organized crime to the dissimilar area of street gangs. Finally, school-based gang suppression efforts seem to be increasing. Zero-tolerance

discipline policies, dress codes, and prohibitions against gang haircuts and other accouterments of gang behavior are tools implemented in many school districts. Again, few data are available regarding the impact of these efforts on gang crime. In general, gang suppression efforts do not appear promising. Not only have gang-related offenses and gang problems continued to escalate even in the presence of gang suppression projects, but the direct cost to communities for the funding of these efforts is high. Although sweeps, enhanced policing and prosecution of gang crimes, and community- and school-based suppression efforts may have temporary and transient effects on the activities or visibility of street gangs, they also clearly create an adversarial situation wherein the street gangs must combat an external threat to their survival. This may well have the unintended effect of strengthening street gangs through an increase in their cohesiveness. It is vital that communities, school boards, and law enforcement agencies alike implement carefully planned and effective gang intervention programs rather than simply responding to the perceived need to do something which does not work, and to do more of the same when efforts are seen to fail. Yablonsky (1997) noted that vigorous law enforcement in the absence of social programs is ineffective. Substantial changes in timing and certainty of consequences, as well as other aspects of the interaction between law enforcement agencies and individual gang members, are needed if gang suppression efforts are to be effective (Covey et al., 1997).

9.10.5.5 Comprehensive Approaches Goldstein and Glick (1994) described an integrated gang intervention approach which consists of more than deterrence and incarceration. This model ªseeks to prescriptively apply major features of detached worker, opportunities provision, and social control programmingº (p. 43). Comprehensive gang intervention programming consists of a three-dimensional approach to street gangs. Individual-oriented interventions include the use of interpersonal skills training, anger control techniques, moral reasoning training, contingency management techniques, and cognitive-behavioral interventions. System-oriented interventions include family- and school-based components, as well as changes in the areas of vocational and employment, recreation, and the community. Criminal justice interventions include suppression efforts described above and encompass

Future Directions for Research and Practice efforts of police, prosecutors, and the corrections system. This combined programming seeks to balance the punishing effects of deterrence efforts to decrease behavior with the establishment of new behavioral repertoires which seek to reward the use of prosocial adaptive behavior. Comprehensive programming uses Aggression Replacement Training (ART) (Goldstein, Glick, Reiner, Zimmerman, & Coultry, 1986) as a pivotal component for gang intervention and instruction in nonviolent and prosocial behavior. ART incorporates the use of modeling and guided practice in the acquisition of new skills, systematic training in the inhibition of aggressive behavior, and enhancement of higher cognitive processes in the areas of moral reasoning and prosocial problem solving. ART has been demonstrated to be effective in improving prosocial skills and behavior, reducing impulsive and acting out behavior, and in enhancing moral reasoning in incarcerated juvenile delinquents. ART programming was applied in a multigang delinquency intervention program in New York, where outcome measures included quantitative appraisal of changes in participants' interpersonal skills, anger reduction, community functioning, and rearrest. Goldstein and Glick (1994) reported improved interpersonal skills and community functioning ratings for youth who participated in ART programming and, although anger control measures did not show statistically significant differences between ART participants and control group members, ART participants demonstrated greater gains in anger control when compared to control group youth. Perhaps most importantly, ART group participants were rearrested at a significantly lower rate (13%) than the control group youth (52%) during the eight-month tracking period, suggesting that the behavioral gains made by ART group youth were effectively transferred to the community.

9.10.6 FUTURE DIRECTIONS FOR RESEARCH AND PRACTICE There is no question that the longstanding problems with street gangs continue to exist. The proliferation of gangs, the increase in violence associated with them, and the significant direct and indirect costs to individuals and society emphasize the pressing need to formulate effective and well-coordinated interventions. Decades of research, high levels of funding, and the efforts of a virtual army of law enforcement personnel have had little demonstrated effect on gang behavior, and may have even exacerbated the problem.

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A plethora of data in many forms tell us what not to do, yet little reliable information is available to tell us what steps to take to effectively impact gang crimes in a lasting manner. This chapter has examined the conceptual and methodological difficulties inherent in addressing street gangs, and has described selected intervention programs utilizing popular approaches. It is vital that individuals and groups seeking to have an impact on street gangs develop a full awareness of the pitfalls and potential boomerang effect of plunging into gang intervention activities which increase gang cohesiveness. Although it may be personally and politically difficult to tolerate a more constrained and less publicized approach to street gangs, it must be recognized that ill-conceived programs may strengthen street gangs and further exacerbate the entire range of problems associated with them. At a federal policy level, a system for uniform data collection related to street gangs must be established. Conceptual and definitional difficulties in the field of gang research are so widespread that valid efforts to assess even the scope of the nation's gang problem must rely on statistical estimates of nonexistent data. Policies which create consistent definitions of street gangs and street gang membership may not immediately impact intervention attempts, but such definitions will clearly contribute to the accurate and reliable assessment of intervention techniques. Reliably defining gang crimes or gang-related episodes will allow improvement in our abilities to assess the magnitude and impact of street gangs and intervention attempts alike. With recognition of the extreme economic impact of street gangs and related crime on America, federal policymakers should also consider the establishment of a national street gang data bank to promote effective research with gangs. By serving as a conduit for information and funding, such an effort could improve the effectiveness of gang prevention and intervention research at all levels. Although the framework for such efforts probably already exists within various federal departments, a national commitment to a concerted effort to effectively impact street gangs seems lacking. Without such a commitment, efforts are likely to remain reactive, ineffective, and poorly coordinated. At the state or regional levels, similar policies coordinating the collection and sharing of accurate data must be developed. Just as importantly, resources and policies which effectively address the factors which contribute to the longevity of street gangs, such as increased group cohesiveness or the lack of

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viable alternative socialization resources, must be further developed. At the individual project intervention level, further exploration is needed of the factors which contribute to or are associated with gang membership and active gang behavior. Rather than devoting extensive resources to large-scale intervention and gang suppression efforts in a poorly focused and unscientific approach, projects must first empirically identify relevant predictor variables for gang membership, determine what techniques are effective in preventing membership, and ascertain effective methods for efficiently implementing such programming. No projects should be undertaken in the absence of rigorous evaluation designs. Although it is unsettling to review the ineffective results of decades of so many seemingly promising projects, it is clear that, as a whole, there are a number of principles that may serve to guide the effective and efficient use of gang intervention resources. First, without improvements in conceptualization and data collection, researchers are doomed to repeat the mistakes of the past. In the absence of the ability to reliably and validly measure the gang problem, intervention efforts cannot be assessed and directed. Second, ill-conceived interventions are likely to make the problem worse. This concern must be acknowledged and effective steps taken to address it. Finally, it is known that street gangs and their associated problems can be eliminated by preventing the influx of new gang members. Research that shapes and refines the technology for accomplishing this goal, however, is sorely needed. Decades of gang intervention programs and research have not been wasted, but the lesson has been costly. Clearly the time has come to reexamine and refocus gang intervention efforts in effective directions.

9.10.7 SUMMARY Street gangs, historically a serious problem in the USA, have proliferated markedly in past decades. Years of traditional intervention programs notwithstanding, estimates of gang membership, gang numbers, and gang-related crimes have increased exponentially. Basic research issues, including reliable and valid definitions of gang variables, have not been consistently addressed, and uniform reporting of gang-related crimes is not being done. Despite research to the contrary, intervention programs which do not work and which may actually amplify and strengthen street gangs continue to be implemented.

9.10.8 REFERENCES Akers, R. L., Krohn, M. D., Lanza-Kaduce, L., & Radosevich, M. (1979). Social learning and deviant behavior: A specific test of a general theory. American Sociological Review, 44, 636±655. Akers, R. L. (1977). Deviant behavior: A social learning approach. Belmont, CA: Wadsworth. Atkinson, W. K. I. (1996). The community response to gangs. Section A: Organizing the community response in Aurora, Colorado. In C. R. Huff (Ed.), Gangs in America (2nd ed., pp. 257±262). Thousand Oaks, CA: Sage. Ball, R. A., & Curry, G. D. (1995). The logic of definition in criminology: Purposes and methods for defining ªgangs.º Criminology, 33, 225±245. Briar, S., & Piliavin, I. (1965). Delinquency, situational inducements and commitment to conformity. Social Problems, 13, 25±45. Cahill, M. A. (1996). A comparison of gang member and non-gang member male juvenile delinquents. Dissertation Abstracts International, 57, 4023B. Caplan, N. S. (1968). Treatment intervention and reciprocal interaction effects. Journal of Social Issues, 24, 63±88. Caplan, N. S., Deshaies, D. J., Suttles, G. D., & Mattick, H. W. (1967). The nature, variety, and patterning of street club work in an urban setting. In M. W. Klein & B. G. Myerhoff (Eds.), Juvenile gangs in context: Theory, research, and action (pp. 194±202). Englewood Cliffs, NJ: Prentice-Hall. Chesney-Lind, M., Shelden, R. G., & Joe, K. A. (1996). Girls, delinquency, and gang membership. In C. R. Huff (Ed.), Gangs in America (2nd ed., pp. 185±204). Thousand Oaks, CA: Sage. Chin, K. I. (1996). Gang violence in Chinatown. In C. R. Huff (Ed.), Gangs in America (2nd ed., pp. 157±184). Thousand Oaks, CA: Sage. Cloward, R. A., & Ohlin, L. E. (1960). Delinquency and opportunity. Glencoe, IL: Free Press. Cohen, A. K. (1955). Delinquent boys. Glencoe, IL: Free Press. Cohen, B. (1969). The delinquency of gangs and spontaneous groups. In T. Sellin & M. E. Wolfgang (Eds.), Delinquency: Selected studies (pp. 61±111). New York: Wiley. Covey, H. C., Menard, S., & Franzese, R. J. (1997). Juvenile gangs. Springfield, IL: Charles C. Thomas. Curry, G. D., Ball, R. A., & Decker, S. H. (1996). Estimating the national scope of gang crime from law enforcement data. In C. R. Huff (Ed.), Gangs in America (2nd ed., pp. 21±36). Thousand Oaks, CA: Sage. Elliott, D. S. (1962). Delinquency and perceived opportunity. Sociological Inquiry, 32, 216±227. Fagan, J. (1989). The social organization of drug use and drug dealing among urban gangs. Criminology, 27, 633±669. Gannon, T. M. (1967). Dimensions of current gang delinquency. Journal of Research in Crime and Delinquency, 4, 119±131. Goldstein, A. P., & Glick, B. (1994). The prosocial gang: Implementing aggression replacement training. Thousand Oaks, CA: Sage. Goldstein, A. P., Glick, B., Reiner, S., Zimmerman, D., & Coultry, T. M. (1986). Aggression replacement training: A comprehensive program for aggressive youth. Champaign, IL: Research Press. Hirschi, T. (1969). Causes of delinquency. Berkeley: University of California Press. Jason, L. A., Thompson, D. W., & Rose, F. T. (1986). Methodological issues in prevention. In B. A. Edelstein & L. Michaelson (Eds.), Handbook of prevention (pp. 1±19). New York: Plenum. Jensen, G. F. (1972). Parents, peers, and delinquent action: A test of the differential association perspective. Amer-

References ican Journal of Sociology, 78, 562±575. Institute for Law and Justice (1993). Gang prosecution: Prosecutor survey. Alexandria, VA: Author. Klein, M. W. (1969). Gang cohesiveness, delinquency and a street-work program. Journal of Research in Crime and Delinquency, 6, 135±166. Klein, M. W. (1971). Street gangs and street workers. Englewood Cliffs, NJ: Prentice-Hall. Klein, M. W. (1995). The American street gang: Its nature, prevalence, and control. New York: Oxford University Press. Kobrin, S., Puntil, J., & Peluso, E. (1967). Criteria of status among street groups. Journal of Research in Crime and Delinquency, 4, 98±118. Los Angeles Times (1986, January 19). Policing gangs: Case of contrasting styles. Los Angeles Times. Matsueda, R. L. (1982). Testing control theory and differential association: A causal modeling approach. American Sociological Review, 47, 489±504. Miller, W. B. (1962). The impact of a ªTotal Communityº delinquency control project. Social Problems, 10, 168±190. Rivera, R. J., & Short, J. F. (1967). Occupational goals: A comparative analysis. In M. W. Klein & B. G. Myerhoff (Eds.), Juvenile gangs in context: Theory, research, and action (pp. 70±90). Englewood Cliffs, NJ: Prentice-Hall. Roff, J. D., & Wirt, R. D. (1984). Childhood aggression and social adjustment as antecedents of delinquency. Journal of Abnormal Child Psychology, 12, 111±126. Short, J. F., (1967). Introduction. Journal of Research in Crime and Delinquency, 4, 1±4. Short, J. F., Tennyson, R. A., & Howard, K. I. (1963). Behavior dimensions of gang delinquency. Sociological Review, 28, 411±428. Spergel, I. (1964). Racketville, Slumtown, Haulberg: An exploratory study of delinquent subcultures. Chicago: University of Chicago Press.

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Spergel, I. (1966). Street gang work: Theory and practice. Reading, MA: Addison-Wesley. Spergel, I. (1967). Deviant patterns and opportunities of preadolescent negro boys in three Chicago neighborhoods. In M. W. Klein & B. G. Myerhoff (Eds.), Juvenile gangs in context: Theory, research, and action (pp. 38±54). Englewood Cliffs, NJ: Prentice-Hall. Spergel, I. A., & Curry, G. D. (1993). The national youth gang survey: A research and development process. In A. Goldstein & C. R. Huff (Eds.), Gang intervention handbook (pp. 359±400). Champaign-Urbana, IL: Research Press. Sutherland, E. H., & Cressey, D. R. (1970). Principles of criminology. New York: J. B. Lippincott. Suzuki, S., Nishimura, H., & Takahashi, Y. (1982). An analysis of the conditions conducive to delinquency involvement among high school students: II. On their weakened bonds to family and school. Reports of the National Research Institute of Police Science, 23, 147±165. Thompson, D. W., & Jason, L. A. (1988). Street gangs and preventive interventions. Criminal Justice and Behavior, 15, 323±333. Thrasher, F. (1927). The Gang: A study of 1,313 gangs in Chicago. Chicago: University of Chicago Press. Weis, J. G. (1977). Comparative analysis of social control theories of delinquencyÐthe breakdown of social controls. Washington, DC: US Government Printing Office. Weis, J. G., & Hawkins, J. D. (1981). Preventing delinquency. Washington, DC: US Government Printing Office. Weis, J. G., Sederstrom, J., Worsley, K., & Zeiss, C. (1980). Family and delinquency. Washington, DC: US Government Printing Office. Yablonsky, L. (1997). Gangsters. New York: New York University Press.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

9.11 Families of Individuals with HIV Infection/AIDS MARC J. TASSE Universite du QueÂbec aÁ MontreÂal, PQ, Canada and SUSAN M. HAVERCAMP The Ohio State University Nisonger Center, Columbus, OH, USA 9.11.1 INTRODUCTION

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9.11.2 NATURE OF THE DISEASE

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9.11.2.1 Description of the Disease 9.11.2.2 Transmission 9.11.2.2.1 During anal or vaginal sexual intercourse 9.11.2.2.2 Intravenous drug use 9.11.2.2.3 From infected mother to fetus 9.11.2.2.4 Breast-feeding 9.11.2.2.5 Through receipt of contaminated blood or blood-products 9.11.2.3 Assessment 9.11.2.4 Course and Prognosis 9.11.2.5 Opportunistic Infections 9.11.2.6 Treatment 9.11.3 IMPACT OF THE DISEASE ON THE FAMILY 9.11.3.1 9.11.3.2 9.11.3.3 9.11.3.4 9.11.3.5 9.11.3.6

170 171 171 171 171 171 171 171 172 172 173 173 173 174 174 175 175 176

Family Stress Emotional Impact The Well-guarded Secret Social Support Triangulation Healthcare

9.11.4 FAMILY NEEDS

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9.11.4.1 Information and Education 9.11.4.2 Medical 9.11.4.3 Psychological Needs 9.11.4.3.1 Grieving 9.11.4.3.2 Social support 9.11.4.3.3 Role of the therapist 9.11.5 FUTURE DIRECTIONS

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9.11.6 REFERENCES

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9.11.1 INTRODUCTION

9.11.2 NATURE OF THE DISEASE

Nearly two decades after the first documented case of human immunodeficiency virus (HIV) infection/acquired immunodeficiency syndrome (AIDS), we are just beginning to focus some clinical attention on its impact on families of individuals with HIV infection/ AIDS, and on their needs. HIV infection and AIDS represent one of the most serious health threats to humankind and carry with them enormous financial, social, and psychological burdens for those infected, their friends, and family. It is an understatement to say that the effect of learning that one has HIV/AIDS can be traumatic for the person infected. Certain populations have been particularly hard hit by the epidemic including male homosexuals, intravenous drug users, and hemophiliacs or others who have disorders that require the frequent use of donated blood products or organs (Tsiantis et al., 1990; Winiarski, 1997). Families are especially burdened when the news of the HIV diagnosis is coupled with the first disclosure of homosexuality or intravenous drug use of their loved one (Kelly & Sykes, 1989). In the case of hemophilia, infected male hemophiliacs may unwittingly transmit the HIV/AIDS virus to their spouse, who may later transmit the virus prenatally or perinatally to their children. This chapter will briefly describe the medical aspects of HIV/AIDS and the course of the disease, then we will focus on the impact of and needs created by HIV/AIDS with regard to the family of the person with AIDS. We will present the impact of HIV/ AIDS in terms of issues related to medical, emotional, and social adjustments. Following the discussion of the different areas impacted by HIV/AIDS with respect to the family, we will present and discuss the needs incurred by the family of a person with HIV/AIDS. The presentation of these needs will center around information and education, and medical, psychological, and social supports. Finally, we will explore future trends for research in the area of families of individuals with HIV/AIDS, what we know and what we have yet to learn. We identify the areas of needed research, mostly applied, that can aid families of persons with HIV/AIDS to care for and support their loved ones with HIV/ AIDS, as well as help them deal with the emotional burden of having a loved one with HIV/AIDS. This chapter will not include issues pertaining to pediatric AIDS. Interested readers should consult Armistead, Forehand, Steele, and Kotchick (1998) for a review.

9.11.2.1 Description and Definition of AIDS/HIV Over 500 000 Americans have been reported with AIDS since the epidemic began (Centers for Disease Control and Prevention, 1997). At least 300 000 of them have died. Researchers estimate that between 650 000 and 900 000 Americans currently carry the human immunodeficiency virus that causes AIDS (Karon et al., 1996). HIV belongs to a group of viruses, called retroviruses, which integrate their genetic material with a cell's genetic material through the complicated process of reverse transcription (Kalichman, 1995). Retroviruses are composed of two strands of ribonucleic acid (RNA) surrounded by a fatty envelope. The HIV envelope and its surface proteins help it enter other cells. Although HIV is believed to attack many kinds of cells by attaching itself at receptors, its infection of T-helper (T4) cells has received the most attention (Winiarski, 1997). This T4 cell helps orchestrate the immune response and serves as a biomedical marker of immune functioning. After attaching itself, HIV fuses with a protein on the T-helper cell which allows the contents of the virus to enter the Thelper cell. One of the contents, reverse transcriptase, produces deoxyribonucleic acid (DNA) from the viral RNA. This DNA, called provirus, is integrated in the host cell's genetic code and new viral RNA is transcribed. Viral proteins follow, and new complete virus particles begin to bud off from the host cell. Ultimately, the T cell playing host to such viral replications is destroyed. This reduction in the number of T4 cells is a characteristic indicator of the onset of AIDS. Depletion of T4 cells happens gradually. Vague symptoms of illness in the early stages of AIDS reflect the initial depression of the immune system. As greater numbers of T4 cells are overwhelmed, the immune response network is thrown into full decline. The individual is then vulnerable to the opportunistic infections that induce the fatal diseases associated with AIDS. AIDS is a specific group of diseases or conditions which are indicative of severe immunosuppression related to infection with the human immunodeficiency virus (Centers for Disease Control and Prevention, 1997). AIDS is diagnosed when the patient both tests positive for the HIV infection and also exhibits severe HIV-related immunosuppression as defined by any of the following three conditions: (i) a Thelper count below 200 per cubic millimeter of blood, (ii) the percentage of T-helper cells

Nature of the Disease relative to total T cells is less than 14%, or (iii) the patient is diagnosed with one of 26 ªAIDSdefining illnessesº (Centers for Disease Control, 1992). More information about these 26 conditions is provided in section 9.11.2.6 9.11.2.2 Transmission HIV exists in bodily fluids. HIV and HIVinfected cells have only been isolated in substantial quantities in human blood, vaginal secretions, semen, and breast milk. Insignificantly low quantities of the virus have been found in other body fluids such as saliva and urine (Glasner & Kaslow, 1990). Infection can occur when the bodily fluid of an HIV-infected person enters the bloodstream of a noninfected person. There is no evidence that HIV can be transmitted through casual contacts with, or even daily household exposure to, infected persons (Kalichman, 1995). According to the Centers for Disease Control and Prevention (1994a), even cases of transmission through direct household exposure to blood or other bodily fluids are rare. Transmission occurs in the following ways. 9.11.2.2.1 During anal or vaginal sexual intercourse Sexual contact appears to be the most common way that HIV is transmitted. Semen or vaginal fluid containing white blood cells infected with HIV comes into contact with genital or rectal tissue. The virus can then enter the bloodstream of the host through microopenings in the tissue surface. The risk is greatest for individuals engaging in receptive anal sex as there is a high probability of rectal tissue damage. However, penile±vaginal intercourse accounts for the greatest number of cases of HIV infection in the world (Mann, Tarantola, & Netter, 1992). Although transmission between men and women is bidirectional, the rates of transmission are 2.3 times higher for male-to-female infection than female-to-male transmission. There have been reported cases of HIV transmitted by artificial insemination with infected semen (Winiarski, 1997). Oral±genital contact appears to carry lower risk for HIV transmission than does anal and vaginal intercourse; however, it is not possible to say that oral sex with semen or vaginal fluid exchange constitutes a low-risk sexual behavior (Kalichman, 1995). 9.11.2.2.2 Intravenous drug use Risk occurs when an HIV-infected person uses a syringe to inject drugs and leaves some

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infected blood in it, and another person then uses the same syringe, thereby injecting infected blood along with the drugs. 9.11.2.2.3 From infected mother to fetus The mother may pass the virus in her blood across the placenta to the fetus or HIV may be transmitted through blood contamination of the fetus at delivery. Because of the presence of the mother's HIV antibodies, all babies born of HIV-infected mothers test HIV-positive immediately after birth. The mother's antibodies gradually disappear and from 13 to 30% of the babies subsequently develop their own antibodies and are found to be truly HIV-infected. A major study has shown that if pregnant women take zidovudine during the pregnancy and childbirth, and if the baby takes it during its first weeks of life, the risk of the baby's becoming HIV-positive is substantially reduced (Centers for Disease Control and Prevention, 1994a). 9.11.2.2.4 Breast-feeding HIV exists in the breast milk of infected women and can be directly passed to the infant during breast-feeding. 9.11.2.2.5 Through receipt of contaminated blood or blood-products In the USA, donated blood has been screened for the presence of HIV since 1985. In other countries, however, such screening is not mandated and does not always occur (Kalichman, 1995). 9.11.2.3 Assessment Several blood tests exist that detect antibodies to an HIV infection. Because the tests screen for antibodies, and not for the virus itself, those who test positive are sometimes referred to as HIV antibody-positive. When routine testing is done, blood is taken from the individual. The most commonly used procedure is the enzymelinked immunosorbent assay (ELISA), which employs a chemical method to indicate the presence of the antibodies. Another test, the Western Blot, is frequently used to confirm initial ELISA findings and provide an added safeguard against potentially inaccurate results. When done competently, these tests are very accurate. In a study testing 630 190 units of blood from 290 110 donors, the rate of obtaining a result that falsely indicated someone was HIV-positive was 0.0006 (MacDonald et al., 1989).

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Polymerase chain reaction (PCR) is a relatively new test which detects HIV in macrophages before antibodies to the virus have formed. In this test, actual genetic material from the virus is magnified from blood and tissue samples. It is hoped that this screening procedure will provide earlier and more accurate detection because HIV has been known to ªhideº in macrophages for variable lengths of time without triggering the production of HIV antibodies.

9.11.2.4 Course and Prognosis HIV kills T-helper cells. With the death of these cells comes a decrease in immune functioning. The T-helper count is a widely accepted marker of immune function, and the diminishing of T-helper cell numbers is viewed as an important sign of disease progression. Normally, a person has in excess of 800 T-helper cells per cubic millimeter of blood. Over the course of infection, the number of T-helper cells decreases as the cells are killed. During the first three years of HIV infection, the T-helper cell count usually remains above 500 per cubic millimeter of blood and the patient is asymptomatic aside from a possible acute viral reaction at the time of infection. As the T-helper cell count drops to 300, typically during the fourth or fifth year of infection, the patient becomes susceptible to opportunistic infections caused by viruses, bacteria, fungi, and protozoa. When the count drops to fewer than 200 cells per cubic millimeter or less than 14% or AIDS-related conditions develop, the HIV-infected person is classified as having AIDS. The first occurrence of AIDS-related conditions occurs between 8 and 11 years after infection on average, as the Tcell count drops below 100 (Kalichman, 1995). The time from infection with HIV until the emergence of AIDS is called the incubation period. Many factors may affect an individual's incubation period. Scientists have suggested that the following factors may be important: other viruses, such as cytomegalovirus and Epstein±Barr virus, bacterial infections, and severe malnutrition. Others have suggested that psychological factors such as emotional welfare and hope can play a part. AIDS often led to death in less than one year early in the epidemic. Now, due to the availability of zidovudine, combination therapies, and pneumocystic prophylaxis, longevity has increased dramatically. Osmond (1994), writing before protease inhibitors were licensed, noted that after the first opportunistic infection and with toleration of zidovudine therapy, the median survival time was from 15 months to two years.

9.11.2.5 Opportunistic Infections Without adequate immune defenses, people suffering with AIDS are susceptible to opportunistic infections and the diseases they engender. The infections connected with AIDS represent a diverse group of pathogens: viruses, bacteria, fungi, and protozoa. Even though everyone is exposed to them daily, these infectious agents do not normally cause illnesses in those whose immune systems are healthy. In patients with AIDS, they are devastating and lethal. The clinical courses of opportunistic infections vary in severity. Some may recede after an initial manifestation, only to reappear soon after, perhaps in a more virulent form. Certain maladies respond to drug therapies and may be brought under control temporarily. However, patients with AIDS are ordinarily afflicted with multiple infections at the same time. Thus, even if one is successfully treated, another will continue to ravage the body. The areas of the body most often targeted by opportunistic infections include the lungs, skin, gastrointestinal tract, eyes, lymph nodes, and brain (Flanders & Flanders, 1991). Twenty-six conditions are considered AIDSdefining. The following conditions are among the most frequently occurring: Pneumocystis carinii pneumonia (PCP), the most common life-threatening condition in AIDS patients, caused by an organism that is genetically a fungus but is regarded as a parasite; retinitis, caused by cytomegalovirus; candidiasis, caused by fungus; and toxoplasmosis, caused by a protozoan parasite. Candida albicans, a yeastlike fungus, initially manifests itself in whitish sores along the mouth and later affects the throat and brain. This can be one of the first signs of an immune system weakened by HIV. Kaposi's sarcoma (KS), a previously rare cancer affecting older men, manifests clinically as painless purple-to-brown skin lesions on the legs and torso. Later, swollen lymph nodes and toxoplasmosis of the brain develops (Winiarski, 1997). The cause of KS is hotly debated; although it is a cancer, there seems to be a viral contribution to its causes (Winiarski, 1997). Persons with AIDS also get malignancies at a rate that far exceeds that in the normal population. Invasive cervical cancer and lymphoma are two malignancies frequently seen in persons with AIDS (Winiarski, 1997). Particularly difficult for family members to cope with is the neurological condition of AIDS-related dementia. The latter is a collection of mental and behavioral disorders related to the toxic effects of HIV infection of the brain. It occurs in as many as 90% of patients in the later stages of

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AIDS (Kalichman, 1995). This condition can cause alterations of consciousness, attention span, short- and long-term memory, motor disturbances, and mood stability and lability (Kelly & Sykes, 1989).

of-care recommendations include medications to prevent the most common opportunistic infections, including those caused by Pneumocystis carinii, or Toxoplasma gondii, and tuberculosis, and often Mycobacterium avium complex infections as well.

9.11.2.6 Treatment

9.11.3 IMPACT OF THE DISEASE ON THE FAMILY

Zidovudine (referred to as AZT, ZDV, or Retrovir) was the first major drug discovered to have an effect against HIV. It belongs to a class of drugs called reverse transcriptase inhibitors that interfere with the replication of HIV. Three additional reverse transcriptase-inhibiting drugs have been developed and tested: dideoxycytidine (ddC), dideoxyinosine (ddI), and 3'deoxythymidine-2'-ene (d4T). Each functions similarly to zidovudine by inhibiting the action of reverse transcriptase and therefore interfering with HIV replication (Kalichman, 1995). Zidovudine is credited with extending the lifespan of many persons with AIDS. It is now studied and more widely used in combination with other drugs. Common side-effects include nausea, fatigue, malaise, and insomnia. Some individuals develop more severe sideeffects such as bone marrow suppression and a reduction in white and/or red blood cell counts. These patients are taken off the medicine immediately. Most, if not all, patients treated with zidovudine for a long time develop some resistance to it, although the clinical significance of this is not always clear. Protease inhibitors are a newer class of drugs that attack HIV at a different point in the reproduction process than does zidovudine. Typically, a protease inhibitor is prescribed along with other drugs to create a manypronged attack on the virus. This results in drug regimens requiring 15 or more pills daily. At least initially, protease inhibitors were priced at thousands of dollars for a year's supply. The typical treatment strategy for an asymptomatic HIV-infected person has two components. The first is an attack on the virus's replication process; the second is prevention of opportunistic infections. The attack on viral replication is typically accomplished through combination therapies: the simultaneous use of different types of drugs to disrupt replication at various stages of the process. The US Public Health Service and the Infectious Diseases Society of America have issued extensive guidelines for the prevention of opportunistic infections. These guidelines appeared in Clinical infectious diseases, and reprints are available from the National AIDS Clearinghouse (USPHS/IDSA Prevention of Opportunistic Infections Working Group, 1995). Standard-

9.11.3.1 Family Stress The impact of HIV/AIDS extends beyond the infected individual to that person's social support network. Referred to by some as the ªsecondary epidemicº (Turner & Catania, 1997), the effects of AIDS on the infected individuals' social support network may include family conflicts, shifts in social roles, financial hardships, deteriorating physical and mental health, and feelings of helplessness, grief, and loss. Research in the area of informal caregiving for HIV/AIDS is increasing (e.g., Pearlin, Mullan, Aneshensel, Wardlaw, & Harrington, 1994; Turner & Catania, 1997; Wardlaw, 1994). Informal caregivers have been defined as friends and family members (Turner & Catania, 1997). Many individuals with HIV/AIDS, who may have long been alienated by their parents and siblings, have come to refer to their friends and partner as their ªfamily of choiceº (Britton, Zarski, & Hobfoll, 1993; Nord, 1996; Wardlaw, 1994). The network of informal caregivers is more often comprised of the family of choice than of the family of origin (Nord, 1996). In surveys of informal caregivers, the person with HIV/AIDS was identified as a friend in 79% (Turner & Catania, 1997) and friend or lover/ partner in 90% (Wardlaw, 1994) of cases. In contrast to research findings on informal caregivers with respect to other illnesses (e.g., cancer, Alzheimer), a large proportion of informal caregivers for HIV/AIDS patients are men (Pearlin et al., 1994; Turner & Catania, 1997; Wardlaw, 1994). HIV/AIDS has been evaluated as the most demanding of chronic illnesses with regard to the care provided, in terms of medical, psychological, emotional, and financial support (Tehan, 1991). Families of choice also seem to have an important place in the lives of intravenous drug users, whose networks of friends are considered to provide more social support that their biological family members (Stowe, Ross, Wodak, Thomas, & Larson, 1993). Like people who are gay, intravenous drug users feel it necessary to constitute families of choice due to rejection or abandonment by the family of origin. When dealing with HIV/AIDS, the family has been defined by the Global Program on AIDS of the

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World Health Organization (1994) as a group of persons linked by feelings of trust, mutual support, and common destiny. In this chapter, when discussing the impact on families, and their needs we will refer to both family of origin and family of choice, unless otherwise indicated. Britton et al. (1993) described the difficulties many families have in dealing with the fact that their adult child is gay and has HIV/AIDS. Many families may not have yet come to grips with their child's homosexuality, denying to themselves and refusing to talk about it with others. These families are poorly prepared to deal with the devastating news that their child now is infected with HIV/AIDS, and often become immobilized by this information or, worse, constitute a source of negative support for the person with HIV/AIDS. Many families experience enormous stress when learning of AIDS and perhaps learning for the first time about their adult child's homosexuality or drug use (Caputo, 1985). Greif and Porembski (1989) reported a less severe impact of the AIDS diagnosis on families where the homosexuality of the person with HIV/AIDS had been previously accepted.

9.11.3.2 Emotional Impact Nichols (1985) referred to the affective reaction in the case of AIDS as the ªAIDS adjustment processº and identified four distinct phases: (i) crisis, (ii) transition, (iii) acceptance, and (iv) preparation for death and bereavement. Many people react with an extreme sense of rage and anger when they discover the HIV/AIDS diagnosis of a loved one. This anger can be diffuse and directed towards federal agencies for not moving quickly enough towards a cure or towards society in general for its stigmatization of persons with HIV/AIDS (Kelly & Sykes, 1989). As previously mentioned, learning of a loved one's HIV/AIDS diagnosis is often the first time the family of origin learns of their homosexuality or intravenous drug use. In families that have known or suspected but did not accept the sexual orientation or drug use, learning of the infection challenges their denial of their loved one's lifestyle. The announcement of the HIV/AIDS diagnosis can in some cases exacerbate family conflicts and tensions, rather than bring the family closer together in this time of need for support (Nord, 1996). In a review of the research literature on social support and HIV, Green (1993) concluded that although there is still much research needed in this area, there is evidence of a link between the psychological well-being of individuals with HIV/AIDS and their social support. For family

members to provide this much needed support, they must first come to grips with the news of their loved one's homosexuality or intravenous drug use and HIV/AIDS diagnosis. One demanding ailment often associated with AIDS is AIDS-related dementia. Its effect on the neurocognitive functioning of the person with HIV/AIDS may result in memory loss, mood disorder, thought disorders, attention problems, and behavior problems. Greif and Porembski (1989) noted the emotional reactions, including denial, guilt, anger, sadness, depression, and shame, frequently experienced by family members of the person with HIV/ AIDS. Greif and Porembski also noted three common behavioral patterns within the families of persons with HIV/AIDS: (i) secrecy regarding the HIV/AIDS diagnosis, (ii) triangulation, and (iii) lingering feelings of hurt and anger.

9.11.3.3 The Well-guarded Secret The proportion of people who say they personally know someone who has HIV/AIDS may in fact be higher than the 15% cited by Turner and Catania (1997), especially considering that many individuals with HIV/AIDS fear letting others know of their illness. People with HIV/AIDS must painfully grapple with the learning of their diagnosis and then determine who they want to or must inform. Family acceptance or awareness of the sexual orientation or drug use of the person with HIV/ AIDS also emotionally prepares the latter to reveal their HIV/AIDS status (Leask, Elford, Bor, Miller, & Johnson, 1997). Because of the strong stigma, keeping the HIV/AIDS diagnosis a secret from friends, families, and others is one of the first issues the person with HIV/AIDS grapples with. The stigma associated with AIDS and homosexuality compounds the already stressful situation (Crawford, 1996; Takigiku, Brubaker, & Hennon, 1993). Even among seronegative gay adolescents, social stigma has been associated with an increased risk for suicide (Radkowsky & Siegel, 1997). Some have referred to the AIDS stigma as a modern-day leprosy (Geis, Fuller, & Rush, 1986). This situation can be so painful that some persons with HIV/AIDS prefer to commit suicide rather than face telling their parents (Kubler-Ross, 1987). Failure on the part of the person with HIV/AIDS to disclose their HIV/AIDS diagnosis to members of their family of origin is even more widespread amongst certain cultural groups such as Latinos (Mason, Marks, Simoni, Ruiz, & Richardson, 1995). Many family members dread the stigma associated with AIDS and battle with issues

Impact of the Disease on the Family of disclosure long after the death of their loved one. Four of nine families interviewed by Greif and Porembski (1989) continued attempts at secrecy even after the death of the person with HIV/AIDS. Despite efforts to educate and inform, social stigma associated with people with HIV/AIDS is prevalent in all societies and is cited as the main reason why the friends and families of many persons with HIV/AIDS find it difficult to disclose (Greif & Porembski, 1988; Harek & Capitano, 1993). The secrecy issues for many family members of the person with HIV/ AIDS may be related to shame, or fears of job loss or ostracism, and occur even when the transmission of AIDS was through a blood transfusion (Kelly & Sykes, 1989). Group support may be an effective means to helping families and persons with HIV/AIDS deal with secrecy issues and stigma associated with the HIV/AIDS diagnosis (Beckerman, 1994; Kelly & Sykes, 1989). Such support is especially important because this refusal to disclose to others leaves them isolated and cut off from natural social supports (Pomeroy, Rubin, & Walker, 1995, 1996). In a study that included 34 gay men seeking treatment in a London clinic, the majority reported a positive change in their relationship with their family of choice following disclosure of their HIV status. A negative change was reported in the relationship with their lover or partner by 33% of men (Leask et al., 1997). When disclosing HIV diagnosis to their family of origin, Leask et al. reported that the gay men in their sample were more likely to disclose to their mother or sister than to their father or brother. Disclosing to their mothers rather than to their fathers may not be surprising, considering that mothers tend to have more positive attitudes than fathers towards homosexuality (Takigiku et al., 1993). However, similar disclosure patterns have been reported in heterosexual couples where one partner is seropositive (Kennedy, Skurnick, Foley, & Louria, 1995). Thus, even within the same family, some members may know of the HIV/ AIDS diagnosis while others are not told.

9.11.3.4 Social Support Greif and Porembski (1989) interviewed 11 significant others after the death of their loved ones. They reported that a common coping strategy used by family members of persons with HIV/AIDS was denial. Denial can be defined according to Billings and Moos (1981) as an avoidant coping measure. The use of avoidant coping strategies has been found to be a risk factor for increased psychological distress

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in persons with HIV/AIDS and their significant others (Klein, Forehand, Armistead, & Wierson, 1996). The lack of information regarding HIV/AID was also noted as an element that hindered their ability to better cope with the situation. The emotional impact of learning of a loved one's HIV/AIDS diagnosis was emphasized by almost all persons interviewed. Finally, the stigma of HIV/AIDS and the irrational fears of contagion prevalent in the general public frequently isolates family members from their own usual sources of social support. Beckerman (1994) suggested that the parents and the person with HIV/AIDS be seen in a therapy session together in order to explore their respective fears and concerns. Acceptance of the diagnosis on the part of the parents may take some time. According to Beckerman (1994), if a family is to become supportive of their loved one with HIV/AIDS they will need to: (i) accept the diagnosis, (ii) accept their child's homosexuality, (iii) disclose (diagnosis and lifestyle), (iv) reintegrate their child into the family, and (v) let go, prepare for the death of the person with HIV/AIDS. Social stigma associated with AIDS remains undeniably very present in all societies and contributes to the hardships attributed to this disease. Much of the negative attitude directed towards people infected with HIV/AIDS and to AIDS in general, may be largely a homophobic reaction (Crawford, 1996; Morin, 1991; Pryor, Reeder, Vinacco, & Kott, 1989; Trezza, 1994). In addition to society's negative reaction to homosexuality, irrational fear of contracting the HIV/AIDS virus is also fueling the shunning of persons with HIV/AIDS and anyone associated to them (Bishop, Alva, Cantu, & Rittiman, 1991). The severe stigma associated with HIV infection and AIDS tops the list of contributing factors to increased risk of suicide amongst persons with HIV/AIDS and their family members (see Wadland & Gleeson, 1991). For example, in a meta-analysis of 21 studies of AIDS stigma, Crawford (1996) found a greater stigma associated with AIDS than with other serious illnesses (e.g., leukemia, Alzheimer, lung cancer). Crawford also found that amongst healthcare professionals a greater magnitude of stigma was associated with AIDS.

9.11.3.5 Triangulation One frequent target for the anger of families of origin of gay men with HIV/AIDS is the lover or partner (Dworkin & Pincu, 1993). Tensions between the parents of gay persons with HIV/ AIDS and their child's lover or partner are common (Greif & Porembski, 1988; Lovejoy,

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1989). Frequently, parents of a gay person with HIV/AIDS may accuse the lover, partner, or family of choice of being responsible for their son's HIV infection (Lovejoy, 1989). Even after the death of the person with HIV/AIDS, tensions and arguments erupt between the family of origin and the family of choice over funeral arrangements and disposition of belongings (Wardlaw, 1994). These reactions obviously cause additional strain and tension in an already painful situation.

9.11.3.6 Healthcare With the ever-increasing cost of healthcare, more and more families of origin and families of choice are being called upon to provide the bulk of the caregiving to persons with HIV/AIDS. Many of these informal caregivers routinely help with such tasks as medical procedures, personal care, and managing the financial and legal affairs of the person with HIV/AIDS (Wardlaw, 1994). The discovery and refinement of effective drug regimens for suppressing symptoms and forestalling AIDS progression changes the nature of caregiving for persons with HIV/AIDS from acute to chronic. In their sample of 642 caregivers, Wardlaw (1994) reported an average caregiving duration of 1.5 years, and some participants reported providing caregiving to a person with HIV/AIDS for more than four years. While the family cares for their loved one, vacations, leisure activities, and longterm plans are put on hold. The burden of having to provide such long-term healthcare can be devastating for family members, especially since most of them receive no caregiving training of any kind (Wardlaw, 1994). One concern of family members who provide home healthcare to loved ones with AIDS is the risk of being infected. Informal caregivers help with dressings on wounds and sores, injections, changing of soiled diapers and bed sheets, feedings, changing of catheters, and the starting of intravenous lines. The medical needs of persons with HIV/AIDS, and hence the demands upon their family, vary enormously with the course of the illness, at times involving intense medical care and at other times primarily social services (Milanese et al., 1997). Aside from the concerns of possible infection, these tasks executed by family members demand considerable time and physical strength and the impact on the family can be overwhelming (Nord, 1996). We will later discuss the needs of family members with respect to education concerning the risks of HIV transmission and the precautions to be taken in order to avoid being infected.

In the USA, the financial burden can be great for families with no health insurance or with a limited health insurance that may cap out quickly. Even for families living in a country that provides universal healthcare (e.g., Canada, Sweden) financial burdens may exist regarding unsubsidized types of care or medications. Persons with HIV/AIDS or their family members often lose their jobs because of inability to work, prolonged absences or an inability to continue working while providing care to a loved one. The economic strain on society attributed to AIDS has at times been alarmingly sounded, such as Lynch's (1989) prediction of bankruptcy of hospital and city administrations in the hardhit areas (such as New York City and San Francisco). Such alarmist statements must be viewed with skepticism. The greatest financial burden created by the HIV infection and AIDS will be borne by persons with HIV/AIDS and their families. 9.11.4 FAMILY NEEDS 9.11.4.1 Information and Education Information and education regarding the nature of HIV/AIDS are crucial in reassuring family members who may harbor irrational fears of contagion (Pomeroy et al., 1995). We only need to look at the historical perspectives of HIV/AIDS information to realize the degree of misinformation and ignorance that has circulated over the years. Initial misleading information announced that the AIDS virus could be transmitted by all bodily fluids, including saliva and tears. Public concern escalated with the speculation that HIV could be transported by mosquitos and that possible mutations could occur that would allow the AIDS virus to become airborne (Lynch, 1989). Stigma and social rejection has certainly been fueled by fear and inaccurate information. Information and education needs to center on basic information regarding the transmission of HIV. As previously mentioned, transmission of HIV is possible through the use of infected needles or syringes during intravenous drug use, by having unprotected sexual intercourse (oral, anal, or vaginal) with an infected person (male or female), or by receiving a blood transfusion or organ/human tissue transplant from an infected donor. Infected mothers can also transmit the HIV virus to their fetus through the placenta or to their babies perinatally or through breast milk. The HIV virus is not transmitted during casual contact with an infected person. It is important to educate family members in order to alleviate the fears they may have of contracting the HIV

Family Needs virus through activities of daily living or caregiving with a loved one who has AIDS. Below is a list published by the Centers for Disease Control and Prevention (1994b) of ways through which you cannot ªcatchº the HIV virus. You will not be infected: (i) through everyday contact with an infected person at home, work, school, etc.; (ii) from clothes, phones, or toilet seats. HIV cannot be passed on by things like forks, cups, or other objects that an infected person has used; (iv) from a mosquito bite. HIV cannot survive in a mosquito, and is not transmitted through a mosquito's bite like malaria. HIV is not transmittable through bedbugs, lice, fleas, or other insects; (v) from an infected person's sweat, saliva or tears; (vi) from a simple kiss from an infected person. Although, HIV transmission may be possible through prolonged or deep kissing, due to potential blood contact, most scientists agree that this would be most unlikely (Centers for Disease Control and Prevention, 1994b, p. 2). If there is a need for education regarding the basics of HIV and AIDS amongst mental health professionals (Knox, Dow, & Cotton, 1989), it is even more pressing for family members called upon to care for a loved one with AIDS. Amongst the family members caring for a person with HIV/AIDS in Wardlaw's (1994) sample of 642 family member/caregivers, less than a third had gotten any type of training on how to care for a person with HIV/AIDS. Knox and Gaies (1990) proposed a model for the provision of effective AIDS education to community mental health professionals. This model can be adapted to educate family members and would consist of the following elements: (i) small group format (6±8 people); (ii) a didactic component to provide basic information about HIV/AIDS; (iii) an experiential component, such as behavioral rehearsal and role playing (e.g., practice safety precautions to guard against infections); and (4) group discussions and establishing social network/support. According to Trezza (1994), HIV prevention programs geared towards college students should aim at reducing homophobia, which is strongly correlated with stigmatization of persons with HIV/AIDS, and address irrational fears pertaining to HIV/AIDS, education concerning high- versus low-risk behaviors, and safe sex techniques. Despite harboring their own negative attitudes towards gays and AIDS, psychologists, having been trained in behavior and attitude change, can become key figures in the elaboration of HIV/AIDS prevention and education programs (Trezza, 1994).

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The American Psychological Association's HIV Office for Psychology Education (HOPE) program offers training workshops for psychologists to better prepare them to do therapy with persons with HIV/AIDS and their family. These continuing education workshops aim at providing current training with regard to case management, psychotherapy, and client education skills, to enable psychologists to work effectively with individuals with HIV infection/AIDS and their families. The HOPE program covers the following areas: (i) HIV disease information related to psychotherapy, (ii) one's own attitudes and values about HIV and individuals with HIV infection, (iii) psychosocial issues confronting clients, (iv) HIV-related counseling skills; (v) barriers to effective clinical practice, (vi) networking opportunities, (vii) awareness of local HIV/AIDS resources; and (viii) AIDS-related grief, loss, and bereavement (Eversole, 1995, p. 206). 9.11.4.2 Medical Finding out that one's child or sibling has been diagnosed with HIV/AIDS can have a devastating effect on the entire family. Many family members may have only limited knowledge of the disease and require immediate information and education regarding the course of the illness, symptoms, opportunistic infections associated with AIDS, necessary precautions regarding contagion, and the types of care needed by a person with HIV/AIDS. Many family members may be called upon to provide care to their child or sibling who has been diagnosed with HIV/ AIDS and will require additional information. As the medical treatment of HIV/AIDS extends the lives of individuals infected, the once acute type of illness becomes a more chronic and prolonged one that requires extended care from family and friends. As the life expectancy of persons with HIV/AIDS is increased so are the needs of the family members who are called upon to provide care. Education is needed regarding medication compliance, medication side-effects and interaction effects, signs of dementia and how to intervene, symptoms and course of HIV/AIDS (e.g., thrush, opportunistic infections, etc.), precautions to take to prevent infection, nutritional needs of persons with HIV/AIDS, and medical resources available for home healthcare. 9.11.4.3 Psychological Needs Counseling and support to help family members cope with the HIV/AIDS infection status of their loved one is an important and

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essential step in providing services for families of individuals with HIV/AIDS (Gurney, 1995; Nord, 1996). Greif and Porembski (1989) pointed out the importance of providing therapeutic services to the members of the families of origin and choice, due to their role as primary caregivers to persons with HIV/AIDS and the toll this takes with respect to their own emotional health. Support groups for family members of persons with HIV/AIDS seem helpful in providing a forum for open discussion and exchange with others about feelings, problems, and fears without being ostracized or stigmatized (Kelly & Sykes, 1989). Considering the societal stigma associated with HIV/AIDS, group-based interventions may be helpful in breaking the barriers of isolation and provide support to these family members. An example of a more structured group intervention program was published by Pomeroy et al. (1995, 1996) where they presented their eight-session psychoeducational group for family members of persons with HIV/AIDS. During these eight sessions, participants are provided with information regarding topics such as dispelling myths about HIV/AIDS, HIV transmission, home healthcare and precautions to take in the home, the course of disease from HIV infection to AIDS, medical and nutritional needs of persons with HIV/AIDS, current treatment modalities and medication, opportunistic infections, and dementia associated with later stages of AIDS. Group members are also provided with a listing of existing resources in their communities that can provide them with a variety of medical or social services that are specialized in the care of persons with HIV/ AIDS. Counseling and information are provided regarding insurance, legal aid, and legal aspects related to death (e.g., living wills) as well as concerning grief and the grieving process. In their group intervention program, Pomeroy et al. (1995, 1996) also provided minimal skills training to the family members of persons with HIV/AIDS in the areas of anger management, relaxation training, assertiveness training, problem solving, and conflict resolution techniques. In addition to the education and support fostered during the group meetings, they added homework tasks that members were asked to complete and report upon at each meeting. These tasks involved phoning another group member and initiating a conversation in an attempt to foster social support amongst group members, finding and practicing a constructive outlet for their anger, and engaging in one leisure activity. This psychoeducational group intervention program provides a range of needed skills and

information for family members of persons with HIV/AIDS and an important component of peer social support for these family members. Their pre- and post-support group assessment indicated a significant improvement on the part of the participants, when compared to a wait-list group, on measures of perceived stigma associated with HIV/AIDS, depression, anxiety, and perceived stress. Surprisingly, the measures of perceived social support showed no appreciable change between the start and completion of the psychoeducational group. It may be that eight 90-minute sessions are insufficient to significantly ameliorate social support deficits in this population. The authors also acknowledged problems in outcome measurement sensitivity. 9.11.4.3.1 Grieving Often, biological parents who learn of their child's HIV/AIDS diagnosis feel a sense of grief at the announcement of the diagnosis and may experience prolonged grief as the condition of the child deteriorates (Greif & Porembski, 1989; Wadland & Gleeson, 1991). Some families experience multiple losses when a loved one has HIV/AIDS. In some cases, such as the family of choice of gay men or the biological family of people with hemophilia, they may have experienced the death of more than one loved one as a result of HIV/AIDS. In some gay communities, entire groups of friends have lost their lives to HIV/AIDS. Nord (1996) presented the clinical case of a mother whose two hemophiliac sons contracted HIV and died of AIDS. Discussing death is often avoided because of the immense emotional pain associated with it. However, being able to openly discuss the impending death of a loved one is critical for the family to begin healing from the loss (Millan & India Ivory, 1994). Honest discussion about death and dying is the penultimate indication of the level of trust between the client/group and the clinician. Dealing with grieving can only be effectively accomplished within a relationship of trust and emotional comfort. 9.11.4.3.2 Social support The major stumbling block to families getting the much needed social support, from friends, family members, or professionals, is secrecy. Fears that fuel the need to keep the HIV/AIDS diagnosis of a loved one a secret isolate the family from everyone who is excluded from the circle of people who know. Group meetings between family members of persons with HIV/ AIDS and therapist are an effective medium during which secrecy issues can be explored and

Future Directions discussed. Social support is crucially important in helping family members cope with the loss of a loved one and support groups are a valuable opportunity for family members to realize that others care and understand how they feel (Nord, 1996). Kelly and Sykes (1989) studied the composition and structure of a support group intervention for family members of persons with HIV/ AIDS. These authors ran a bi-monthly support group composed of a mix of family of origin and family of choice members. The support group provided a forum in which members could safely disclose that their loved one had AIDS, share with others their difficulties related to caring for a person with HIV/AIDS, and ventilate their rage and anger, as well as deal with issues of acceptance of their loved one's homosexuality or intravenous drug use. Pomeroy et al. (1995, 1996) addressed issues of lack of social support in addition to providing information, education, and some coping skills training. Social support was provided by the group members within and between the group meetings. Members exchanged stories regarding their experiences in caring for a loved one with HIV/AIDS, the anger and guilt they at times felt towards the person with HIV/AIDS, their feelings of helplessness and depression, and how they dealt with these different issues. The fact, however, that group members did not report significantly higher perceptions of social support may indicate a need for more pervasive supports or the inclusion of natural supports such as friends and family members. 9.11.4.3.3 Role of the therapist A certain cautionary note is needed with respect to cultural differences and the clinician's attempt to progress through different areas of need. Millan and India Ivory (1994) pointed out the important need for Latinos to feel a strong personal and intimate rapport with the therapist before dealing with issues such as completing a living will. The clinician must recognize the importance of ensuring that persons with HIV/ AIDS and their family members are aware of and prepared for the important financial issues tied to their disease and that they are aware that their financial needs will certainly fluctuate with the course of the disease (Wadland & Gleeson, 1991). Secrecy is a critical element in the client± therapist relationship. The therapist must abide by the desire for secrecy of a person with HIV/ AIDS and must support the client who has HIV/ AIDS in making progress towards dealing with the diagnosis and the difficult issues of disclosure (Greif & Porembski, 1989). Yet,

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Dworkin and Pincu (1993) recommended that clinicians ensure that their client is not using nondisclosure as a means to ªavoidº dealing with the disease. This avoidance coping can contribute to more distress and emotional problems (Fukunishi et al., 1997). The clinician can play a crucial role in coaching and helping the person plan and rehearse how to tell people (e.g., role-play). Persons with HIV/AIDS, in an attempt to take charge of the situation and project an image of self-assurance, conversely, may decide to disclose their HIV/AIDS status to everyone they know. Dworkin and Pincu (1993) recommended clinicians prepare these clients for possible negative reactions from some individuals. Clinicians must support the person with HIV/AIDS in making rational and careful disclosure of their diagnosis. Psychologists must be aware of their biases and negative attitudes towards homosexuals and HIV/AIDS. Trezza (1994) reported that in his sample of nearly 600 clinical and counseling psychologists, many lacked the knowledge regarding HIV/AIDS that is necessary for effective counseling of persons with HIV/AIDS and their families.

9.11.5 FUTURE DIRECTIONS With the advent of more effective means for slowing down the progression of the HIV virus, AIDS care is moving from a relatively shortterm care plan to more chronic long-term managed care needs. Wardlaw (1994) advanced the concern regarding the resilience of families with respect to the emotional and physical strain involved in caring for a loved one with a lengthening interval between the AIDS diagnosis and death. Given the ever-increasing desire to reduce healthcare costs, supports will be needed to provide home-based healthcare and help maintain HIV/AIDS infected people in their homes versus more expensive hospital settings. This emphasis on home-based healthcare creates an increased burden on family members, who will be expected to assume a greater caregiver role and heavier responsibilities. Service providers will need to plan the provision of needed family supports in educational, financial, medical, social, and psychological areas. Pomeroy et al. (1995) suggested additional research, to study the contribution of psychoeducational interventions that support informal caregivers in providing in-home healthcare to persons with HIV/AIDS, and the effectiveness of these education programs in reducing hospitalizations of persons with HIV/AIDS. Clearly, social supports are a buffer, protecting the person with HIV/AIDS and their family

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from psychological distress associated with AIDS (Green, 1993; Klein et al., 1996). Further research is needed to evaluate and improve the effectiveness of support groups in significantly augmenting the level of perceived social support of family members and persons with HIV/ AIDS. This need may be most keenly felt by family members who resist disclosure and are therefore cut off from their pre-established social support networks. Given the over-representation of AfricanAmerican and Hispanic persons with HIV/ AIDS, more attention should be given to crosscultural differences in counseling, support groups, and service delivery with respect to HIV/AIDS. Kelly and Sykes (1989) observe the under-representation of minority members in their support group sample, and emphasize the importance of offering support groups in a manner that ethnic minorities can and will accept. Studies examining caregiving have raised interesting questions regarding gender and cultural differences in the perceived burden on caregivers (see Takigiku et al., 1993; Turner & Catania, 1997). Given the unusually high percentage of male caregivers of persons with HIV/AIDS, research is needed to investigate possible gender differences in the disruptions caregiving creates within caregivers' jobs and social relationships. Further research is needed to study the relationship between individual caregiver characteristics and resilience to the caregiving burden, psychological distress, and complicated grieving. A detailed examination of risk factors for poor caregiving outcome is needed (Turner & Catania, 1997). Factors that may differentiate high- versus low-stressed parent caregivers include the family ethos of affection versus obligation, and attitudes toward homosexuality need futher investigation (Takigiku et al., 1993). Additional research and clinical work is needed to provide a better understanding of the relationship between psychological distress experienced by family members and their perceived social support. Drotar, Agle, Eckl, and Thompson (1997) recommended the study of family relationships and family supports, including any fluctuation in these supports or changes in relationships over the course of the disease. They have suggested the need to study in greater depth the relationship between family support, stressful events, and psychological distress amongst the family members, both within the HIV/AIDS families and healthy families. Further, they suggested that research should identify specific elements of family relationships that parents experience as most supportive and hence may be most influential in reducing the psychological distress associated

with AIDS. Future research is needed to better understand the coping behaviors of persons with HIV/AIDS and their families. As pointed out by Pomeroy et al. (1995), few studies have attempted to follow on a longitudinal basis the impact of HIV/AIDS on the family, and their needs as the disease progresses. Wardlaw (1994) has pointed out the dearth of studies regarding the study of the psychological strain from AIDS mortality and morbidity on family members who have cared for and survived several other family members. Further studies are needed to better understand the repercussions of HIV infection/AIDS on families, even after the death of the person with HIV/AIDS. Future studies will also need to address the issue of social stigma. Social stigma is one of the major variables contributing to increased stress and isolation for persons with HIV/AIDS and their families (Crawford, 1996; Greif & Porembski, 1988; Harek & Capitano, 1993; Trezza, 1994). Following her meta-analysis of 21 studies, Crawford (1996) concluded that there is a pressing need for further theory-driven empirical investigation of AIDS stigma, in order to better understand the underlying and mediating variables fueling the AIDS stigma in our societies, and to identify possible strategies to reduce this stigma. The elevated social stigma associated with AIDS is present in both the lay and professional populations (Crawford, 1996). Along with social stigma, future research also needs to examine the different patterns of AIDS disclosure and its impact within the family (Levine, 1995). Research is needed to evaluate the impact on children who lose family members to AIDS and to assess their needs (Carten & Fennoy, 1997). Children and adolescents suffer the loss of a family member and disruption of the family without knowing what is really happening. Youngsters are kept in the dark in a misguided attempt to protect them. The discovery of the HIV infection and possible homosexuality of a family member may be especially difficult for the young, especially for adolescents who are still confronting their own sexuality. Research is needed to investigate the effects of information and support groups targeted at children and adolescents (Aronson, 1995; Kelly & Sykes, 1989; Levine, 1995). We need to further study and better understand the role of social support in buffering against psychological distress, depression, stress, and other negative effects HIV/AIDS has upon the person with HIV/AIDS and the family. More empirical work is needed to study the effects of actual social supports (i.e., inventory) versus perceived social support on

References these psychological variables, and how the buffering effects of social support fluctuate over the course of the disease. Britton et al. (1993) found that support systems may or may not be perceived as helpful depending on the perceived distress of the person with HIV/ AIDS. Further research towards understanding this phenomenon may help to plan interventions that will be perceived as beneficial and timely. More work is needed in educating family members about this disease, and it is crucial to tailor this information or education to the culture and level of comprehension of the targeted audience. Improvements in AIDS awareness and education should focus on reducing high-risk behaviors associated with HIV infection, but also on promoting a better understanding of homosexuality, and of HIV infection and contagion, and on attacking the existing and pervasive irrational fear of AIDS, sometimes refer to as ªAFRAIDSº (Doubleday, 1986). 9.11.6 REFERENCES Armistead, L., Forehand, R., Steele, R., & Kotchick, B. (1998). Pediatric AIDS. In T. H. Ollendick & M. Hersen (Eds.), Handbook of child psychopathology (pp. 463±481). New York: Plenum. Aronson, S. (1995). Five girls in search of a group: A group experience for adolescents of parents with AIDS. International Journal of Group Psychotherapy, 45, 223±235. Beckerman, N. L. (1994). Psychosocial tasks facing parents whose adult child has AIDS. Family Therapy, 21, 209±216. Billings, A., & Moos, R. (1981). The role of coping responses and social resources in attenuating the stress of life events. Journal of Behavioral Medicine, 4, 139±157. Bishop, G. D., Alva, A. L., Cantu, L., & Rittiman, T. K. (1991). Responses to persons with AIDS: Fear of contagion of stigma? Journal of Applied Social Psychology, 21, 1877±1888. Britton, P. J., Zarski, J. J., & Hobfoll, S. E. (1993). Psychological distress and the role of significant others in the population of gay/bisexual men in the era of HIV. AIDS Care, 5, 43±54. Caputo, L. (1985). Dual diagnosis: AIDS and addiction. Social Work, 30, 361±364. Carten, A. J., & Fennoy, I. (1997). African American families and HIV/AIDS: Caring for surviving children. Child Welfare, 76, 107±125. Centers for Disease Control (1992). 1993 revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. Morbidity and Mortality Weekly Report, 41(RR-17), 1±19. Centers for Disease Control and Prevention (1994a). Recommendations of the US Public Health Service Task Force on the use of zidovudine to reduce perinatal transmission of human immunodeficiency virus. Morbidity and Mortality Weekly Report, 43(RR-11), 1±20. Centers for Disease Control and Prevention (1994b). HIV infection and AIDS: Are you at risk? Atlanta, GA: US Department of Health and Human Services. Center for Disease Control and Prevention. (1997). HIV/ AIDS surveillance report (Vol. 9 No. 1, pp. 1±37).

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Atlanta, GA: US Department of Health and Human Services. Crawford, A. M. (1996). Stigma associated with AIDS: A meta-analysis. Journal of Applied Social Psychology, 26, 398±416. Doubleday, W. A. (1986). Death, dying, and AIDS. In V. Gong & N. Rudnick (Eds.), AIDS: Fact and issues (pp. 291±302). New Brunswick, NJ: Rutgers University Press. Drotar, D., Agle, D. P., Eckl, C. L., & Thompson, P. A. (1997). Correlates of psychological distress among mothers of children and adolescents with hemophilia and HIV infection. Journal of Pediatric Psychology, 22, 1±14. Dworkin, S. H., & Pincu, L. (1993). Counseling in the era of AIDS. Journal of Counseling and Development, 71, 275±281. Eversole, T. (1995). Family therapists' response to AIDS: An examination of attitudes, knowledge and contacts. Journal of Marital and Family Therapy, 21, 205±206. Flanders, S. A., & Flanders, C. N. (1991). Library in a book: AIDS. New York: Facts On File. Fukunishi, I., Hosaka, T., Negishi, M., Moriya, H., Hayashi, M., & Matsumoto, T. (1997). Avoidance coping behaviors and low social support are related to depressive symptoms in HIV-positive patients in Japan. Psychosomatics, 38, 113±118. Geis, S. B., Fuller, R. L., & Rush, J. (1986). Lovers of AIDS victims: Psychological stresses and counseling needs. Death Studies, 10, 43±53. Glasner, P. D., & Kaslow, R. A. (1990). The epidemiology of human immunodeficiency virus infection. Journal of Consulting and Clinical Psychology, 58, 13±21. Global Program on AIDS of the World Health Organization (1994). World AIDS Day Newsletter, 2, 1. Green, G. (1993). Social support and HIV. AIDS Care, 5, 87±104. Greif, G. L., & Porembski, E. (1988). AIDS and significant others: Findings from preliminary exploration of needs. Health and Social Work, 13, 259±265. Greif, G. L., & Porembski, E. (1989). Implications for therapy with significant others of persons with AIDS. Journal of Gay and Lesbian Psychotherapy, 1, 79±86. Gurney, S. (1995). Counseling the HIV affected individual: A case study. Counseling Psychology Quarterly, 8, 17±25. Harek, G. M., & Capitano, J. P. (1993). Public reactions to AIDS in the United States: A second decade of stigma. American Journal of Public Health, 83, 574±577. Kalichman, S. C. (1995). Understanding AIDS: A guide for mental health professionals. Washington, DC: American Psychological Association. Karon, J. M., Rosenberg, P. S., McQuillan, G., Khare, M., Gwinn, M., & Petersen, L. R. (1996). Prevalence of HIV infection in the United States, 1984 to 1992. Journal of the American Medical Association, 276, 126±131. Kelly, J., & Sykes, P. (1989). Helping the helpers: A support group for family members of persons with AIDS. Social Work, 34, 239±242. Kennedy, C. A., Skurnick, J. H., Foley, M., & Louria, D. B. (1995). Gender differences in HIV-related psychological distress in heterosexual couples. AIDS Care, 7 (Suppl. 1), S33±S37. Klein, K., Forehand, R., Armistead, L., & Wierson, M. (1996). The contributions of social support and coping methods to stress resiliency in couples facing hemophilia and HIV. Advancement in Behaviour Research and Therapy, 16, 253±275. Knox, M. D., Dow, M. G., & Cotton, D. A. (1989). Mental health care providers: The need for AIDS education. AIDS Education and Prevention, 1, 285±290. Knox, M. D., & Gaies, J. S. (1990). The HIV clinical tutorial for community mental health professionals. Community Mental Health Journal, 26, 559±566.

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Kubler-Ross, E. (1987). AIDS: The ultimate challenge. New York: Macmillan. Leask, C., Elford, J., Bor, R., Miller, R., & Johnson, M. (1997). Selective disclosure: A pilot investigation into changes in family relationships since HIV diagnosis. Journal of Family Therapy, 19, 59±69. Levine, C. (1995). Orphans of the HIV epidemic: Unmet needs in six US cities. AIDS Care, 7(Suppl. 1), S57±S62. Lovejoy, N. C. (1989). AIDS: Impact on the gay man's homosexual and heterosexual families. Marriage and Family Review, 14, 285±316. Lynch, R. D. (1989). Psychological impact of AIDS on individual, family, community, nation, and world in a historical perspective. Family and Community Health, 12, 52±59. MacDonald, K. L., Jackson, J. B., Bowman, R. J., Polesy, H. F., Rhame, F. S., Balfour, H. H., Jr., & Osterholm, M. T. (1989). Performance characteristics of serologic tests for Human Immunodeficiency Virus type I (HIV-I) antibody among Minnesota blood donors. Public health and clinical implications. Annals of Internal Medicine, 110, 617±621. Mann, J., Tarantola, D. J. M., & Netter, T. W. (1992). A global report: AIDS in the world. New York: Oxford University Press. Mason, H. R. C., Marks, G., Simoni, J. M., Ruiz, M. S., & Richardson, J. L. (1995). Culturally sanctioned secrets? Latino men's nondisclosure of HIV infection to family, friends, and lovers. Health Psychology, 14, 6±12. Milanese, G., Abeni, D., Cancelli, A., Brancato, G., Fabrizi, E., Borgia, P., Perucci, C. A., & Rocchi, G. (1997). Heterogeneity of home care assistance needs of people with AIDS. AIDS Care, 9, 27±33. Millan F., & India Ivory, L. (1994). Group therapy with the multiply oppressed: Treating Latino, HIV-infected injecting drug users. GROUP, 18, 154±166. Morin, S. F. (1991). Removing the stigma: Lesbian and gay affirmative counseling. The Counseling Psychologist, 19, 245±247. Nichols, S. E. (1985). Psychosocial reactions of persons with the acquired immunodeficiency syndrome. Annals of Internal Medicine, 103, 765±767. Nord, D. (1996). The impact of multiple AIDS-related loss on families of origin and families of choice. The American Journal of Family Therapy, 24, 129±144. Osmond, D. H. (1994). Trends in HIV disease survival time. In P. T. Cohen, M. A. Sande, & P. A. Volberding (Eds.), The AIDS knowledge base (2nd ed., pp. 1.3.1±1.3.7). Boston: Little, Brown. Pearlin, L. I., Mullan, J. T., Aneshensel, C. S., Wardlaw, L., & Harrington, C. (1994). The structure and functions of AIDS caregiving relationships. Psychosocial Rehabilitation Journal, 17, 51±67.

Pomeroy, E. C., Rubin, A., & Walker, R. J. (1995). Effectiveness of a psychoeducational and task-centered group intervention for family members of people with AIDS. Social Work Research, 19, 142±152. Pomeroy, E. C., Rubin, A., & Walker, R. J. (1996). A psychoeducational group intervention for family members of persons with HIV/AIDS. Family Process, 35, 299±312. Pryor, J. B., Reeder, G. D., Vinacco, R., & Kott, T. L. (1989). The instrumental and symbolic functions of attitudes towards persons with AIDS. Journal of Applied Social Psychology, 19, 377±404. Radkowsky, M., & Siegel, L. J. (1997). The gay adolescent: Stressors, adaptations, and psychosocial interventions. Clinical Psychology Review, 17, 191±216. Stowe, A., Ross, W., Wodak, A., Thomas, G. V., & Larson, S. A. (1993). Significant relationships and social supports of injecting drug users and their implications for HIV/AIDS services. AIDS Care, 5, 23±33. Takigiku, S. K., Brubaker, T. H., & Hennon, C. B. (1993). A contextual model of stress among parent caregivers of gay sons with AIDS. AIDS Education and Prevention, 5(1), 25±42. Tehan, C. (1991). The cost of caring for patients with HIV infection in hospice. AIDS in the Hospice Community, 7, 41±59. Trezza, G. R. (1994). HIV knowledge and stigmatization of persons with AIDS: Implications for the development of HIV education for young adults. Professional Psychology: Research and Practice, 25, 141±148. Tsiantis, J., Anastasopoulos, D., Meyer, M., Panitz, D., Ladis, V., Platokouki, N., Aroni, S., & Kattamis, C. (1990). A multi-level intervention approach for care of HIV-positive haemophiliac and thalassaemic patients and their families. AIDS Care, 2, 253±266. Turner, H. A., & Catania, J. A. (1997). Informal caregiving to persons with AIDS in the United States: Caregiver burden among central cities residents eighteen to fortynine years old. American Journal of Community Psychology, 25, 35±59. USPHS/IDSA Prevention of Opportunistic Infections Working Group (1995). USPHS/IDSA guidelines for the prevention of opportunistic infections in persons infected with the Human Immunodeficiency Virus: Disease-specific recommendations. Clinical Infectious Diseases, 21(Suppl. 1), S32±S43. Wadland, W. C., & Gleeson, C. J. (1991). A model for psychosocial issues in HIV disease. Journal of Family Practice, 33, 82±86. Wardlaw, L. A. (1994). Sustaining informal caregivers for persons with AIDS. Families in Society, 75, 373±384. Winiarski, M. G. (1997). HIV mental health for the 21st century. New York: University Press.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

9.12 Families of Individuals with Developmental Disabilities OLIVER C. MUDFORD and GILL McGRANE University of Keele, UK 9.12.1 INTRODUCTION

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9.12.2 PSYCHOLOGICAL THERAPIES FOR FAMILY MEMBERS

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9.12.2.1 Guilt and Self-blame 9.12.2.2 Stress Management and Coping Skills 9.12.2.3 Inclusion of Psychological Interventions in Family Support Programs

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9.12.3 BEHAVIORAL INTERVENTIONS WITH FAMILY MEMBERS AS THERAPISTS

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9.12.3.1 Characteristics of Developmental Disorders with Mental Retardation 9.12.3.2 Importance of Behavioral Deficits and Problems for Families 9.12.3.3 Characteristics of the Behavior Analytic Approach 9.12.3.4 Outcomes of the Behavioral Approach 9.12.3.5 Characteristics of Families Who Have Benefited Most from Behavioral Training 9.12.3.6 Basic Behavioral Skills Taught to Families: Target Behaviors for Families 9.12.3.7 Which Family Members are Taught? 9.12.3.8 Which Teaching Formats are Families Taught to Use? 9.12.3.9 How are Basic Behavioral Skills Taught by Professionals to Families? 9.12.3.10 Teaching Parents to Manage Problem Behaviors 9.12.3.10.1 Timeout as a standard component in parent training programs 9.12.3.10.2 The least intrusive treatments imperative 9.12.3.10.3 One model for evaluating the least intrusive treatment 9.12.3.10.4 An even less intrusive treatment? 9.12.3.10.5 Treatment recommendations should be based on functional assessment 9.12.3.10.6 Should errorless compliance training replace CMT in parent training? 9.12.3.11 Families and Insufficiently Validated Treatment Recommendations

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9.12.4 CONCLUSIONS

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9.12.5 REFERENCES

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for their child with disabilities and also places children with developmental disabilities at risk of abuse and neglect (Lutzker, Campbell, Harrold, & Huynen, 1992). For example, some research suggests that such stressed families have higher rates of divorce and lower rates of remarriage (Singer & Irvin, 1990), and less marital satisfaction, psychological well-being, and social support than families of children without disabilities (Friedrich & Friedrich, 1981). Other problems which have been identi-

9.12.1 INTRODUCTION It is generally recognized that the demands of caring for a child with disabilities can place families under stress which is likely to have an adverse effect on relationships within and outside the family. This stress exceeds that reported by parents of nondisabled children and may be chronic (Dyson, 1993; Flynt, Wood, & Scott, 1992). Chronic stress on families can result in their seeking out-of-home placement 183

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fied are social isolation related to the negative reactions of others, the unavailability of social support and respite care, and limited financial resources as a result of the cost of caregiving, and the restrictions that caregiving places on parents' ability to work. Families may experience considerable fatigue, strain, and distress as a result of their child's behavior problems or the level of physical care that the child may need (Tausig, 1985). The need to arrange family activities and schedules to accommodate the medical, physical, and emotional needs of a disabled child can place further restrictions on the ability of the family to function normally. Research on family stress has tended to give a negative perception of family functioning by concentrating on dysfunctions (Singer & Irvin, 1990). However, professionals who interact and advise families may discover that there are additional problems beyond the original reason for referral of the parent or, more likely, the child. Family responsibility for a member with disabilities can extend to a lifelong role involving the whole family (Singer, Irvin, Irvine, Hawkins, & Cooley, 1989; Smith, Tobin, & Fullmer, 1995). Due to decreased mortality, improved healthcare, and the changes from institutional to community-based services, older parents increasingly are having to be involved in lifetime planning, even when the family member with disabilities is not living at home (Griffiths & Unger, 1994). For example, a recent survey of 140 adult siblings having a brother or sister with disabilities found that 36% expressed an intention to remain involved to the extent that they would eventually live together (Krauss, Seltzer, Gordon, & Friedman, 1996). The presence of a child with developmental disabilities in the family may affect individual family members differentially. For example, mothers and fathers of a child with disabilities can significantly differ on psychological variables, with mothers often reporting significantly more negative effects (Beckman, 1991; Kravetz, Nativitz, & Katz, 1993). Dyson (1993) reported that family relationships were the most consistent factor that influenced parental stress which was not found to be the case for families of children without disabilities. This suggests that primary caregivers of children with disabilities expect greater levels of familial support than those of children without disabilities which may reflect the absence of extended networks of informal social support that are associated with decreased stress (Beckman, 1991). A comparison of needs between mothers and fathers of children with disabilities showed mothers as expressing significantly more needs than fathers (Bailey, Blasco, & Simeonsson, 1992). In

particular, a need to have more time to themselves, for help in explaining their child's disability to others, and help with child care. Furthermore, they expressed more interest in having opportunities to meet and interact with other parents (Bailey et al., 1992). As with most of the research on family characteristics, the results with regard to siblings are conflicting (e.g., Lobato, Faust, & Spirito, 1988). The effects of a family member with disabilities on their siblings have been the subject of recent research. For example, on a variety of ratings of psychological adjustment by the siblings of 19 children with autism, 20 children with Down's syndrome, and 20 children without disabilities, only on the Child Behavior Checklist (completed by mothers) were significant differences found (Rodrigue, Geffken, & Morgan, 1993). However, none of the grouped results were outside the normal range. Rodrigue et al. (1993) noted that these results are contrary to commonly held beliefs. However, they cited other research supporting the view that siblings may well not experience poor psychological adjustment. These findings are consistent with those reviewed by Lobato et al. (1988) that included chronically ill as well as siblings with developmental disabilities. The effect on and of other family members has also received research attention. For example, Hornby and Ashworth (1994) assessed the amount of help and emotional support given by grandparents to 25 parents who had children with severe disabilities. Although 54% of grandparents provided little or no support, only 22% of parents reported that they would have liked more support. This survey was conducted in England and, compared with North American studies, levels of grandparental support were relatively low. Recent American research found that support from grandparents was positively correlated with family adjustment (Sandler, Warren, & Raver, 1995). The recognition of the highly complex interactions between child characteristics, intrafamilial relationships, social and financial resources, environmental demands, and lifecycle transitions, has encouraged researchers to take an ecological perspective. In this model, the family is viewed as a unit consisting of multiple interacting elements in contrast to focusing on one element, such as the target child or mother (e.g., Lutzker et al., 1992; Sanders, 1992; Singer & Irvin, 1990). Many of the elements of an ecological approach do not constitute psychological interventions but may have psychological sequelae. An example of this concerns the costs of caring for a family member who is disabled (Fujiura, Roccoforte, & Braddock, 1994). For example, Herman (1994) and

Psychological Therapies for Family Members Herman and Thompson (1995) reported that provision of a monthly cash subsidy increased parents' access to services such as respite care, professional support services, and parent support services. These supports in turn might be expected to have an impact upon psychological functioning within the family.

9.12.2 PSYCHOLOGICAL THERAPIES FOR FAMILY MEMBERS In this section, we discuss interventions that were specifically targeted to the psychological distress experienced by parents. These interventions were not designed to change the behaviors of the family member with developmental disabilities.

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monstrated. ªShouldº statements are believed to be particularly guilt-producing and parents were taught should-removal strategies, while reattribution taught parents to accept some responsibility for negative events but not all the blame. Finally, faulty schemas were addressed by reinterpreting and restructuring them into realistic and attainable goals. Later sessions concerned issues such as control, misattributions concerning explanation of events, and parental schemas in order to provide parents with adaptive strategies that enabled them to maintain a sense of perceived control and reduce their need to self-blame. Results of the study showed that self-blame, guilt, internal negative attributions, automatic thoughts, and depression were significantly reduced.

9.12.2.2 Stress Management and Coping Skills 9.12.2.1 Guilt and Self-blame Families of children with disabilities often suffer from excessive amounts of guilt and selfblame (Nixon & Singer, 1993). In the absence of a clear causal explanation for their child's disability, as is often the case in diagnoses of mental retardation, parents search for an explanation which may result in self-blame. We suspect that some of the causes of guilt may stem from psychiatric opinion in the 1950s that attributed the etiology of some developmental disorders to parental personality characteristics. While these views no longer have credence in modern psychiatry, there may be residual negative attitudes among the general public towards parents resulting from these earlier professional views. Nixon and Singer (1993) evaluated the use of cognitive restructuring as a means of changing self-blaming attributions. Their study included parents of children having developmental disabilities in the moderate to profound range. Parents were randomly assigned to either a treatment or a control group. One two-hour treatment session of cognitive therapy per week took place over a period of five weeks, containing a lecture, group discussion, and small-group exercises. The first treatment session introduced a cognitive model of emotions based on the assertion that people can change their feelings by changing their thinking. The second session introduced strategies for changing cognitive distortions and automatic thoughts. Parents' awareness of cognitive distortions and automatic thinking was facilitated by daily monitoring of their thoughts, and the links between selfblame, guilt, and depression with cognitive distortions and automatic thoughts were de-

Stress management training was evaluated by Singer, Irvin, and Hawkins (1988) in a study with 36 parents of children with severe handicaps. They were randomly assigned to either a treatment group or a waiting-list control group. The treatment consisted of one, two-hour class per week for eight weeks. The classes took the form of lecture, demonstration, and discussion during which three techniques were taught: (i) self-monitoring of stressful events and physiological reactions to them; (ii) muscle relaxation skills; and (iii) modification of cognitions associated with distress. Self-monitoring involved teaching the parents to recognize their own symptoms of stress and to identify the events which triggered those symptoms. Homework assignments required parents to assess their tension levels three times a day and to note any specific event which seemed to precipitate increased tension. Physiological symptoms of stress, such as headaches, insomnia, and indigestion, were also noted. Various stages of muscle relaxation were taught, progressing from a long form (25±30 min) to a very short form that could be used at work and in domestic situations where it was not possible to avoid the stressful event. To learn cognitive modification skills, parents were required to note their thoughts at times when they were feeling particularly tense. Parents were taught to use structured diaries to recognize thoughts which were exaggerated or distorted, and to think in more realistic terms. Homework assignments and class demonstrations provided opportunities for parents to practice each newly acquired skill and encouraged generalization to the home environment. The results of the study indicated that stress management training did prove to be effective.

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9.12.2.3 Inclusion of Psychological Interventions in Family Support Programs We do not know whether guilt reduction has been included in most parent support programs, however, stress management and coping skills training has been incorporated into a comprehensive set of support services, including provision of case management, respite care, and behavioral parenting skills training (Singer et al., 1989). Mothers who received stress management training in addition to other services were less depressed and anxious up to a year following the multicomponent intervention. Given that the majority of parents do not experience excessive stress, we would have to question the automatic inclusion of stress management training in programs for helping parents. In the Lutzker et al. (1992) model for family support systems, parents who have particular need of cognitive or cognitive-behavioral interventions have the opportunity to receive such therapies. Included are stress reduction, including relaxation training and/or anger control management, and problem-solving skills training. These options are in addition to training in providing routine care, behavioral pediatrics, and behavioral parenting skills. This model may be more economical and less intrusive for parents because only the components considered necessary are provided. Similarly, in another comprehensive family intervention model, Sanders and Dadds (1993) described what can be viewed as a least intrusive and most economical approach to helping families whose children have problem behaviors. Psychological intervention for parents is provided only if necessary, and usually in the context of helping to increase the likelihood of success of a child management program.

9.12.3 BEHAVIORAL INTERVENTIONS WITH FAMILY MEMBERS AS THERAPISTS 9.12.3.1 Characteristics of Developmental Disorders with Mental Retardation Children and adults with mental retardation have deficits in two or more of the following skill domains: communication, self-care, self-direction, social skills, domestic (home living), functional academics, work, leisure, health, safety, and use of community resources. These areas of deficit define mental retardation, provided the deficits occur with an IQ of less than 70, in the DSM-IV classification system (American Psychiatric Association, 1994) or an

IQ of less than 75 as in the American Association on Mental Retardation definition (Luckasson et al., 1992). In addition, significant behavioral problems (e.g., self-injury, aggression to others, repetitive stereotypies, and property destruction) may be exhibited by people with mental retardation. Current estimates of the prevalence of such problems range between 20 and 40% (Einfeld & Aman, 1995).

9.12.3.2 Importance of Behavioral Deficits and Problems for Families The significance of behavioral deficits and problems for families are highlighted by Bromley and Blacher (1991) in a study into the reasons for parents seeking out-of-home residential services for their children with severe mental retardation. The families of 63 children rated the degree of influence of 21 variables in their decision for out-of-home residential services. The three variables which were rated highest in being a strong or very strong influence on the placement decision were day-to-day stress (81%), level of functioning of their child (75%), and behavior problems (60%). It seems likely that significant deficits and problems contributed to the reported levels of daily stress in families. Tausig's (1985) study included 64 families that had sought residential placement for their young family member with disabilities. Problem behaviors were the strongest predictor for seeking placement, and they were more important predictors than the level of retardation. Therefore, families generally welcome interventions that change behaviors of their children with developmental disabilities, for the benefit of the children and their families.

9.12.3.3 Characteristics of the Behavior Analytic Approach Interventions to change behaviors either increase the rate of appropriate behavior which already occurs, teach new desirable behaviors which do not occur, or reduce the frequency and/or intensity of problem behaviors. Interventions which successfully change behaviors by altering the naturally occurring environmental antecedents and consequences are the procedures of applied behavior analysis (ABA). This approach was formerly known as behavior modification, and was based on operant laboratory findings in the experimental analysis of behavior. There is more to ABA than behavior modification procedures because it is not merely a successful technology for changing

Behavioral Interventions with Family Members as Therapists behavior. Analysis of the maintaining variables in baseline and of the intervention (independent) variables responsible for behavior change in individuals is a defining characteristic of ABA. These analytic skills include accurate measurement of behaviors of the individual and of that individual's social and physical environment and single-subject experimental designs. Regarding family members' involvement in changing behavior, Graziano and Diament (1992) highlight the differences between the traditional child psychotherapy approach and that of psychologists guided by the ABA paradigm. Whereas the traditional approach involved psychologist±child interactions almost exclusive of family involvement, the ABA approach is for the psychologist to teach family members to act as therapists, that is, to become the agents of change for the behaviors of their family member with developmental disabilities. A review of all parent training research published between 1975 and 1990 identified the behavioral approach as most common, outnumbering all other approaches combined by a ratio of 9:1 (Rogers Wiese, 1992). The child behaviors targeted for change through family-mediated behavioral interventions have been numerous. Some common examples are provided. Skill deficits addressed include language, especially with autistic disorder (e.g., Laski, Charlop, & Schreibman, 1988), social skills (e.g., Strain & Danko, 1995), self-care (e.g., Kashima, Baker, & Landen, 1988), play (e.g., Moran & Whitman, 1991), and independent walking (Robbins & Dunlap, 1992). Behavioral problems targeted have included aggression (e.g., Niemeyer & Fox, 1990) and oppositional behaviors, that is, tantrums, screaming, and refusal (Sanders & Plant, 1989). A common difficulty reported by parents has been failure of their children to follow their instructions, which can be viewed as either a deficit in compliance or a problem with noncompliance. This has been one of the primary reasons for referral by families for behavior change services for children with and without developmental disorders. The potential advantages of family-mediated behavior therapy include: behavior is changed in a person's natural environment (settings and people), leading to the likelihood of improved maintenance and generalization of behavior change; generalized use by families of behavior change procedures beyond the initial reason for learning them; increased satisfaction for family members from successful outcome through their own efforts; reduction in stress associated with the increase in skills and/or reduction of problem behaviors; and increased cost-effectiveness (Graziano & Diament; 1992).

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9.12.3.4 Outcomes of the Behavioral Approach Concerning the effectiveness of parent training in ABA procedures, two outcome measures are most pertinent: (i) change in parent behavior, that is, the extent to which parents learned to perform the procedures taught; and (ii) change in child behavior, that is, whether parent training affected the child's behavior. Comprehensive reviews of the outcomes of parent behavioral training have concluded that the training of family members to act as therapists/trainers for their children provides benefits to both more often than not (see Graziano & Diament, 1992), even when the parents trained have developmental disabilities themselves (see Feldman, 1994, for a review). On the other hand, reviews of the methodology in parent training research have suggested that caution should be exercised in the interpretation of, and extrapolation from, the majority of such research (e.g., Rogers Wiese, 1992). In general, when the children of parents-in-training have developmental disabilities, desired parent behavior change is reported more often than desired change in their children (Graziano & Diament, 1992). A recent example was provided by Paisey, Fox, Curran, Hooper, and Whitney (1991) in which the mother of an 11-year-old girl with autism was unsuccessful in her attempts to reduce aggression using differential reinforcement and required relaxation. The combination of procedures was observed to be applied correctly by the mother, but was significantly effective only when conducted by trained staff in the family home. That is, the mother learned to perform the procedures and was consistent in their application, but they did not work for her. A recent counterexample, reporting two successes at reducing aggressive behavior with parental implementation of differential reinforcement, was provided by Niemeyer and Fox (1990). Considering that production of truly socially significant improvement in individuals with profound disabilities (Reid, Phillips, & Green, 1991) or autism (McEachin, Smith, & Lovaas, 1993) has not been demonstrated consistently by behavior analytic researchers, yet it is not surprising that parental efforts are not always totally successful even if they have been trained adequately to use state-of-the-art behavioral procedures. This suggests that a realistic, but not pessimistic, view of potential behavioral gains should be communicated to families based on a thorough assessment of the child and of the intervention research literature. Maurice (1996) stated that parents can value (i.e., be reinforced for their training) the attainment of even small gains in their disabled children's skills. That is,

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parents need not, and should not, be promised unrealistically that behavioral methods will cure their child to become involved in training. Generalization of parents' teaching skills from trained to novel tasks sometimes occurs without the addition of specific programming for generalization by the trainer (e.g., Bruder, 1987; Moran & Whitman, 1991). More often, generalization to other behaviors, settings, and siblings has not been spontaneous (Sanders & James, 1983) and requires deliberate promotion by the trainer. For example, Cordisco, Strain, and Depew (1988) found that one of three trained parents of children with autism generalized their learned behavioral skills. The data on maintenance of skills by parents are also equivocal. For instance, Forehand et al. (1979) followed up seven parents one year after their training had been completed and found that five continued to employ all learned skills. Potential disadvantages have been suggested when behavior change agents are family members rather than a professional behavior analyst. One is that family stress may be increased by demands of carrying out behavioral teaching procedures. This question was addressed by Baker, Landen, and Kashima (1991) with 39 of 49 families who had completed a training program that focused on teaching self-care skills to their children. Questionnaires measuring depression, stress, and family adaptation and cohesion were administered before training and one year after training. There were small but significant decreases in grouped scores for depressive symptoms and stress, and an increase in family adaptation score. At present, there are insufficient data to suggest that parent training increases the burden on parents with children who have developmental disabilities.

9.12.3.5 Characteristics of Families Who Have Benefited Most from Behavioral Training Reviewers of parent behavioral training research have indicated that desired behavior change in both parents and children is more likely when families have particular advantages (Frankel & Simmons, 1992; Graziano & Diament, 1992; Griest & Forehand, 1982; Webster-Stratton & Hammond, 1990). Higher socioeconomic status, a wide range of social contact and support, absence of psychopathology (particularly depression and psychosis), membership of the ethnic majority, absence of negative life crises and environmental stress, and an intact family low on marital distress have been found to be predictors of success. Families without some of these advantages may

drop out of training (Frankel & Simmons, 1992), or they may not access training that may be available, or they may complete training but not benefit. 9.12.3.6 Basic Behavioral Skills Taught to Families: Target Behaviors for Families What particular behavioral skills are taught to families with children who have, or are at risk of, developmental disabilities? For increasing behavioral repertoires, basic behavioral procedures are taught. Providing clear verbal prompts, hierarchies of prompting, contingent reinforcement, and shaping continue to be common elements across parent training programs (e.g., Harrold, Lutzker, Campbell, & Touchette, 1992; Moran & Whitman, 1991; Robbins & Dunlap, 1992; Sanders & Dadds, 1993). Basic procedures for reducing problem behaviors commonly include timeout (e.g., Harrold et al., 1992; Sanders & Dadds, 1993), physical guidance (Robbins & Dunlap, 1992), extinction, physical restraint, and differential reinforcement (Moran & Whitman, 1991). It should be noted that the basic procedures listed are examples of the technology of ABA. Generalizable procedures are taught, but the analytic skills component seems not to be included generally. The teaching and/or training of skills to families may be viewed as a cookbook approach. At least some parents who have been exposed to the analytic nature of ABA advocate that the analytic aspect should be emphasized (e.g., Maurice, 1996). 9.12.3.7 Which Family Members are Taught? The majority of studies of behavioral training in intact families with children with developmental disorders have focused on mothers as primary carers (Singer & Irvin, 1990). Although some reports do not differentiate between parents, others can be examined to illustrate the relatively low involvement of fathers (e.g., Kashima et al., 1988; Schreibman, Kaneko, & Koegel, 1991). However, fathers have been taught successfully in generalized behavioral skills, and there is some evidence that fathers may learn skills incidentally through a modeling effect from a trained mother (Horton, 1984). Horton's review of fathers' involvement in parent training was mainly of studies in which children with problem behaviors did not have additional disabilities. Although there may be an assumption that fathers ought to (or even must) be included in training, this may not be necessary for successful outcome for the child. Horton suggested that a husband's support of

Behavioral Interventions with Family Members as Therapists his wife's skill acquisition may be a more important determinant of success than being directly trained himself. Also, children have been taught to teach their sibling with disabilities (e.g., Coe, Matson, Craigie, & Gossen, 1991). 9.12.3.8 Which Teaching Formats are Families Taught to Use? The discrete trials format involves repeated presentation of learning trials in discrete teaching sessions (Robbins & Dunlap, 1992). This format has been the one most often used to teach parents until relatively recently (Petronko, Harris, & Kormann, 1994). Some dissatisfaction has been expressed by parents and professionals (e.g., Laski et al., 1988; Singer & Irvin, 1990) with the artificiality and demands of the discrete trials approach. In contrast, the incidental teaching format requires therapists to contrive or identify teaching opportunities that occur more or less naturally during the course of regular activities and enable the use of more natural reinforcers (Hart & Risley, 1975). Parents may well prefer the more naturalistic format which has been incorporated into several comprehensive programs variously described as the natural language paradigm (e.g., Laski et al., 1988), pivotal response training (e.g., Pierce & Schreibman, 1995), milieu teaching (e.g., Hemmeter & Kaiser, 1994), and planned activities training (e.g., Harrold et al., 1992; Sanders & Dadds, 1993). In studies that have compared the two approaches, autistic children (Koegel, Koegel, & Surratt, 1992; Mirandalinne & Melin, 1992) and adults with severe/profound mental retardation (Elliot, Hall, & Soper, 1991) have gained language skills at least as well with the naturalistic format. Parents have been trained successfully to use the naturalistic methods (e.g., Alpert & Kaiser, 1992; Hemmeter & Kaiser, 1994; Koegel, Bimbella, & Schreibman, 1996; Schreibman et al., 1991). The more naturalistic approaches appear to have significant advantages. For example, both children and parents have been found to show more behavioral expressions of positive affect while training is conducted (Schreibman et al., 1991) and outside specific training times (Koegel et al., 1996); children exhibit less disruptive behavior (Koegel et al., 1992); and there is some evidence of greater generalization (Elliot et al., 1991; Mirandalinne & Melin, 1992). However, evidence of comprehensive and maintained gains comparable to those demonstrated for the more traditional approach (McEachin et al., 1993) has not been reported. Although the majority of research in the 1990s with parents as trainers for their children

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with developmental disabilities has emphasized and found benefits in the more naturalistic approach, we cannot recommend that the teaching of the discrete trials format to families be discarded yet for three main reasons. First, some well-validated and replicable child teaching programs which include extensive family participation prescribe this format, at least for initial training (e.g., Lovaas, 1987; Lovaas & Buch, 1997; McEachin et al., 1993). Second, given that the basic behavioral procedures are common across teaching formats, parents may find it easier to learn these within a discrete trials format before their incorporation into regular activities. Third, acquisition of new skills by a child may be faster when massed trials are employed, which could be expected to provide early positive encouraging feedback to families on their successful teaching (Mirandalinne & Melin, 1992). However, it may be advisable to move from discrete trials to a more naturalistic format once the basic behavioral skills are demonstrated by parents and some child learning has been shown to occur. A further potential disadvantage of training parents to teach their children using behavioral methods has been mooted. Family members may come to view themselves and behave primarily as therapists or trainers rather than maintain their special role as mother, father, sister, and brother (Singer & Irvin, 1990). It does not seem to us that these roles are necessarily mutually exclusive, although there may be some formats for parents to be therapists that capitalize on a combined role better than others. For example, Schreibman et al. (1991) showed five-minute videotape segments of 24 parents conducting behavioral training for increasing language skills in their children with autism. Viewers were 120 undergraduates who were naive with respect to the study. The students rated levels of parental affect, specifically enthusiasm, interest, and happiness exhibited by the parent while training. The students judged that positive affect on all these dimensions was exhibited by parents when a more naturalistic child training method (i.e., pivotal response training) was being used by the parents. Ratings of affect were significantly lower when parents were shown using a discrete trial training format. In another study, Koegel et al. (1996) found that ratings of parental affect from videotapes of extratraining family interactions were positive if families had been taught to use the more naturalistic teaching paradigm. In contrast, families that had received training to use the discrete trial format were rated as showing negative affect in the same setting. Studies of this type can be seen as approaching the

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question about parental behavior while interacting with their child according to a behavioral training protocol. The results imply that naturalistic formats for training children appear more parent-like. Koegel et al. suggest that the more naturalistic the format, the more likely the program may reduce family stress in everyday life.

9.12.3.9 How are Basic Behavioral Skills Taught by Professionals to Families? Methods that have been used, either alone or in various combinations, include parent training manuals (Bernal & North, 1978), group training (Hornby & Singh, 1983), and individualized training (e.g., Ducharme & Popynick, 1993; Robbins & Dunlap, 1992). All of these teaching methods have been shown to be effective in some dimensions with some parents in one or more studies. Written material alone may be most useful when validated manuals address specific deficits or problems, although some parents have learned how to teach self-help skills generalizably from manuals alone (Bernal & North, 1978). There seems to be conflicting data on this particular issue. A study required 19 parents to read sections of the same publication as well as attend four workshops on those readings presented by experienced presenters (Kashima et al., 1988). Parents, as a group, did not increase their scores on an analogue teaching simulation test more than a control group who had received no training. The conclusion must be that some parents learn (i.e., change their teaching behaviors with respect to their children's deficits in self-care skills) from books/ manuals, and some do not. The study also assessed the effects of teaching parents in groups using videotapes of experienced presenters' workshops. Group exercises and discussions facilitated by inexperienced group leaders were interspersed. Little difference was found between the two groups. Although knowledge of behavioral procedures increased for both groups, improvements in demonstrable application did not exceed gains in the control group. Nevertheless, we expect and encourage further studies of the use of videotape as a means to increase parents' knowledge and skills. If training tapes can be produced that are successful, both for parents and their children, this could become the presentation format of choice as ongoing professional involvement would be minimized. Reviews of studies comparing of the effects of group and individual instruction to parents

suggest (Hornby & Singh, 1983) or recommend (e.g., Baker, 1989; Graziano & Diament, 1992) that reported outcomes favor the group teaching format. The results are similar across the formats so recommendations are based on other considerations. Group teaching is more costeffective, and the opportunity for social contact with parents in similar situations may be beneficial. Hornby and Singh (1983) caution that some parents may prefer not to be part of a group. These parents may not accept the opportunity to receive training if the group format is the only available option. Alternatively, they may not benefit through dropping out before successful completion of training, especially when they have depression or low socioeconomic status (Forehand, Middlebrook, Rogers, & Steffe, 1983). A further important consideration is the ethnic and linguistic composition of groups for parent training. For example, Rueda and Martinez (1992) described a group education and training forum for parents of children with developmental disabilities in the US for whom Spanish was their first language. The authors mentioned that groups for ethnic Korean and Chinese parents have also been established. It is not clear whether the content of training included ABA methods, however, the availability of culturally sensitive presentation would be expected to increase the acceptability of group training to parents who may not otherwise access services (Rueda & Martinez, 1992). The effective components for teaching parents to employ basic behavioral skills have been identified, whether parents are taught in groups or individually. The usual order in which these components are provided is: brief instructions in a skill; modeling of the skill by the trainer; behavioral rehearsal (i.e., role play with the parent demonstrating the skill and differential feedback on role play performance by trainer); and differential feedback by trainer on parents' performance of the skill with their children, either in a clinical setting or preferably in the families' natural environments. Thus, active participation by parents in training, rather than passive receipt of information, may be a necessary component required to obtain behavior change. Bearing this in mind, designers of future video-based training efforts may have to include effective prompting strategies to promote active learning. An innovative approach to delivery of parent training was reported recently by Neef (1995), which replicated and extended earlier work by Bruder (1987). A pyramidal parent training method for teaching functional skills to children with autism was evaluated. First, the

Behavioral Interventions with Family Members as Therapists procedure involved professional training of five parents in the use of generalizable behavioral skill-training methods, that is, task analysis, defining target behaviors, selecting opportunities for teaching during regular household routines, selecting materials, presenting instructions to children, providing prompts, delivering consequences, and recording data. These parents were described as tier 1 in the pyramid. Second, when the tier 1 parents had achieved mastery, they taught the methods to another parent (tier 2). Third, four tier 2 parents subsequently taught the methods to one tier 3 parent each. Parents who were trained by other parents demonstrated acquisition of child-skill training methods to levels of mastery comparable with those shown by 12 parents who had been trained by a master's level professional. Although all parents' teaching skills increased, seven of 26 children did not show improvements on the skills targeted for increase. Future replications should attempt to assess the following: the extent to which trained teaching skills are used by parents in their homes; the acceptability of peer training, both by trainer/parents and trainee/parents; and, why some children do not apparently benefit.

9.12.3.10 Teaching Parents to Manage Problem Behaviors So far we have discussed the often successful training of families to increase their use of potentially generalizable skills to reduce the behavioral deficits that define mental retardation and to reduce or possibly avert the development of some problem behaviors by the use of basic behavioral techniques. Methods for reducing deficits have not changed markedly in clinical or family settings over the last three decades, although there is more emphasis now in research and in parent training on adapting operant techniques so that antecedent stimuli and reinforcers become more naturalistic, as discussed earlier. The situation regarding reduction of problem behaviors is quite different. There has been considerable controversy regarding the inclusion of punishment in programming for reduction of problem behaviors (Repp & Singh, 1990; Singh, 1997). There are strong beliefs in psychology concerning the inclusion in treatment recommendations of any practices that can be considered coercive (e.g., Sidman, 1989). Coercive therapeutic interventions can be viewed to include the use of punishment and negative reinforcement procedures and physical guidance that is resisted by the client.

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9.12.3.10.1 Timeout as a standard component in parent training programs Timeout continues to be taught routinely as one component in training programs for parents to enable them to reduce common problem behaviors (e.g., Lutzker, 1992; Sanders & Plant, 1989). All these studies used a version of child contingency management training (CMT), a component of a comprehensive behavioral family intervention system developed by Sanders and Dadds (1993). It should be emphasized that behavioral family intervention has other components in which parents are trained, for example, planned activities training (Sanders & Dadds, 1982). Although the procedures were developed and researched with children without developmental disabilities with behavior problems, these studies have demonstrated the generalizability of the parent training methods and content to children with disabilities. The CMT prescription for managing noncompliance or disruptive child behavior when it occurs during an activity is, briefly: (i) obtain child's attention; (ii) briefly explain what child was doing wrong; (iii) prompt appropriate behavior; (iv) praise correct behavior if it occurs; (v) if disruptive behavior continues, place child in timeout chair or area; (vi) after two minutes of quiet in timeout, remove child from timeout; (vii) return to activity; and (viii) praise correct behavior when it occurs. What happens if the child resists the timeout procedure? Unfortunately procedures for dealing with this situation have not been fully described in the CMT research. However, Roberts and Powers (1990) describe studies with 36 preschool children who resisted chair timeout for continued noncompliance in a parent implemented program rather similar to CMT. Four backup procedures were assessed: (i) spank twice on the buttocks; (ii) hold, that is, physical restraint; (iii) barrier, that is, seclusion timeout; and (iv) release, that is, child was told that since he or she had decided to leave the chair he or she was obviously ready to behave appropriately. Only spank and barrier were effective with the majority of timeout-resistant children. When the procedures were used at home, 64% of mothers elected to use spank as a backup to timeout. Although the authors cautioned that careful training must be used to prevent misuse, that potential clearly exists. Even though a hierarchy of contingencies, whether it includes spanking or not, may be effective at increasing compliance, it represents escalating coercion, which is best avoided if behavioral research suggests the availability of alternative procedures.

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9.12.3.10.2 The least intrusive treatments imperative Parents have reported high levels of satisfaction with their training to use timeout (McMahon & Forehand, 1983). Some mothers of oppositional children clearly believe that being taught a particular way by a professional to spank their children is acceptable (Roberts & Powers, 1990). However, ABA practitioners and researchers generally subscribe to the view that it is an ethical imperative to evaluate the effects of the least intrusive but likely-effective methods for reducing problem behaviors (Van Houten et al., 1988). The question is to what extent should professionals' recommendations to parents regarding the treatment of their children and training provided to parents be coherent with their own professional practice? 9.12.3.10.3 One model for evaluating the least intrusive treatment The methods demonstrated by Harding, Wacker, Cooper, Millard, and Jensen-Kovalan (1994) with seven children with problem behaviors may provide a model for parental and professional involvement in developing effective treatment. The purpose of the assessment was to determine the least intrusive intervention that was likely to be effective for referred problem behaviors including aggression, destructive behavior, noncompliance, and tantrums. During a 90-minute session at an outpatient clinic, parents were first instructed and then verbally prompted to provide each potentially effective treatment for five minutes in a hierarchy of intrusiveness starting from encouraging their children to choose an activity, a low-intrusion procedure that has been shown to reduce problem behavior in children with developmental disabilities (e.g., Dunlap et al., 1994). Other levels of treatment were added cumulatively until an effective set of components was obtained. These were differential reinforcement with attention for appropriate behavior, differential reinforcement of communication, and, finally, either guided compliance (manual guidance response prompt) or one-minute timeout (standing facing a blank wall). Only one child required guided compliance and none required timeout. Telephone follow-up on six families at six months indicated that parents were highly satisfied with the assessment procedures, had continued to use the treatments identified in the assessment, and they were satisfied with the changes in their children's behaviors. As the authors acknowledged, direct observational measurement of child and parent behavior in

the home would have provided more valid data concerning outcome. 9.12.3.10.4 An even less intrusive treatment? An example of taking a new approach that avoids coercive interactions to reduce a common problem behavior, with mothers as change agents, has been demonstrated by Ducharme and his colleagues (Ducharme et al., 1994; Ducharme & Popynick, 1993; Ducharme & Worling, 1994). Ducharme and Popynick assessed a procedure for errorless learning of compliance with four children with developmental disorders. First, parents rated the frequency with which their children complied with common requests on a four-point scale from ªalmost always compliesº (level 1) to ªrarely compliesº (level 4). Second, the frequencies of compliance for 12 requests at each rated level were empirically evaluated in the families' homes. Following assessment of baseline compliance at each level, the third phase involved training mothers to provide level 1 requests only and to reinforce their child's compliance with praise and/or physical contact (e.g., hugs and kisses). Mothers were taught not to repeat the same request or to provide any consequences for noncompliance. When high (4 80%) and stable levels of compliance had been achieved with level 1 requests, mothers were instructed to introduce level 2 requests gradually, for example, 14 level 1 requests interspersed with seven level 2 requests. In the following session, the proportions of requests at each level were reversed and, in subsequent sessions, even greater densities of the level 2 requests were included until high and stable compliance to these requests were achieved. Likewise, level 3 and level 4 requests were introduced. Problem behaviors reduced markedly when compliance increased. For example, level 4 requests which had been associated with tantrums and aggression on 51% of trials in baseline reduced to 10% following the intervention. Considering that these behaviors were not targeted directly, their reduction showed a valuable side effect of the mother-mediated compliance training. Ducharme et al. (1994) replicated their previous study with four children with developmental disabilities and a nondisabled sibling of two of those, all of whom were referred for lack of compliance. The therapist's input with each mother was reduced from 34 hours in Ducharme and Popynick (1993) to 17 hours, on average, by abbreviating the initial empirical assessment procedure and assessment of intervention. There was no decline in the clinical significance of outcome with these refinements.

Behavioral Interventions with Family Members as Therapists Both studies assessed consumer satisfaction with the intervention. The mean score was 6.3 out of a maximum possible of 7.0, indicating that mothers found the intervention highly satisfactory. The authors note that therapist involvement in errorless compliance training can be implemented with fewer (five or six) sessions either at a clinic or in the family home when a case is not intended to provide research data for publication. 9.12.3.10.5 Treatment recommendations should be based on functional assessment Research on treatment of aberrant behavior that has been based on thorough analysis of the environmental function of individual's problem behavior(s) has increased the range of effective treatments that do not include a punishment or other coercive components (see Singh, 1997). Briefly, reinforcers for aberrant behavior can be classified on two dimensions. One dimension is positive vs. negative reinforcement, that is, occurrence or termination (respectively) of a stimulus following the behavior. The other dimension concerns whether the reinforcing stimulus is external or internal. Behaviors reinforced by internal stimuli are variously named as self-stimulatory behaviors or automatically reinforced behaviors. In the present context we will not consider internal reinforcers further. External positive reinforcers for individuals in some settings (e.g., persons with disabilities in family environments) are usually dependent on other persons for their provision, and these reinforcers can be classified as social (e.g., parental attention, praise, physical contact, etc.) or, at least, socially mediated (e.g., parent provides food or a preferred activity). Identification of the reinforcers for the aberrant behavior leads to treatment recommendations. If an aberrant behavior is positively reinforced, the individual may be taught a more appropriate behavior to access the reinforcer. If negatively reinforced, either the stimulus that terminates following the behavior is removed from the environment or the individual may be taught appropriate behavior to terminate it. The treatments that follow from such individualized assessment of antecedents and reinforcers for problem behavior are themselves individualized. This represents a shift from treatment recommendations based on the form of the behavior, for example, if any child does behavior X, apply treatment component Y. It also increases the complexity of assessment and treatment design. The emphasis on the social and physical environment of the individual with problem behaviors may provoke reassessment of general parent training programs to the

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extent that they are intended to help parents reduce problem behaviors. In other words, parent trainers may view the analytic components of ABA as a necessary inclusion in their programs. There are many considerations for professionals in ABA with respect to educating and/or teaching parents to manage problem behaviors with increasing complexity of professional ªbest practice.º Should, for example, parents be taught to perform functional assessment of problem behaviors and reinforcer assessment? It might be that retrospective reports based on informal parental observation may render these detailed and time-consuming assessments unnecessary. That is, parents can tell professionals accurately what are their children's motivations for problem behaviors and their reinforcers. We are unaware of research into the validity of parental reports on these issues, however, studies have shown that caregiving staff opinions are insufficiently reliable for designing effective and least intrusive interventions. Lack of reliability of staff opinions has been found in the areas of function of problem behavior (e.g., Zarcone, Rodgers, Iwata, Rourke, & Dorsey, 1991) and reinforcers that can be used to increase alternative behaviors (e.g., Green et al., 1988). It is probably unnecessary to teach parents about the whole process of functional assessment, although some parents may find this information useful (e.g., Maurice, 1996). It is unrealistic to expect them to undertake such analyses. However, the parents' role in such assessment has been expanded from providing historical information about problem behaviors to becoming the therapist during such analyses (e.g., Derby et al., 1992). Given that sociallymediated reinforcement is the controlling function for many behaviors, and that parents are likely to be the providers of this reinforcement when the child is at home, it appears vital to include parents in the role of a therapist. In the case of aggressive or noncompliant behaviors, social reinforcers are likely to account for a greater percentage of function, so parents' involvement in assessment of function is even more essential. 9.12.3.10.6 Should errorless compliance training replace CMT in parent training? Given that Ducharme and Popynick (1993) have demonstrated an alternative treatment for parents to use to increase compliance that appears not to include any coercive elements, should we advocate for the termination of parent training programs that teach parents how to use timeout? Given the ethical

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imperative to use the least intrusive treatment, and that timeout and manual guidance are judged as more intrusive than reinforcement, should not errorless compliance training replace CMT as the method of choice for managing disruptive behavior by their children, whether or not the children have disabilities? Despite the apparent success, acceptability, and efficiency of the errorless compliance training programs, its proponents do not recommend the immediate introduction of such innovative procedures into general parent training curricula. Further research is required. First, replication by other researchers is required to determine whether professionals not involved with the origination of the procedures can obtain similar results. Second, further generalizability across children with developmental disabilities, levels of severity of noncompliance, and other parents needs to be established beyond two children in Ducharme and Worling (1994), four in Ducharme et al. (1994), and four in Ducharme and Popynick (1993). Third, the procedures were evaluated in homes. Cross-setting generalizability needs to be established. Parents may find it extremely difficult to avoid higher level requests than currently programmed for training or maintenance in other settings where noncompliance can be even more problematic. In community settings, parents may have difficulty in following the program component requiring that they ignore noncompliance. Fourth, Ducharme and Worling (1994) acknowledge that further research is required to establish further the efficacy of the procedures for ªdon'tº and ªstopº requests. Fifth, maintenance of parent and child behavior beyond four months needs to be assessed. Sixth, comparison of the acceptability of CMT and similar programs with that of errorless compliance training needs to be assessed by parents of children who need such interventions.

9.12.3.11 Families and Insufficiently Validated Treatment Recommendations Psychologists and other professionals should be well aware of an extensive history of strong advocacy for unvalidated methods for remediating deficits and/or reducing problems for people with developmental disorders and their families. Jacobson, Mulick, and Shwartz (1995) discuss how families can be particularly vulnerable to the false promises of insufficiently researched treatments for their children with disabilities. Examples they cite are patterning, gentle teaching, and especially facilitated communication. To these, we would add holding

therapy (see Maurice, 1993, for a personal account of her experience with this treatment) and auditory integration training (e.g., Berkel, Malgeri, & Streit, 1996, for a review of current controversy). Silver (1995) has suggested some other controversial therapies that may be oversold to families, including those based on optometric visual training, cerebellar-vestibular dysfunction, applied kinesiology, tinted lenses, megavitamins, trace elements, and allergic sensitivities. Space does not permit discussion of the individual therapies listed above. Ongoing research may clarify whether any of these treatments have benefit and whether families should be encouraged to learn or purchase these treatments. Until these or any other new procedures can be properly recommended by professionals, families may need advice to protect them from false hopes. One approach to protecting families from ill-founded claims for successful treatment has been to address parent groups on this very issue (Favell, 1996). Parents often welcome presentations on how to distinguish scientifically validated treatments from those for which the research had not been sufficient to justify widespread adoption.

9.12.4 CONCLUSIONS Review of the effects on families of a member with developmental disabilities indicates that parents may have a multitude of problem, some psychological, but others of a social or economic nature. Research on these issues has produced equivocal results, although it has been sufficient to prompt a more ecological approach to providing services to families. That is, more comprehensive services are being developed that facilitate multiple interventions for families, where necessary. These interventions may be targeted at the person with disabilities, or at mothers or fathers or other family members. With respect to psychological interventions, we have reviewed parent behavioral training in more detail as this type of intervention has attracted most research, and it continues to be a cornerstone of service provision. Recent research in this area suggests that continuing efforts to make training by parents of their child with developmental disabilities more naturalistic, while still preserving methods derived from basic operant studies, will be welcomed by families. Early results from studies incorporating more natural antecedents and consequences for desired behaviors suggest that increased benefits for the child and family may result. Such training may reduce parental psychological distress, as well as increase childrens' skills.

References 9.12.5 REFERENCES Alpert, C. L., & Kaiser, A. P. (1992). Training parents as milieu language teachers. Journal of Early Intervention, 16, 31±52. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association. Bailey, D. B., Blasco, P. M., & Simeonsson, R. J. (1992). Needs expressed by mothers and fathers of young children with disabilities. American Journal on Mental Retardation, 97, 1±10. Baker, B. L. (1989). Parent training and developmental disabilities. Washington, DC: American Association on Mental Retardation. Baker, B. L., Landen, S. J., & Kashima, K. J. (1991). Effects of parent training on families of children with mental retardation: Increased burden or generalized benefit? American Journal on Mental Retardation, 96, 127±136. Beckman, P. J. (1991). Comparison of mothers' and fathers' perceptions of the effect of young children with and without disabilities. American Journal on Mental Retardation, 95, 585±595. Berkel, D. E., Malgeri, S. E., & Streit, M. K. (1996). Auditory integration training for individuals with autism. Education and Training in Mental Retardation and Developmental Disabilities, 31, 66±70. Bernal, M. E., & North, J. A. (1978). A survey of parent training manuals. Journal of Applied Behavior Analysis, 11, 533±544. Bromley, B. E., & Blacher, J. (1991). Parental reasons for out-of-home placement of children with severe handicaps. Mental Retardation, 29, 275±280. Bruder, M. B. (1987). Parent-to-parent training. American Journal of Mental Deficiency, 91, 435±438 Coe, D. A., Matson, J. L., Craigie, C. J., & Gossen, M. A. (1991). Play skills of autistic children: Assessment and instruction. Child and Family Behavior Therapy, 13, 13±40. Cordisco, L. K., Strain, P. S., & Depew, N. (1988). Assessment for generalization of parenting skills in home settings. Journal of the Association for Persons with Severe Handicaps, 13, 202±212. Derby, K. M., Wacker, D. P., Sasso, G., Steege, M., Northup, J., Cigrand, K., & Asmus, J. (1992). Brief functional assessment techniques to evaluate aberrant behavior in an outpatient setting: A summary of 79 cases. Journal of Applied Behavior Analysis, 25, 713±721. Ducharme, J. M., Pontes, E., Guger, S., Crozier, K., Lucas, H., & Popynick, M. (1994). Errorless compliance to parental requests II: Increasing clinical practicality through abbreviation of treatment parameters. Behavior Therapy, 25, 467±487. Ducharme, J. M., & Popynick, M. (1993). Errorless compliance to parental requests: Treatment effects and generalization. Behavior Therapy, 24, 209±226. Ducharme, J. M., & Worling, D. E. (1994). Behavioral momentum and stimulus fading in the acquisition and maintenance of child compliance in the home. Journal of Applied Behavior Analysis, 27, 639±647. Dunlap, G., DePerczel, M., Clarke, S., Wilson, D., Wright, S., White, R., & Gomez, A. (1994). Choice making to promote adaptive behavior for students with emotional and behavioral challenges. Journal of Applied Behavior Analysis, 27, 505±518. Dyson, L. L. (1993). Response to the presence of a child with disabilities: Parental stress and family functioning over time. American Journal on Mental Retardation, 98, 207±218. Einfeld, S. L., & Aman, M. (1995). Issues in the taxonomy of psychopathology in mental retardation. Journal of Autism and Developmental Disorders, 25, 143±167.

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Elliot, R. O., Hall, K., & Soper, H. V. (1991). Analog language teaching versus natural-language teaching: Generalization and retention of language-learning for adults with autism and mental retardation. Journal of Autism and Developmental Disorders, 21, 433±447. Favell, J. E. (1996, May). Developmental disabilities and behavior analysis: Can this relationship be saved? Paper presented at the 22nd Annual Convention of the Association for Behavior Analysis, San Francisco, CA. Feldman, M. A. (1994). Parenting education for parents with intellectual disabilities: A review of outcome studies. Research in Developmental Disabilities, 15, 299±332. Flynt, S. W., Wood, T. A., & Scott, R. L. (1992). Social support of mothers of children with mental retardation. Mental Retardation, 30, 233±236. Forehand, R., Sturgis, E. T., McMahon, R. J., Aguar, D., Green, K., Wells, K. C., & Breiner, J. (1979). Parent behavioral training to modify child noncompliance: Treatment generalization across time and from home to school. Behavior Modification, 3, 3±26. Forehand, R., Middlebrook, J., Rogers, T., & Steffe, M. (1983). Dropping out of parent training. Behavior Research and Therapy, 6, 663±668. Frankel, F., & Simmons, J. Q. (1992). Parent behavioral training: Why and when some parents drop out. Journal of Clinical Child Psychology, 21, 322±330. Friedrich, W. N., & Friedrich, W. L. (1981). Psychosocial assets of parents of handicapped and nonhandicapped children. American Journal of Mental Deficiency, 85, 551±553. Fujiura, G. T., Roccoforte, J. A., & Braddock, D. (1994). Costs of family care for adults with mental retardation and related developmental disabilities. American Journal on Mental Retardation, 99, 250±261. Graziano, A. M., & Diament, D. M. (1992). Parent behavioral training: An examination of the paradigm. Behavior Modification, 16, 3±38. Green, C. W., Reid, D. H., White, L. K., Halford, R. C., Brittain, D. P., & Gardner, S. M. (1988). Identifying reinforcers for persons with profound handicaps: Staff opinion versus systematic assessment of preferences. Journal of Applied Behavior Analysis, 21, 31±43. Griest, D. L., & Forehand, R. (1982). How can I get any parent training done with all these other problems going on?: The role of family variables in child behavior therapy. Child and Family Behavior Therapy, 4, 73±80. Griffiths, D. L., & Unger, D. G. (1994). Views about planning for the future among parents and siblings of adults with mental retardation. Family Relations, 43, 221±227. Harding, J., Wacker, D. P., Cooper, L. J., Millard, T., & Jensen-Kovalan, P. (1994). Brief hierarchical assessment of potential treatment components with children in an outpatient clinic. Journal of Applied Behavior Analysis, 27, 291±300. Harrold, M., Lutzker, J. R., Campbell, R. V., & Touchette, P. E. (1992). Improving parent±child interactions for families of children with developmental disabilities. Journal of Behaviour Therapy and Experimental Psychiatry, 23, 89±100. Hart, B., & Risley, T. R. (1975). Incidental teaching of language in the preschool. Journal of Applied Behavior Analysis, 8, 411±420. Hemmeter, M. L., & Kaiser, A. P. (1994). Enhanced milieu teaching: Effects of parent-implemented language intervention. Journal of Early Intervention, 18, 269±289. Herman, S. E. (1994). Cash subsidy program: Family satisfaction and need. Mental Retardation, 32, 416±421. Herman, S. E., & Thompson, L. (1995). Families' perceptions of their resources for caring for children with developmental disabilities. Mental Retardation, 33, 73±83.

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Hornby, G., & Ashworth, T. (1994). Grandparents' support for families who have children with disabilities. Journal of Child and Family Studies, 3, 403±412. Hornby, G., & Singh, N. N. (1983). Group training for parents of mentally retarded children: A review and methodological analysis of behavioural studies. Child: Care Health and Development, 9, 199±213. Horton, L. (1984). The father's role in behavioral parent training: A review. Journal of Clinical Psychology, 13, 274±279. Jacobson, J. W., Mulick, J. A., & Schwartz, A. A. (1995). A history of facilitated communication: Science, pseudoscience, and antiscience. American Psychologist, 50, 750±765. Kashima, K. J., Baker, B. L., & Landen, S. J. (1988). Media-based versus professionally led training for parents of mentally retarded children. American Journal on Mental Retardation, 93, 209±217. Koegel, R. L., Bimbella, A., & Schreibman, L. (1996). Collateral effects of parent training on family interactions. Journal of Autism and Developmental Disorders, 26, 347±359. Koegel, R. L., Koegel, L. K., & Surratt, A. (1992). Language intervention and disruptive behavior in preschool children with autism. Journal of Autism and Developmental Disorders, 22, 141±153. Krauss, M. W., Seltzer, M. M., Gordon, R., & Friedman, D. H. (1996). Binding ties: The roles of adult siblings of persons with mental retardation. Mental Retardation, 34, 83±93. Kravetz, S., Nativitz, R., & Katz, S. (1993). Parental coping styles and the school adjustment of children who are mentally retarded. The British Journal of Developmental Disabilities, 39, 51±59. Laski, K. E., Charlop, M. H., & Schreibman, L. (1988). Training parents to use the natural language paradigm to increase their autistic children's speech. Journal of Applied Behavior Analysis, 21, 391±400. Lobato, D., Faust, D., & Spirito, A. (1988). Examining the effects of chronic disease and disability on children's sibling relationships. Journal of Pediatric Psychology, 13, 389±407. Lovaas, O. I. (1987). Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55, 3±9. Lovaas, O.I., & Buch, G. (1997). Intensive behavioral intervention with young children with autism. In N. N. Singh (Ed.), Prevention and treatment of severe behavior problems: Models and methods in developmental disabilities (pp. 61±86). Pacific Grove, CA: Brooks/Cole. Luckasson, R., Coulter, D. L., Polloway, E. A., Reiss, S., Schalock, R. L., Snell, M. E., Spitalnik, D. M., & Stark, J. A. (1992). Mental retardation: Definition, classification, and systems of supports. Washington, DC: American Association on Mental Retardation. Lutzker, J. R. (1992). Developmental disabilities and child abuse and neglect: The ecobehavioural imperative. Behaviour Change, 9, 149±156. Lutzker, J. R., Campbell, R. V., Harrold, M. E., & Huynen, K. B. (1992). Project Ecosystems: An ecobehavioral approach to families with children with developmental disabilities. Journal of Developmental and Physical Disabilities, 4, 1±14. McEachin, J. J., Smith, T., & Lovaas, O. I. (1993). Longterm outcome for children with autism who received early intensive behavioral treatment. American Journal on Mental Retardation, 97, 359±372. McMahon, R. J., & Forehand, R. (1983). Consumer evaluation in behavioral treatment of children: Types, issues, and recommendations. Behavior Therapy, 14, 209±225. Maurice, C. (1993). Let me hear your voice: A family's

triumph over autism. New York: Fawcett Columbine. Maurice, C. (1996, May). One parent's reflections on persuasion and partnership. Paper presented at the 22nd Annual Convention of the Association for Behavior Analysis, San Francisco, CA. Mirandalinne, F., & Melin, L. (1992). Acquisition, generalization, and spontaneous use of color adjectives: A comparison of incidental teaching and discrete-trial procedures for children with autism. Research in Developmental Disabilities, 13, 191±210. Moran, D. R., & Whitman, T. L. (1991). Developing generalized teaching skills in mothers of autistic children. Child and Family Behavior Therapy, 13, 13±37. Neef, N. A. (1995). Pyramidal parent training by peers. Journal of Applied Behavior Analysis, 28, 333±337. Niemeyer, J. A., & Fox, J. (1990). Reducing aggressive behavior during car riding through parent-implemented DRO and fading procedures. Education and Treatment of Children, 13, 21±35. Nixon, C. D., & Singer, G. H. S. (1993). Group cognitivebehavioral treatment for excessive parental self-blame and guilt. American Journal on Mental Retardation, 97, 665±672. Paisey, T. J., Fox, S., Curran, C., Hooper, K., & Whitney, R. (1991). Case study: Reinforcement control of severe aggression exhibited by a child with autism in a family home. Behavioral Residential Treatment, 6, 289±302. Petronko, M. R., Harris, S. L., & Kormann, R. J. (1994). Community-based behavioral training approaches for people with mental retardation and mental illness. Journal of Consulting and Clinical Psychology, 62, 49±54. Pierce, K., & Schreibman, L. (1995). Increasing complex social behaviors in children with autism: Effects of peerimplemented pivotal response training. Journal of Applied Behavior Analysis, 28, 285±295. Reid, D. H., Phillips, J. W., & Green, C. W. (1991). Teaching persons with profound and multiple handicaps: A review of the effects of behavioral research. Journal of Applied Behavior Analysis, 24, 319±336. Repp, A. C., & Singh, N. N. (1990). Perspectives on the use of nonaversive and aversive interventions for persons with developmental disabilities. Sycamore, IL: Sycamore. Robbins, F. R., & Dunlap, G. (1992). Effects of task difficulty on parent teaching skills and behavior problems of young children with autism. American Journal on Mental Retardation, 96, 631±643. Roberts, M. W., & Powers, S. W. (1990). Adjusting chair timeout enforcement procedures for oppositional children. Behavior Therapy, 21, 257±271. Rodrigue, J. R., Geffken, G. R., & Morgan, S. B. (1993). Perceived competence and behavioral adjustment of siblings of children with autism. Journal of Autism and Developmental Disorders, 23, 665±674. Rogers Wiese, M. R. (1992). A critical view of parent training research. Psychology in the Schools, 29, 229±236. Rueda, R., & Martinez, I. (1992). Fiesta educativa: One community's approach to parent training in developmental disabilities for Latino families. Journal of the Association for Persons with Severe Handicaps, 17, 95±103. Sanders, M. R. (1992). Enhancing the impact of behavioural family intervention with children: Emerging perspectives. Behaviour Change, 9, 115±119. Sanders, M. R., & Dadds, M. R. (1982). The effects of planned activity and child management procedures in parent training: An analysis of setting generality. Behavior Therapy, 13, 452±461. Sanders, M. R., & Dadds, M. R. (1993). Behavioral family intervention. Needham Heights, MA: Allyn and Bacon. Sanders, M. R., & James, J. E. (1983). The modification of parent behavior: A review of generalization and maintenance. Behavior Modification, 7, 3±27. Sanders, M. R., & Plant, K. (1989). Programming for

References generalization to high and low risk parenting situations in families with oppositional developmentally disabled preschoolers. Behavior Modification, 13, 283±305. Sandler, A. G., Warren, S. H., & Raver, S. A. (1995). Grandparents as a source of support for parents of children with disabilities: A brief report. Mental Retardation, 33, 248±250. Schreibman, L., Kaneko, W. M., & Koegel, R. L. (1991). Positive affect of parents of autistic children: A comparison across two teaching techniques. Behavior Therapy, 22, 479±490. Sidman, M. (1989). Coercion and its fallout. Boston: Authors Cooperative. Silver, L. B. (1995). Controversial therapies. Journal of Child Neurology, 10, S96±S100. Singer, G. H. S., & Irvin, L. K. (1990). Supporting families of persons with severe disabilities: Emerging findings, practices, and questions. In L. H. Meyer, C. A. Peck, & L. Brown (Eds.), Critical issues in the lives of people with severe disabilities (pp. 271±312). Baltimore: Paul H. Brookes. Singer, G. H. S., Irvin, L. K., & Hawkins, N. (1988). Stress management training for parents of children with severe handicaps. Mental Retardation, 26, 269±277. Singer, G. H. S., Irvin, L. K., Irvine, B., Hawkins, N. & Cooley, E. (1989). Evaluation of community-based support services for families of persons with developmental disabilities. Journal of the Association for Persons

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with Severe Handicaps, 14, 312±323. Singh, N. N. (1997). Prevention and treatment of severe behavior problems: Models and methods in developmental disabilities. Pacific Grove, CA: Brooks/Cole. Smith, G. C., Tobin, S. S., & Fullmer, E. M. (1995). Elderly mothers caring at home for offspring with mental retardation: A model of permanency planning. American Journal on Mental Retardation, 99, 487±499. Strain, P. S., & Danko, C. D. (1995). Caregivers' encouragement of positive interaction between preschoolers with autism and their siblings. Journal of Emotional and Behavioral Disorders, 3, 2±12. Tausig, M. (1985). Factors in family decision-making about placement for developmentally disabled individuals. American Journal of Mental Deficiency, 89, 352±361. Van Houten, R., Axelrod, S., Bailey, J. S., Favell, J. E., Foxx, R. M., Iwata, B. A., & Lovaas, O. I. (1988). The right to effective behavioral treatment. Journal of Applied Behavior Analysis, 21, 381±384. Webster-Stratton, C., & Hammond, M. (1990). Predictors of treatment outcome in parent training for families with conduct problem children. Behavior Therapy, 21, 319±337. Zarcone, J. R., Rodgers, T. A., Iwata, B. A., Rourke, D., & Dorsey, M. F. (1991). Reliability of the Motivation Assessment Scale: A failure to replicate. Research in Developmental Disabilities, 12, 349±360.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

9.13 Families of Alcoholics BARBARA S. McCRADY, ELIZABETH E. EPSTEIN, and CHRISTOPHER W. KAHLER Rutgers-The State University of New Jersey, Piscataway, NJ, USA 9.13.1 INTRODUCTION

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9.13.2 PREVALENCE

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9.13.2.1 Alcohol Use Disorders and Families with Alcohol Problems 9.13.2.2 Consequences of Alcoholism to the Individual and Family 9.13.2.3 Gender, Ethnic, and Cultural Factors

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9.13.3 EARLY MODELS OF FAMILIES OF ALCOHOLICS

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9.13.4 CURRENT MODELS: THEORY, ASSESSMENT, AND TREATMENT

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9.13.4.1 Cognitive-behavioral Models 9.13.4.1.1 Cognitive-behavioral theory 9.13.4.1.2 Cognitive-behavioral assessment 9.13.4.1.3 Cognitive-behavioral treatment 9.13.4.2 Family Systems Models 9.13.4.2.1 Family systems theory 9.13.4.2.2 Family systems assessment 9.13.4.2.3 Family systems treatment 9.13.4.3 Family Disease Models 9.13.4.3.1 Family disease model theory 9.13.4.3.2 Family disease model assessment 9.13.4.3.3 Family disease model treatment 9.13.5 SUMMARY AND CONCLUSIONS

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9.13.5.1 Common Elements of the Models 9.13.5.2 Strengths of Each Model

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9.13.6 REFERENCES

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alcohol treatment facility to exclude family treatment from its program. There are several advantages to a familybased approach to conceptualizing and treating substance-use disorders. Family involvement is associated with better compliance with treatment (e.g., Berger, 1981) and with better treatment outcome. In addition, substance use has a negative impact on the functioning of the rest of the family, and involving the family in treatment may ease their distress as well. Family treatment models provide a framework for conceptualizing the inter-relationships between

9.13.1 INTRODUCTION The effects of alcohol use on family and marital functioning are complex, and several models have evolved to describe inter-relationships between alcoholic drinking and family life. In addition, because alcoholism has profound effects on the family, and because intrafamilial relationships and family patterns affect the course, severity, and pattern of alcohol misuse, several models of family-focused treatments for the alcoholic and his or her family members are in use. In fact, it is unusual for a contemporary 199

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substance use and family functioning, can reduce isolation of the alcoholic, can facilitate establishment of common family goals, can help the family identify and deal with other problems such as poor communication, and can be used as a guide for treatment with any part of the family that is available for treatment (Collins, 1990; McCrady & Epstein, 1996). This chapter is designed to acquaint the reader with theoretical and treatment models related to families of alcoholics. The first section provides a brief review of prevalence of alcohol use disorders and of alcohol-related consequences to spouses and children of alcoholics. Gender, ethnic, and cultural factors are considered. Early models of functioning in families with an alcoholic member are then reviewed. These include psychodynamic models and sociological models of stress and coping. The primary focus of the rest of the chapter is on three family models of alcoholism: cognitivebehavioral family, family systems, and family disease models. Theory, assessment, and treatment techniques for each model are described. Treatment of the alcoholic using a family approach, as well as treatment of family members of alcoholics are discussed. 9.13.2 PREVALENCE 9.13.2.1 Alcohol Use Disorders and Families with Alcohol Problems The Diagnostic and statistical manual of mental disordersÐFourth Edition (DSM-IV; American Psychiatric Association [APA], 1994) defines an individual as having alcohol dependence if he or she meets three of seven criteria within one year. Criteria relate to impaired control over alcohol consumption, unsuccessful attempts or a persistent desire to quit drinking, excessive time spent drinking or recovering from the effects of drinking, curtailment of occupational, social, or recreational functioning due to drinking, continued drinking despite known physical and psychological problems related to drinking, and physical tolerance and withdrawal. Alcohol abuse is diagnosed if drinking continues despite any one of four symptoms: recurrent failure to fulfill obligations, recurrent legal problems, recurrent social or occupational problems due to substance use, or repeated use of alcohol in physically hazardous situations. In the USA, alcohol abuse and dependence are ªamong the most prevalent mental disorders in the general populationº (APA, 1994, p. 203). Based on the Epidemiologic Catchment Area (ECA) study begun in 1980 using DSM-III (APA, 1980) criteria for alcohol abuse and

dependence, the estimated lifetime prevalence rate of alcoholism in the USA is 13.8% and the one-year prevalence is about 6.8% (Bucholz, 1992). Data from the National Health Interview Survey (NHIS) 1988 Supplement put the 1-year prevalence of DSM-III-R (APA, 1987) defined alcohol abuse and dependence at 8.6%. An even larger number of people may have problems related to alcohol use but do not meet diagnostic criteria. The prevalence of alcohol abuse and dependence may be increasing in the overall population and may be increasing faster among females than males (National Institute on Alcohol Abuse and Alcoholism, 1993). Given the large number of individuals with alcohol use disorders, the number of family members potentially affected by the drinking of a relative is considerable. Because alcoholism is most prevalent from ages 18±44, many individuals are actively alcoholic at the time in their lives when they are most likely be married and raising children (Bucholz, 1992). Although lifetime prevalence of alcoholism is lowest among those stably married, the one-year prevalence of alcohol abuse or dependence among married people is 4.2%. Based on NHIS data, it is estimated that 22.6% of people in the USA have a first-degree blood relative who is alcoholic (Harford, 1992).

9.13.2.2 Consequences of Alcoholism to the Individual and Family The consequences of alcoholism and heavy alcohol use are well documented. Five percent of all deaths in the USA in 1988 were attributable to alcohol (NIAAA, 1993). Heavy alcohol use has been associated with a number of types of liver injury, various cardiac conditions, immune system depression, damage to endocrine system and reproductive function, and multiple adverse neurological effects. Alcoholism is also associated with a high incidence of serious and fatal injuries, high-risk behavior, and suicide. About 48% of people with alcohol abuse/dependence meet criteria for another psychiatric disorder, a rate two times greater than that of nonalcoholics (Helzer, Bucholz, & Robins, 1992). The consequences of living with an alcoholic family member are also significant. The divorce rate of alcoholics is estimated to be about four times that of the general population, and family disruption is probably much more likely with alcoholism than with other mental disorders (Paolino, McCrady, & Diamond, 1978). Families with alcoholic parents experience more marital conflict and more parent±child conflict than control families (Reich, Earls, & Powell,

Prevalence 1988). Sixth-grade (11±12 year old) children of alcoholics have been found to experience more negative events within the family, more family conflict, less positive family events, and less family cohesion than sixth-grade children of nonalcoholic parents (Heavey & Dodd, 1995). Families of relapsed alcoholics have been found to have significantly less cohesion and expressiveness than control families and families in which the alcoholic has relapsed to heavy drinking have been found to have more conflict and less familial organization (Moos & Moos, 1984). As well as being linked to divorce and family disruption, alcoholism has often been linked to family violence. Although problems with research design, methodology, and the sampling have not allowed a causal relationship between alcohol use and violence to be established (Leonard & Jacob, 1988; Martin, 1992; Sher, 1991), the literature on spouse abuse has found consistently that many abused wives view their husbands as alcoholic or problem drinkers, with estimates of alcoholism in the husband ranging from 35 to 93% (Leonard & Jacob, 1988). Studies have found alcohol present in 25±50% of all incidents of wife beating (Martin, 1992) and have found violence levels in couples with alcoholic husbands to be five to six times greater than national prevalence estimates (O'Farrell & Choquette, 1991). Research suggests that a substantial number of child abusers are also excessive drinkers and that alcohol often is involved in the abuse when the abuser is alcoholic (Leonard & Jacob, 1988). However, the relationship between alcoholism and child abuse may not be as strong as with spouse abuse (Sher, 1991) as major portions of the variance in child abuse are not accounted for by the use of alcohol (Leonard & Jacob, 1988). Some studies have found that alcoholic or highly intoxicated parents are more likely to abuse their children than other parents and that alcoholism is four times greater in parents of abused children than in parents of sick children (Martin, 1992). However, other studies have found no differences in alcoholism rates between abusive and nonabusive parents. Rates of parental alcoholism in families with reported child abuse have ranged from 0±92% (Sher, 1991). Estimates of the incidence of incest and alcoholism also vary with two reviews of the literature finding alcohol problems in 20±50% (Miller, 1990) and 20±75% (Hurley, 1991) of incestuous fathers. Research indicates that family members of alcoholics experience higher levels of psychological distress than individuals without alcoholic family members. Most empirical work has studied wives and children of alcoholic men.

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For instance, in an early study, Kogan and Jackson (1965) found that wives of alcoholics showed elevations on a number of MMPI clinical subscales when compared to community controls, but less than half of these women were in the disturbed range on MMPI scale. Moos, Finney, and Gamble (1982) reported that spouses of relapsed alcoholics were functioning more poorly than community controls on a number of dimensions including depression, anxiety, alcohol consumption, physical health, and family cohesion. Hill (1993) found that nonalcoholic wives of alcoholics did not differ from female community controls on any of the scales of the Minnesota Personality Questionnaire and differed on only the Psychopathic Deviate (PD) scale of the MMPI. In a study comparing wives of incestuous sexual offenders, wives of alcoholics, and wives whose spouses were neither alcoholics nor sexual offenders, wives of alcoholics were found to differ from controls on a few subscales of the MMPI that dealt with transient states and on the PD scale (Pitman & Taylor, 1992). This elevation was due to an elevation in self-alienation, which reflects problems in concentration, feeling that life is unrewarding, feelings of guilt, and possible alcohol abuse. Children of alcoholics also appear to function more poorly when compared to children from nonalcoholic families, although elevations in distress reported remain on average below clinical levels (Heavey & Dodd, 1995; Johnson & Jacob, 1995). Empirical studies consistently have found an increased risk of alcohol problems in children of alcoholics, and alcohol use during pregnancy has been the only factor associated with Fetal Alcohol Syndrome, which is now ªthe leading known environmental cause of mental retardation in the Western Worldº (NIAAA, 1993, p. 221). Children of alcoholics have been found to show less social competency, more internalizing and externalizing behaviors, and more total problem behaviors than children of control families (Johnson & Jacob, 1995). Adolescent children of alcoholics also exhibit more internalizing and externalizing behavior and are at increased risk for using alcohol (Chassin, Rogosch, & Barrera, 1991). Among college freshmen, children of alcoholics manifest more alcohol and drug problems, more behavioral under control and negative affectivity, and more psychiatric distress relative to peers without alcoholic parents, although differences found were small to moderate (Sher, Walitzer, Wood, & Brent, 1991). Although alcoholism has been associated with numerous severe consequences such as domestic violence and divorce, it appears that many families with alcoholic members are

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financially stable, avoid violence, and experience no higher levels of depression or anxiety than the general population (Steinglass, Bennett, Wolin, & Reiss, 1987). However, even if more dramatic consequences are avoided, alcoholism in a family member can still have detrimental effects. For instance, a review of the literature suggests that not only are alcoholics susceptible to a wide range of traumas and diseases, but their families also utilize healthcare services at rates higher than the population as a whole (Langenbucher, McCrady, Brick, & Esterly, 1994). One study (Holder & Hallan, 1986) reports that members of alcoholic families used more than four times the amount of healthcare resources used by matched nonalcoholic families.

9.13.2.3 Gender, Ethnic, and Cultural Factors In studying and treating alcoholics and their families, it is important to recognize that there may be systematic differences in the expression of alcoholism and its effects on the family according to the ethnicity or race of the family and the gender of the alcoholic involved. Such differences are not well understood, as research on ethnic minority populations often has used biased sampling procedures, failed to recognize heterogeneity within minority groups, and has been flawed by inconsistencies in the definitions of constructs used across studies (Collins, 1992). Alcoholism in women and their families also has been understudied (Nathan & Skinstad, 1987). In the ECA study, no significant differences were found in lifetime alcoholism prevalence rates of African-Americans, Caucasian, and Hispanics in the USA (Helzer, Burnam, & McEvoy, 1991). Native Americans appear to have substantially higher rates of alcoholism and heavy drinking than other groups in the USA, although drinking varies greatly from tribe to tribe (Lex, 1987; Manson, Shore, Baron, Ackerson, & Neligh, 1992). Among adolescents, Native American youth also have been found to have particularly high rates of alcohol use and alcohol-related problems (Welte & Barnes, 1987). The expression of alcoholic symptoms across cultures and countries is remarkably similar (Helzer & Canino, 1992). However, some ethnic or racial groups are more susceptible to certain consequences of heavy alcohol use (Herd, 1994; Lex, 1987; Welte & Barnes, 1987). In both ECA and NHIS studies, the prevalence rates of alcohol abuse and dependence were at least twice as high among men as compared to women (Bucholz, 1992). Men have

been found to drink more and to manifest more alcoholism than women in almost all cultures studied (Helzer & Canino, 1992). However, this difference is particularly great in Hispanic and Asian cultures as compared to Western and Anglo-Saxon cultures. Among adolescents, males report drinking more than females in all ethnic groups, but this difference is largest among Asians and smallest among Caucasians (Welte & Barnes, 1987). One of the few studies conducted that included families of female alcoholics found no differences in family functioning between families with alcoholic husbands and those with alcoholic wives (Moos & Moos, 1984). However, the amount of drinking by women in a given subculture could affect how a family reacts to alcoholism in a female family member and either heighten or lessen the stigma associated with being alcoholic. For instance, it has been reported that alcoholic African-American women have their drinking criticized by their husbands less often than their Caucasian counterparts (Lex, 1987). Data from the NHIS study reveal differences by ethnic group and gender in the rates of having at least one first, second, or third degree blood relative who was alcoholic (Harford, 1992). The lowest rate of familial alcoholism is in Asian-Americans, around 14%, and the highest rate is in Native Americans, over 50%. Females more often reported having alcoholic family members than males, suggesting possible differences by gender in conceptions of or concern with alcoholism. Cultural differences also exist in the conceptualization of alcoholism (Babor, 1992), which could influence how families react to and interpret alcohol problems in family members. Studies in other countries reveal variations in how families respond to alcoholism and what concerns they express about the consequences of alcohol use. For example, 76% of alcoholics in Puerto Rico reported that their families had objected to their drinking (Canino, Burnam, & Caetano, 1992), whereas only 36% of alcoholics in the former West Germany reported familial objections (Wittchen & Bronisch, 1992). A study of Indo-Pakistani, Latin American, and Chinese groups in British Columbia, Canada, found that subjects from the Indo-Pakistani subsample more often disapproved of alcohol use by women and placed greater emphasis on a full range of family related consequences of heavy drinking than the other groups; the Latin American subsample expressed the least concern about wife and child abuse related to excessive alcohol use (Legge & Sherlock, 1991). Finally, differences have been found between African-American, Caucasian, and Asian-American families in family

Early Models of Families of Alcoholics management practices, involvement in family activities, sibling deviance, family structure, and parental attitudes toward children's drinking (Catalano et al., 1992) and evidence has suggested that ªthere may well be cultural differences in family processes leading to early variety of substance initiationº (p. 216). Alcohol use problems are widespread and affect a large number of families. Although gender, ethnicity, and culture generally are assumed to play a role in alcohol use and family functioning, research on the relationships among these factors is in its infancy. The models described below outline broad principles about the relationships between alcohol use and family and individual functioning that are hypothesized to operate in most families. None of these models explicitly addresses the role of gender, ethnicity, or culture, but clinicians and researchers should be aware that not all families subscribe to the same set of values and beliefs and that ways of coping with alcohol problems that seem unusual or intractable may be influenced by factors unaccounted for by present models.

9.13.3 EARLY MODELS OF FAMILIES OF ALCOHOLICS In the 1930s, many alcoholics received treatment in state mental hospitals. Social workers in those facilities who interviewed the wives of alcoholic men observed the significant distress, particularly anxiety, depression, and psychosomatic symptoms that these women experienced (e.g., Lewis, 1937). Theoretical models were developed to explain these observations. The earliest model, the Disturbed Personality Hypothesis, was derived from the psychodynamic models that predominated at the time, and postulated that wives of alcoholics were disturbed women who resolved neurotic conflicts through their marriage to an alcoholic man. Although some authors postulated one primary underlying conflict, Whalen (1953) hypothesized four different types of conflicts that could be resolved through marriage to an alcoholic, including conflicts with aggression, control, masochism, and ambivalence. A corollary to the Disturbed Personality Hypothesis was the Decompensation Hypothesis. Central to psychodynamic models is the notion that neurotic conflicts serve as a defense against more basic or primitive conflicts. If defenses are removed, an individual would be expected to exhibit these more primitive conflicts and decompensate. Thus, it was hypothesized that if a married alcoholic successfully stopped drinking, his wife would decompensate

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and exhibit more severe psychopathology. MacDonald (1956) reported, among 18 women hospitalized in a state mental hospital who were married to alcoholics, that 11 of the women's husbands had decreased their drinking recently, suggesting that these observations supported the Decompensation Hypothesis. No other study, however, has supported this hypothesis. In the 1950s, alternative models began to be developed. Jackson (1954), after interviewing women who were attending Al-Anon meetings, suggested that a stress and coping perspective would better explain the experiences of these women than the prevailing psychodynamic models. She suggested that living with an alcoholic is stressful, and that most of the symptoms that wives of alcoholics experienced were common to family members living with long-term, familial stressors. She also suggested that families progress through ªstagesº in coping with alcoholism, and that each stage is characterized by different psychological phenomena. Family stages included family denial of the problem in the earliest stage, followed by attempts to control the problem, feeling hopeless and chaotic, attempting to maintain stable family functioning with the alcoholic present, attempting to escape from the problem through marital separation, organizing and maintaining the family without the alcoholic present, and a final adjustment phase if the alcoholic stopped drinking. Cross-sectional and prospective tests supported Jackson's model (Kogan & Jackson, 1965; Moos et al., 1982), finding that women whose husbands were actively drinking showed substantial psychological distress, but that wives of men who were not drinking were indistinguishable from wives of nonalcoholic men. Concern about children of alcoholics dates to a compassionate book that reported clinical interviews and observations of children of alcoholics, and underscored the difficulties they experienced growing up in an alcoholic household (Cork, 1969). Concern was also stimulated by early genetic research suggesting a strong heritable component to more severe forms of alcohol dependence (Goodwin, Schulsinger, Hermansen, Guze, & Winokur, 1973). Popular clinical models for understanding and treating children of alcoholics evolved, and scientific research has progressed as well. Stress and coping models in particular have been supported in studies of children of alcoholics, with results showing that adolescent children with an alcoholic parent who has had no drinking problems for a period of three years function better than children of nonrecovered alcoholics but not as well as children with no alcoholism in the family (Chassin et al., 1991).

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Beginning in the 1970s, three contemporary models for conceptualizing alcohol and family functioning began to evolve. These models, based in social learning theory, general systems theory, and the disease model of alcoholism, predominate theory, research, and clinical models of alcoholism and family functioning in the 1990s. All three models provide frameworks for understanding the relationships between drinking and family functioning, and also provide frameworks for understanding the functioning of individual family members. 9.13.4 CURRENT MODELS: THEORY, ASSESSMENT, AND TREATMENT 9.13.4.1 Cognitive-behavioral Models 9.13.4.1.1 Cognitive-behavioral theory Cognitive-behavioral models have been used to describe a range of human problems. These models use social learning theory to explain the relationships among problem behaviors, environmental events, and private events (cognitions and emotions). Cognitive-behavioral models analyze controlling events for each problem behavior, and assume that controlling events will differ across individuals, rather than assuming the same controlling variables for all individuals with the same problem. As a consequence, cognitive-behavioral models of alcohol problems and family functioning examine classes of variables hypothesized to control the functioning of each family member as well as the interactions among family members. In this section, the cognitive-behavioral models developed to understand the interactions between drinking and family functioning are described and then the cognitivebehavioral applications to conceptualizing the problems of spouses and of children of alcoholics are detailed. Subsequent sections describe approaches to the assessment and treatment of the interactions between alcohol and family functioning, and then describe assessment and treatment of spouses and children. (i) Drinking and family functioning Cognitive-behavioral models in use in the 1990s describe current factors maintaining drinking, and include detailed consideration of the role of the family in the maintenance of drinking and the process of change. These models emphasize the drinker and spouse's roles as agents of change, and the paradigm has empirical support for its efficacy in treating alcoholic couples (McCrady & Epstein, 1995; McCrady, Stout, Noel, Abrams, & Nelson, 1991). Several basic assumptions are central: (i)

reciprocal interactions between the drinker and his or her environment determine repetitive, stressful intra- and interpersonal behavioral patterns; (ii) external antecedents to drinking have a lawful relationship to subsequent alcohol consumption, through repeated associations with reinforcement or anticipation of reinforcement; (iii) cognitive and affective events mediate the relationship between external antecedents and drinking; and (iv) drinking is maintained by physiological, psychological, and/or interpersonal consequences (McCrady & Epstein, 1996). Cognitive-behavioral models assume that substance use occurs in response to antecedent stimuli or cues. These stimuli or cues precede the substance use, and their presence increases the probability that substance use will occur. External antecedents may relate to the individual, familial, or other social systems. Familial antecedents might include family membersº attempts to control the alcoholic's drinking, or negative interactions around specific problems resulting from the drinking, such as problems in communication, sexual functioning, or finances. Aspects of the environment become cues for substance use through repeated sequences of events that include the antecedent stimulus, substance use, the occurrence of stimuli that reinforce use, and the lack of occurrence of punishing stimuli. The spouse and other family members unwittingly may supply positive consequences of drinking, for instance, by taking care of the intoxicated family member, pampering him or her when sick from drinking too much, or may protect the drinker from naturally occurring negative consequences, for instance, by calling in sick when the drinker cannot go to work. For certain couples, alcohol also may be associated with an increase in positive interactions. The relationship between an antecedent stimulus and substance use is believed to be mediated by organismic events, including thoughts, feelings, and physiological reactions. Substance abusers may have a variety of positive expectancies about the reinforcing consequences of substance use, or may use in response to negative affect or physiological cues such as decreasing blood alcohol level. Substance abusers may also have cognitive and affective reactions to interpersonal situations such as an argument with a spouse, and may drink in response. A number of cognitive constructs are important to conceptualizing couplesº relationships. Couples make certain attributions about the motivations underlying each other's behavior, assuming that they know the reasons for certain actions. They also have certain expectancies about each other's future behavior,

Current Models: Theory, Assessment, and Treatment based partly in past experience and partly in their distorted attributions about the partner's motivations. The repertoire of behavioral responses available to the substance user and to the couple or family is important. Alcoholic families often have skills deficits. Couples may have difficulty in coping with alcohol-related situations, expressing affect, disagreeing, making requests for change, listening to and understanding the partner's communication, providing positive support, or solving problems productively as a couple. Spouses may lack coping skills to respond effectively to the drinker and to drinking situations, and may have difficulty balancing attention to their own needs, the responsibilities they may have to maintaining the integrity and functioning of their families, and the stresses presented by the alcoholic's behavior. The effect of alcohol on family interactions is complex, and negative consequences are often quite prominent. Family members may avoid or criticize the drinker. Verbal or physical aggression may be prominent. Typically, these negative consequences exacerbate the problems; the spouse and children may become fearful and angry; the drinker may leave the house and drink elsewhere, or may learn to drink secretly. In either case, a pattern of lying on the alcoholic's part, and hypervigilance and mistrust by the family may result, severely damaging family functioning. Finally, since alcoholics with a moderate to severe problem spend an inordinate amount of time seeking, consuming, or recovering from the effects of alcohol, they are typically unable to contribute fully to ensure daily functioning of the household. The nonalcoholic spouse and children must then take on more responsibilities around the house, leading to increased resentment and stress. All of this may serve to deepen the unhappiness in the home, cue the alcoholic to spend more time out of the home and drinking, and create further stress on the rest of the family. (ii) Functioning of family members Cognitive-behavioral models of the functioning of spouses and children in alcoholic families utilize a stress and coping perspective. Multiple factors are hypothesized to impact on the functioning of family members, including their own coping repertoire, other psychological problems, the types of stressors in their environment created by the drinking, and the quality of the marital or parent-child relationship (McCrady, Kahler, Shraedley, Epstein, & Hirsch, 1995). Family members utilize a variety

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of maladaptive coping strategies to deal with the chronic stressor of living with an actively drinking alcoholic family member. Spouses may engage in a variety of ineffective behaviors intended to change the drinking, such as nagging the drinker to change, or attempting to control the drinking or the drinker's behavior. These behaviors are conceived as maladaptive coping strategies, rather than indicators of underlying psychopathology. Over time, spouses assume extra role responsibilities, and often decrease the time they devote to activities that they experience as pleasurable. Depression, anxiety, and social isolation are understandable consequences. Children in these families may be exposed to inconsistent parenting, high levels of conflict, and low levels of support from the alcoholic parent. Children may lack coping strategies to deal with common developmental stressors and may have learned to use alcohol as a primary coping strategy. They also may lack other social supports within or outside of the family that could buffer the negative effects of the stressors within the alcoholic family (e.g., Begun & Zweben, 1990). 9.13.4.1.2 Cognitive-behavioral assessment The focus of a cognitive-behavioral assessment varies with the presenting problems and with who presents for treatment. Ideally, the clinician would see the entire family when alcohol problems are present, and the clinician would assess the functioning of each individual family member, the interrelationships between drinking and family functioning, and the quality of the marital and family relationships. However, if individual family members present without the drinker, the assessment addresses their individual functioning as well as how they are coping with the drinking. The goals of a comprehensive cognitivebehavioral assessment are to assess the interrelationships between drinking and family behaviors, evaluate the current functioning of each member of the family unit, including strengths, problem areas, and coping skills, and assess the functioning of the family as a unit. The results of the assessment are used to develop a specific treatment plan to impact on the individual's drinking, enhance positive coping for members of the family, and to enhance the quality of marital or family relationships. Assessment of the spouse focuses on behaviors related to coping with the partner's alcohol use as well as a broader assessment of functioning. A number of measures assess different aspects of the spouse's coping with drinking:

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(i) The Spouse Enabling Inventory. This assesses spouse behaviors that may facilitate or maintain the partner's drinking (Thomas, Yosioka, & Ager, 1994a). Behaviors are divided into two types: those that increase events that facilitate the partner's drinking (e.g., buying liquor), and those that decrease events that could inhibit the partner's drinking (e.g., lying about the drinking to others). (ii) The Spouse Sobriety Influence Inventory. This assesses partner behaviors intended to control the drinking, and behaviors intended to support the partner in efforts not to drink (Thomas, Yosioka, & Ager, 1994b). (iii) The Spouse Behavior Questionnaire. This assesses spouse behaviors that may serve as cues for drinking, reinforce drinking, punish drinking, support sobriety, or that represent ways for the spouse to take care of his or her own physical and psychological needs (McCrady, Miller, Epstein, & Van Horn, 1993). (iv) The significant other behavior questionnaire. This is an adaptation of the Spouse Behavior Questionnaire that assesses coping of any significant other, not just the spouse (Love, Longabaugh, Clifford, Beattie, & Peaslee, 1993). (v) The Spouse Situation Inventory. This is a set of role play stimuli with scoring guidelines that allows the clinician to assess the actual behaviors that spouses use to cope with alcoholrelated situations (Rychtarik, 1990). Although there are a number of very good measures to assess the ways that spouses cope with the drinking itself, a broader assessment framework is necessary. A comprehensive assessment of the spouse of an alcoholic should evaluate: level of distress; behavioral repertoire for coping with alcohol related situations; social supports; social and economic resources and problems; and individual strengths and sources of positive reinforcement. Standardized behavioral assessments specifically related to the effects of parental alcoholism on children are not in widespread use. The literature suggests that specific domains to target for assessment in children of alcoholics would include mood (i.e., depressive) disorders, hyperactivity, conduct disorder, and early (i.e., young adolescence) development of heavy alcohol and drug use. In addition, assessment of coping strategies is indicated. Assessment must also take into account several complexities, including comorbid psychiatric problems of the parent, for example, depression or antisocial personality, socioeconomic status of the family, genetic loading for substance-use disorders, psychosocial functioning of the parents, the marital relationship of the parents, degree of conflict or cohesion in the family, whether one or both parents have an alcohol

problem, and the quality of the parent±child relationship (see Sher, 1991, for a complete review). The preceding discussion of assessment of family members focuses on their individual behavior. It is also important to assess the degree to which there is a contingent relationship between family membersº actions and the individual's drinking. Several strategies facilitate this assessment: (i) completing a functional analysis of specific drinking episodes (e.g., McCrady, 1993) to identify antecedent cues for the drinking, the drinker's cognitive and affective responses to family membersº actions, and family behaviors consequent to drinking that might either reinforce or punish the drinking; (ii) using behavioral self-recording of drinking episodes and drinking urges, in conjunction with a functional analysis of these episodes; (iii) using drinker self-report questionnaires that identify high risk situations for drinking, such as the Inventory of Drinking Situations (Annis, 1982). Assessment of marital and family functioning uses a wide range of assessment approaches from the broader behavioral marital and family field. For example, marital satisfaction and marital problems may be assessed with questionnaires such as the Dyadic Adjustment Scale (Spanier, 1976), or the Areas of Change Questionnaire (Margolin, Talovic, & Weinstein, 1983). Communication and problem solving skills may be assessed using self-report measures such as the Primary Communication Inventory (Navran, 1967), or by structured observations of interactions coded using any of a variety of standardized coding systems such as the Specific Affect Coding System (Gottman, 1996), or the Rapid Couples Interaction Scoring System (Gottman, 1996). Domestic violence should also be assessed, using such instruments as the Conflict Tactics Scale (Strauss, 1979). Family communication and problem solving, role responsibilities, and parenting skills can be assessed using measures from the broader cognitive-behavioral family therapy literature.

9.13.4.1.3 Cognitive-behavioral treatment At the completion of the assessment the clinician develops a treatment plan tailored to the individual case. Preferably treatment would begin with the couple. Drinking, spouse coping, and relationship functioning would be addressed. The functioning of the children would be evaluated, and appropriate treatment would be provided if necessary. If the drinker is not willing to come into treatment, the spouse

Current Models: Theory, Assessment, and Treatment would be engaged first, and treatment would address the spouse's individual coping and would also be directed at getting the drinker into treatment. Again, the functioning of the children would be evaluated. (i) Cognitive-behavioral treatment of couples The treatment model described here follows logically from cognitive-behavioral theory (McCrady & Epstein, 1995). This model for conceptualizing drinking problems necessitates intervention at multiple levels: with the individual, the spouse, the marital relationship, and other social systems in which the drinker is involved. To implement the therapeutic model, couples are seen together to educate both partners about the nature of drinking problems and the model of change, to decrease the mistrust and hypervigilance that are common in such relationships, and to increase the information available to the therapist. Alcohol is typically the primary focus of the early treatment sessions, and the relationship is addressed more as therapy progresses. By focusing on alcohol at the beginning of treatment, the therapist allies with both partners, who are presenting with drinking as their major concern. At the individual level, the treatment helps the client assess reinforcers for continued drinking and for abstinence, as well as assessing negative consequences of drinking and abstinence. This provides an incentive framework for the rest of the therapy. Other strategies are also used to enhance motivation to change. Clients are taught individual coping skills to deal with alcohol-related situations such as self-management planning, stimulus control, drink refusal, and self-monitoring of drinking and drinking impulses. Behavioral and cognitive coping skills, individually tailored to the types of situations that are the most common antecedents to drinking (ªhigh-risk situationsº) are also taught and include assertiveness, cognitive restructuring, relaxation, lifestyle balance, and recreational activities. A second set of interventions revolves around the coping behaviors of the partner. The partner's motivation for entering and continuing in treatment, and the partner's perceptions of the positive and negative consequences of changes in drinking and the marital relationship are important factors contributing to the partner's willingness to engage in new behaviors and be an active participant in the therapy. If the client is successful in changing his or her drinking, the spouse may be more amenable to examining and changing his or her own behavior. Spouse coping skills might include

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learning new ways to discuss drinking and drinking situations, learning new responses to the partner's drinking and alcohol-related behavior, or individual skills to enhance functioning. The third set of interventions focuses on the interactions between the two partners, around both alcohol and other issues. Alcohol-focused couples interventions use alcohol-related topics as a vehicle to introduce communication and problem solving skills. Such topics as how the couple could manage in a situation where alcohol is present, whether or not they will keep alcohol in the house, how the partner could assist the drinker in dealing with impulses to drink, or what the couple will tell family and friends about the alcoholic's treatment are all relevant topics that the couple must face in the process of dealing with the drinking. By using such topics as vehicles for discussion, the couple is taught basic communication skills. In addition, the model suggests that many alcoholic couples need to learn general communication and problem-solving skills, to decrease marital conflicts that may cue drinking, and to increase the rate of positive exchanges. When appropriate, the treatment also incorporates general reciprocity enhancement interventions to increase the overall reward value of the relationship. As the alcoholic becomes sober and both marital partners adjust their behavior to accommodate this change, the marital relationship typically improves and communication between partners increases and becomes more productive. In this way, positive benefits of the therapy filter to other family members and to family functioning as a whole. Specific domains of family functioning may be targeted in treatment, for example, both spouses may be encouraged to discuss and improve parenting skills. In therapy, partners may be encouraged to discuss initiation of nonalcohol focused family rituals or events. As couples learn to problem-solve more effectively together, they are better able to set the tone for effective and healthier family functioning. The fourth set of interventions focuses on other social systems important to the drinker and partner. Clients are helped to identify interpersonal situations and persons who are associated with heavy drinking, and are also helped to identify potential social situations and people who would be supportive of abstinence or decreased drinking. Social skills such as refusing drinks or general assertiveness may be taught. Finally, the model includes techniques to increase generalization to the natural environment and maintenance of new behaviors.

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Homework assignments, teaching clients how to anticipate high-risk situations, and planned follow-up treatment sessions all are designed to contribute to maintenance of change. Research studies evaluating the effectiveness of conjoint behavioral alcohol treatment compared to individually-focused treatment generally have shown an incremental benefit for spouse involvement, that is, such treatment results in significant reductions in alcohol consumption and improvements in marital functioning (O'Farrell, 1993), and lead to reductions in marital violence (O'Farrell & Murphy, 1995). (ii) Cognitive-behavioral treatment of family members of the alcoholic Research has indicated that including behavioral marital therapy in the treatment of alcohol problems can enhance treatment success and improve marital functioning. However, it has not been established whether behavioral treatment involving family members is more beneficial to the family members than treatment that is conducted only with the alcoholic or is conducted non-behaviorally. Research has indicated that, regardless of the manner in which an alcohol problem was addressed, families of alcoholics often function as well as nonalcoholic families if the alcoholic is able to achieve stable abstinence. If disturbances in family members persist after the alcoholic has become abstinent, these disturbance can be treated using cognitivebehavioral techniques specific to the observed problems; the model does not assume that families of alcoholics are unique in their functioning. If the alcoholic continues to drink and is unwilling to seek treatment, a number of cognitive-behavioral interventions can be utilized to improve the coping of family members and to enhance the likelihood of the alcoholic seeking treatment. These interventions are described below. (a) Unilateral Family Therapy. Unilateral Family Therapy (UFT) (Thomas & Ager, 1993) has been developed to treat families in which an alcoholic family member is unwilling to reduce or quit drinking or seek treatment. The main goal of UFT is to use family members, usually spouses, as a positive rehabilitative influence to motivate the alcoholic family member to change drinking behavior or seek treatment for alcohol problems. Therapy focuses on three areas of intervention: the coping of the spouse; the interactions of the couple; and the individual alcoholic or identified patient. The cooperative spouse first is educated about alcohol problems and their treatment and an assessment of the alcoholic's

drinking is done based on an interview with the spouse. Steps are taken to help the spouse assume a rehabilitative role. Spouses are asked to monitor the alcoholic's drinking, both to reinforce their own recognition of the drinking problem and to provide the therapist with more information about the alcoholic. Unilateral relationship enhancement is used to reduce conflict and increase positive reinforcement from the relationship. Spouses are encouraged to increase the rates of pleasing behaviors, such as demonstrating affection, when the alcoholic is sober. Spouses are taught to reduce their use of coercive techniques for controlling their partnersº drinking such as nagging and threatening. Also, the therapist assesses and tries to prevent enabling behaviors by the spouse that protect the alcoholic partner from the consequences of heavy drinking. After the coping of the cooperative spouse and the interactions of the couple have been addressed, efforts are aimed at helping the spouse encourage the alcoholic partner to acknowledge the existence of an alcohol problem and to take steps towards moderating or discontinuing alcohol use. Efforts begin with nonconfrontive interventions such as increased support for sobriety or recommendation from a physician to change alcohol use. If there is some indication that the alcoholic family member may respond favorably, more confrontive interventions may be used such as bringing the alcoholic to session with the therapist and making a direct request for change or having family and friends gather to state their support for reduced drinking or abstinence. Assessment of the alcoholic's drinking and decisions about the most appropriate treatment setting for the alcoholic are completed prior to the programed request so that the alcoholic can be moved into treatment as soon as he or she agrees to seek help. Once the alcoholic seeks treatment, spouse-mediated relapse prevention training is provided and efforts at relationship enhancement continue. A pilot study and an experimental evaluation of UFT found that spouses in UFT decreased control attempts and enabling behaviors and showed improvements in psychological distress. Alcoholics in UFT decreased drinking and were more likely to seek treatment than a wait-list control group. UFT appears to be effective particularly if the spouse is compliant with treatment and has a lower level of psychopathology and if the couple has lower levels of marital conflict. (b) The Community Reinforcement Approach. Models of family treatment of uncooperative alcoholics based on the Community

Current Models: Theory, Assessment, and Treatment Reinforcement Approach (CRA) (Sisson & Azrin, 1993) have been developed and are being investigated. Like UFT, CRA also uses family members, generally spouses or parents, as a positive rehabilitative influence. In the first few sessions, family members provide information on the alcoholic's drinking pattern, discuss the problems caused by the alcoholic's drinking, and are given the opportunity to vent emotions related to these problems. The therapist describes CRA and the importance of Antabuse and instructs family members to monitor alcohol consumption. Family members are then taught to help reduce the alcoholic's drinking and enhance motivation for treatment by providing the alcoholic positive consequences of sobriety and negative consequences of drinking, appropriately discussing drinking with the alcoholic, and scheduling events incompatible with drinking. The family members are taught how to assess potentially violent or dangerous situations and to remove themselves before violence occurs. They are also encouraged to become more independent from the alcoholic by developing outside interests. A plan for getting the alcoholic into treatment is developed with the family member that can be implemented quickly at any time. The request or demand for the alcoholic to seek treatment is made at a time when the alcoholic's motivation for treatment might be high, such as following a particularly embarrassing episode of drunkenness. If the alcoholic agrees to seek treatment, he or she is seen immediately and prescribed Antabuse so that alcohol consumption will not take place for at least a few days. Treatment then follows the basic program of CRA as practiced with alcoholics seeking treatment on their own. Early evaluations of the effectiveness of CRA for families are promising and this approach appears to be particularly effective in families in which parents are trying to encourage their children to seek treatment (Meyers, 1996). CRA resulted in more identified patients seeking treatment when compared with families randomly assigned to a Johnson Institute Intervention. Dropout was particularly high in the Johnson Institute Intervention condition, suggesting that CRA is more broadly accepted by significant others. (i) Treatment of children Behavioral treatments have been developed to treat young children of alcoholic parents regardless of whether the parents change their own drinking behavior. For instance, Nye, Zucker, and Fitzgerald (1995) reported that

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three to six-year-old sons of alcoholic fathers showed increases in prosocial and decreases in negative behaviors following a behavioral intervention. The treatment consisted of social learning based parent training and marital conflict problem-solving components. Outcome was most positive when the mother was involved and invested in the program. Mothersº psychopathology was associated with outcome, highlighting the importance of addressing psychological distress in the nonalcoholic parent. No controlled trials of behavioral interventions have been reported on daughters of alcoholic fathers or children of alcoholic mothers. No studies are known to have reported on treatments aimed at improving functioning of elementary school-age children or adolescent children of alcoholics. The stress and coping model suggests that children of alcoholics will manifest symptoms of distress because they are forced to cope with a chronic and unpredictable stressor. Research has shown that increased levels of environmental stress and parental psychopathology are related to the poorer functioning of children of alcoholics (Chassin et al., 1991; Johnson & Jacob, 1995) and that children with difficult temperaments may be particularly likely to evidence behavioral problems when living with parents with high levels of antisocial behavior, low socioeconomic status, and frequent alcohol-related problems (Jansen, Fitzgerald, Ham, & Zucker, 1995). Furthermore, because of the disruptions caused by the alcoholic parent's drinking, children of alcoholics may lack appropriate role models and therefore show generalized social and problem-solving deficits (Begun & Zweben, 1990). These research results suggest possible targets of interventions for children of alcoholics. As with spouses of alcoholics, changing the drinking of the alcoholic is likely to be the most powerful intervention for the child. If drinking continues, general training in problem-solving skills and stress management techniques may enhance functioning of children. The importance of the nonalcoholic parent to the functioning of children suggests that interventions aimed at improving the psychosocial functioning, communication skills, and parenting skills of the nonalcoholic parent could ameliorate problems related to the alcoholic parent's drinking. Interventions in the school system as well as in the peer network should also be considered. Because children of alcoholics are at increased risk for alcohol problems, both alcohol and drug use problems in adolescents should be assessed and treated as early as possible to prevent further dysfunction.

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9.13.4.2 Family Systems Models 9.13.4.2.1 Family systems theory Whereas cognitive-behavioral models of alcoholism and the family grew out of social learning theory, family systems models grew out of General Systems Theory, which was developed as an alternative to reductionistic/mechanistic, linear models of the functioning of biological systems. Although several different systems theory models have been developed, all focus on patterns of interrelationships between parts of larger systems, rather than focusing on the individual as the sole unit of analysis. Systems theory focuses on pattern recognition rather than deductive reasoning, and explains individual behavior within the context of larger systems such as the marriage, family, or community. Different systems theory models place differential emphasis on three concept areas: wholeness, organization, and relationships (Steinglass, 1978). Family systems models began to influence the alcohol field in the 1970s. In a series of studies, Steinglass and colleagues observed the behavior of alcoholics and family members hospitalized on an experimental unit, noting repetitive, patterned interactions (Steinglass, Davis, & Berenson, 1977; Steinglass, Weiner, & Mendelson, 1971) as well as significant differences in their patterns of interaction when sober than when intoxicated. These observations led to the hypothesis that alcohol performed certain positive functions in a family, by stabilizing family roles, allowing for the expression of affection, allowing for greater intimacy among family members, or allowing for the exploration of topics that the family might avoid when sober. These positive functions were called the ªadaptive consequences of alcoholismº (Davis, Berenson, Steinglass, & Davis, 1974). After these initial observational studies, alcoholic families were studied later in their homes as well as in the laboratory. It was reported that there were observable differences among families with an alcoholic family member who was drinking, sober, or in transition from one drinking status to another. Families with a sober alcoholic were most flexible in their functioning, having a balance between time together and time apart when at home (Steinglass, 1981) and showed more flexibility in solving structured tasks in the laboratory (Steinglass, 1979). Drinking families showed the most rigidity of family roles and interactions, while transitional families were intermediate in their functioning. Wolin, Bennett, Noonan, and Teitelbaum (1980) provided a second family systems perspective on alcoholism, focusing primarily on the intergenerational transmission of alco-

holism. Their work examined the family ªritualsº that characterize all families: how families vacation, have dinner, celebrate holidays, etc. They found that those families whose rituals were maintained intact were least likely to have offspring who became alcoholic; those families whose rituals were most disrupted were most likely to have alcoholic offspring. Family systems theory has contributed a number of constructs to the conceptualization of family functioning. Families are assumed to be governed by the law of homeostasis. All systems are assumed to operate to try to maintain balance, stability, equilibrium. Factors that threaten to change the functioning of a family threaten that homeostasis, and the family system is assumed to function to try to avoid change. Thus, family systems models would assume, if an alcoholic family has functioned as a stable family unit with a drinking member, that introducing sobriety into the system would threaten homeostasis. A variety of aspects of the family's structure and functioning (organization) all serve to maintain homeostasis. Family members have defined roles that guide their actions. Roles may range from caretaker to bad child, but these roles are well defined and are assumed to be difficult to modify over time. Families also have unwritten family rules that govern the functioning of the family. These rules are not necessarily explicit or deliberate, but are more likely to be implicit and unspoken. Families have a variety of boundaries that define relationships within the family and between the family and the rest of the world. Boundaries define alliances between family members and the degree to which information is available to different family members, family members have influence in the decision-making of the family, outsiders are welcomed into the family, and the family seeks interaction with outside persons and social institutions. Family systems models (e.g., Steinglass et al., 1987) stress the reciprocal interactions between substance use and family functioning. Steinglass et al. posit that all families obey the general laws of all systems, including organization, homeostasis, circular causality of events, and feedback. For some families, alcoholism or drug abuse is an organizing principle for the family, and the presence or absence of the drug is the most important variable defining interactional behavior in the family. 9.13.4.2.2 Family systems assessment Assessment in family systems models varies depending on the school of family therapy. Family therapy assessment focuses on assessment of the structure and functioning of the

Current Models: Theory, Assessment, and Treatment family as a unit, with more limited focus on assessment of the functioning of individual family members. There may be structured initial assessment, but assessment is an ongoing process that occurs throughout therapy, particularly when the clinician assesses the family's response to specific interventions. The initial interview provides crucial assessment data for the family therapist. The family therapist asks specific questions about the family's view of their presenting problems and goals for therapy (e.g., Wetchler, McCollum, Nelson, Trepper, & Lewis, 1993). Some family therapists will also conduct a traditional diagnostic interview and mental status examination, and will assess for violence, suicidality, individual health, alcohol and drug use, and other aspects of individual functioning (Wetchler et al., 1993). The family therapist observes family interactions such as communication patterns, mixed messages, and approaches to conflict resolution skills, and observes structural aspects of the family such as boundaries, coalitions, shifting alliances, family rules and roles, splits, and triangulations (Kaufman, 1985). An important aspect of the family assessment involves assessment of behavioral sequences that involve alcohol use. A variety of structured family assessment devices may be used with alcoholic families. Killorin and Olson (1984), who use Olson's Circumplex Model to conceptualize functioning in alcoholic families, use a Clinical Rating Scale to assess cohesion and adaptability in the family. Family therapists may also use a genogram interview to assess multigenerational alcohol and drug use, domestic violence, family rituals, and the role of alcohol in family rituals (Wetchler et al., 1993). 9.13.4.2.3 Family systems treatment (i) Treatment of the alcoholic using family systems models Using a family systems approach to treatment, the therapist must first differentiate ªfamilies with alcoholic members,º from the ªAlcoholic Familyº (Steinglass et al., 1987). In the Alcoholic Family, family regulatory behaviors have been reorganized around the alcohol such that alcohol-related behaviors are central to family life. In the Alcoholic Family, change in the alcoholic's drinking necessitates a change in the family's basic organization and regulatory system. Interventions are rooted in the developmental perspective of the family systems approach, the Family Life History Model (FLH) (Steinglass et al.) which divides the family life cycle into early-, middle-, and late-

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phase developmental stages. Each phase presents particular systemic tasks, and the role of alcohol in the Alcoholic Family varies depending on life cycle phase. This introduces heterogeneity into the treatment approach, since treatment must be geared toward the appropriate family life cycle phase issues. For example, in an early-phase couple, the primary developmental task is differentiation of the family unit from the two families of origin, and the meaning of alcohol in the new unit will be influenced strongly by the view or use of alcohol in both families of origin. In the middle-phase Alcoholic Family, the alcoholic identity has been established, but the alcoholic behavior is embedded in short-term problem-solving behavior and, thus, will probably not be seen by the family members as the primary problem. In latephase Alcoholic Families, it is often the children in the family who are struggling, either with drinking themselves or with establishing a separate identity for themselves. In the first, diagnostic stage of treatment, the therapist takes a detailed history from the family and pays particular attention to three regulatory behaviors of the family: short-term problem-solving strategies, daily routines, and family rituals. Preferably, all individuals in the nuclear family are included in the family therapy sessions, especially in the beginning of treatment. Family members are encouraged to express their views of the problem. In later sessions, therapy may focus on the parental unit, and other family members may discontinue attendance at the sessions. During the early sessions, the therapist determines which areas of family life have been ªinvadedº by the alcohol use. The therapist diagnoses alcoholism, labels it a family problem rather than a problem of the identified patient, and helps to identify what functions the alcohol plays in maintaining homeostasis for the family. Using reframing techniques, the therapist explains to the family the functions that alcohol serves (McKay, 1996). In this way, the focus is taken off the alcoholic and placed more squarely on the family system as a whole. At this point implications of sobriety for family functioning and homeostasis become more clear. The therapist then focuses on removal of alcohol from the family system by helping the alcoholic to become abstinent. This is predicated on clarification of the problem and commitment of family members to common goals. Once drinking has stopped, the family faces reorganization of problem-solving strategies, family rituals, and interpersonal distances and boundaries, all of which have been structured around the alcohol. This stage of

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treatment is difficult; Steinglass et al. (1987) call this the ªEmotional Desert,º a period of dysphoria and disorganization. The therapist helps the family through to a resolution phase, during which a new homeostatic level is achieved, independent of a sobriety-intoxication cycle that defined the earlier homeostasis. (ii) Family systems treatment of family members of the alcoholic Individual family members are seen as components of a primary organizational unit, that is, the family. The alcoholic carries the family symptom, but the object of treatment is considered to be the interrelationships among family members, family behavior patterns, and the balance of the family system. Thus, family systems treatment of family members of the alcoholic is the same treatment as described above for the alcoholic. Even without the family member with the alcohol problem being involved in the treatment, family systems treatment focuses on all individuals in the family and the imbalances in the system as a whole. 9.13.4.3 Family Disease Models 9.13.4.3.1 Family disease model theory The two previous models, cognitive-behavioral and family systems, developed outside of the alcohol field and have been applied to a wide range of human problems, including alcoholism. In contrast, family disease models initially were developed to explain drinking and family problems, and only later have been applied to a broader range of human problems. The family has been a focus of the disease model almost from the beginning of Alcoholics Anonymous (AA), a self-help group intended to provide support for alcoholics. The primary publication of AA, often called the ªBig Bookº (Alcoholics Anonymous, 1976), includes a chapter with advice to family members. AlAnon began in 1949 as a separate organization to assist the family and friends of alcoholics. The contemporary family focus of disease model approaches began with Cork's (1969) book on children of alcoholics, followed by Wegsheider's (1981) and other books about children in alcoholic families and the adult sequelae of their early experiences. Later authors began to focus on the partners of alcoholics (e.g., Beattie, 1987; Cermak, 1986). Although controlled research related to disease model conceptualizations is limited, these models have had a substantial impact on treatment and on popular thinking.

In the 1990s, disease model approaches describe alcoholism as a ªfamily disease.º Family members are seen as suffering from a disease, just as is the alcoholic. The ªdiseaseº of the family member is called ªcodependence,º which has been described as a ªrecognizable pattern of personality traits, predictably found within most members of chemically dependent familiesº (Cermak, 1986, p. 1). Cermak proposed several specific symptoms of codependence: investing self-esteem in controlling self and others in the face of serious adverse circumstances, assuming responsibility for meeting the needs of others before one's own, anxiety and distortions of boundaries around issues of intimacy and separation, enmeshment in relationships with persons with personality disorders or alcohol or drug problems, and having at least three of ten other signs and symptoms: (i) denial as a primary coping strategy; (ii) constricted emotions; (iii) depression; (iv) hypervigilance; (v) compulsive behavior; (vi) anxiety; (vii) being a substance abuser; (viii) being a victim of physical or sexual abuse; (ix) having stress-related illnesses; and (x) being in a relationship with a substance abuser for more than two years without seeking help. Family members who are codependent are assumed to engage in a variety of behaviors that enable the substance abuser. Enabling refers to patterns of behavior that perpetuate the substance use, either by making it easier for the person to use, or by providing positive responses to use and avoiding negative or limit-setting responses. 9.13.4.3.2 Family disease model assessment Assessment from a family disease perspective focuses on the individual functioning of spouses and children of the alcoholic, and does not address assessment of the functioning of the family or the marital dyad as a unit. Similar to family systems approaches, assessment may be embedded within the therapy, with clients selfidentifying their own codependent characteristics as they listen to lectures, read program materials, and participate in group discussions. In addition, a number of self-report measures of codependency have been developed. PotterEfron and Potter-Efron (1989) have developed a definition of codependency that focuses on the effects of involvement with an alcoholic, and identified eight major types of effects: fear, shame and guilt, ªprolonged despair,º anger, denial, rigidity, ªimpaired identity developmentº (p. 39), and confusion. They developed an instrument to assess each of these areas of functioning, and defined criteria for diagnosing a respondent as codependent. The WebbFabean Codependence Assessment Guide

Current Models: Theory, Assessment, and Treatment (Webb, Fabean, & Whalen, 1993a, 1993b) takes a broader view of codependence, drawing upon family systems perspectives as well as the family disease model, and emphasizes dysfunctional patterns of interaction, loss of autonomy, and ªa distortion of realityº (1993a, p. 41). Another aspect of family disease model assessment focuses on the identification of children of alcoholics. The Children of Alcoholics Screening Test (CAST) (Jones, 1983; Staley & el-Guebaly, 1991) assesses latency age, adolescent and adult children of alcoholicsº perceptions of the drinking of their parents, and also assesses psychological characteristics believed to be characteristic of children of alcoholics. A short version of the CAST focuses only on the actual drinking of the parents (Hodgins, Maticka-Tyndale, el-Guebaly, & West, 1993). 9.13.4.3.3 Family disease model treatment (i) Family disease model treatment of the alcoholic Since proponents of the disease model consider alcoholism a family disease, treatment focuses on the alcoholic and family members. In this way, family disease models of treatment are somewhat similar to family systems models. In fact, family disease model treatment is based partially on the work of early system theorists, such as Bowen (1978), and some family disease model programs incorporate systems-based interventions in their treatment agenda (Laundergan & Williams, 1993) A major difference, however, is the disease model focus on self-help groups and on concepts such as enabling, detachment, and codependency, which are not associated with systems approaches. Through separate but parallel involvement with aspects of the 12-step recovery program, the alcoholic works on becoming and remaining abstinent while family members learn about chemical dependency and are encouraged to focus on their own needs rather than continue to organize their lives around alcoholism. A basic tenet of the family disease model is that family members should recognize the effect that alcoholism has had on their lives but allow the alcoholic to take responsibility for his or her own recovery. Treatment of the alcoholic family member focuses on facilitation of participation in AA. This can be done on an inpatient or outpatient basis. Also, many people with an alcohol problem do not seek formal counseling, but become involved with AA on their own. The focus of AA on the alcoholic's recovery, especially in the early stages of recovery,

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precludes formal marital or family therapy until the alcoholic has attained sobriety on their own. Some disease model treatment programs (Nowinski, Baker, & Carroll, 1992) include conjoint sessions towards the end of treatment, to specifically address issues such as enabling and detachment. (ii) Family disease model treatment of family members of the alcoholic As mentioned above, families of alcoholics are presumed to suffer from the disease themselves, though it takes a different form in family members than in the alcoholic. Family members are treated not for a drinking problem, but for codependence. Treatment is through attendance at disease model self-help groups, such as Al-Anon, Al-Ateen (groups for teenaged family members or alcoholics), ACOA (Adult Children of Alcoholics) groups, and COA (Children of Alcoholics) groups. Family members learn about the concept of codependence, and about the effect alcohol has had on their lives and their behavior. They learn that a primary component of overcoming codependence is to stop taking responsibility for the alcoholic's drinking. Family members learn to do this by stopping their enabling behaviors, which minimize the negative consequences of the drinking (Nowinski et al., 1992). Family members are also encouraged to work towards ªdetachment,º which is a functional response to the alcoholism that allows the alcoholic to take responsibility for their alcoholic behavior and its consequences. In detaching, the family members are encouraged to focus on their own well being, and to neutralize alcohol and the alcoholic as the focus of their lives. Treatment of family members can occur on an inpatient basis. Most inpatient rehabilitation programs include a family component in which family members participate in family psychoeducational sessions. Families can also opt for more intensive involvement in some treatment sites, and spend several days living at the treatment facility and participating in a family program. The Hazelden Residential Family Program is a good example of this intensive type of treatment for family members of alcoholics (Laundergan & Williams, 1993). Family members live on site for five days, and participate in 12-step Al-Anon focused treatment in a multifamily group format. Treatment objectives include educating family members about chemical dependency and recovery and their effects on the family, learning about the universality of experience among family members of alcoholics, developing new strategies for coping with family

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relationships and anxiety, and learning about Al-Anon concepts such as enabling and detachment. Finally, in instances where the alcoholic is unwilling to seek treatment, therapists following the disease model may utilize a particular type of family-based technique, called ªIntervention,º which is designed to motivate alcoholics to enter treatment. Intervention assumes that the alcoholic is in denial of their alcohol problem, that the family may have significant influence over the alcoholic's decision to seek treatment, and that the family can begin to recover along with the alcoholic (Liepman, 1993). This technique is also based on the family systems perspective. A family member (or ªemissaryº) contacts a treatment professional who determines if the family is a good candidate for Intervention. Particular family members are then chosen to attend Intervention team training sessions. Teams may include both family members and close friends who have been affected by the alcoholism and who have influence over the alcoholic. Training sessions are used to prepare the team for the process of Intervention, to generate a list of concerns about the alcoholic's drinking and desired outcomes of the Intervention, to teach appropriate communication skills, and to rehearse the presentation. Contingency plans are made for possible resistance. A site is selected, and the alcoholic is brought to the site on the specified day, without prior knowledge, for the ªconfrontation.º The alcoholic is asked to listen quietly while each team member presents their concerns about the drinking. The team emphasizes the effect the alcoholism has had on the alcoholic and on themselves, and the notion that the Intervention is being done in the context of love and concern for the alcoholic. The team asks the alcoholic to accept treatment. If the Intervention is successful, the alcoholic typically is taken immediately to a preselected treatment site, where preparations for admission have been made in advance. In order for an Intervention to be successful, the Interventionist must be highly skilled, the family must be quite motivated, and the preparations extensive (see Liepman, 1993).

9.13.5 SUMMARY AND CONCLUSIONS Alcoholism affects the family profoundly, and family members are in a unique position to exert influence to help the alcoholic stop drinking. This chapter provides a broad overview of historical and modern theory, research, and treatment related to families of alcoholics, focusing, in particular, on three contemporary

models of family treatment of alcoholism: cognitive-behavioral, family systems, and family disease models.

9.13.5.1 Common Elements of the Models Although each model is distinct and has evolved from a different school of thought, several elements are common to the three approaches. All three approaches share the common goal of helping the alcoholic to eliminate alcohol use and to reduce the number and severity of alcohol-related problems. Each model seeks to enhance well being, to relieve alcohol-related distress of the alcoholic and family members, and to improve psychosocial and interactional functioning of the family in general. For all three treatments, the issue of motivation to seek treatment is especially important, and each model has developed techniques to employ the spouse and/or family's influence to motivate the alcoholic, or to help the family despite lack of motivation on the alcoholic's part. The most extreme example is the Intervention, which uses both family disease and family systems interventions to reduce denial of the alcoholic and move the alcoholic toward acceptance of treatment. Unilateral family therapy has been developed to treat spouses and other family members of treatment refusing alcoholics. In each case, the family is involved in the issue of treatment seeking behavior of the alcoholic. Future research might focus on continuing to develop and evaluate methods by which family members can help motivate the alcoholic to get help. Another issue common to all three models is the unit of target for treatment, that is, who is being treated, and who is included in the treatment sessions. Family therapy can include the spousal dyad, the entire nuclear family, the family of origin, and, in some systems and disease models, even other relatives and close friends. Cognitive-behavioral models, up to 1997, have focused on the parent dyad; techniques which include the entire family have yet to be developed. Family systems therapists view family interactions as the target of treatment, while family disease approaches emphasize personal responsibility and separate but parallel treatments. Researchers have focused on integration of disease model concepts into a cognitive-behavioral marital therapy format, with good results (McCrady, Epstein, & Hirsch, 1996). Further work might address the efficacy of cognitive-behavioral family therapy, and incorporation of family disease techniques in the context of couples or family therapy sessions.

References 9.13.5.2 Strengths of Each Model Each of the three models of families of alcoholics has particular strengths. The cognitive-behavioral family model is grounded in a broader social learning theory, and is based on empirical studies of efficacy. Detailed manuals are available to help with training and delivery of cognitive-behavioral treatments. Cognitive-behavioral models are also very strong in assessment of alcohol consumption patterns, including behavioral and cognitive antecedents and consequences, and of coping patterns of the alcoholic and spouse. The family systems model for alcoholism also has several strengths. For instance, this approach is rooted in a broader, theory-based systems model which is well-known and widely accessible. Family systems treatment of alcoholism allows for extensive family involvement and, thus, facilitates comprehensive assessment of the impact of alcohol on family functioning. This approach also facilitates identification and treatment of associated family problems and focuses attention on changes in family patterning and readjustment to a sober lifestyle. Several strengths of the family disease model are notable. Family disease model treatment is quite prevalent, and AA and Al-Anon meetings are available almost daily in most areas. AA and other 12-step meetings are free of charge, making them even more accessible for attendance whenever necessary. Family disease model treatment thus provides free and accessible fellowship, psychoeducational components, and support on an ongoing basis, for years if necessary. In summary, the three contemporary models of family treatment of alcoholism each have particular strengths, a defined theoretical approach, a set of treatment techniques, and varying degrees of empirical support. The choice of which approach to use typically is based not on particular patient characteristics, but on the training and theoretical framework of the therapist. Further work on patient± treatment matching is warranted. The notion of cross-fertilization of treatment techniques is being explored on a limited basis. It is quite difficult to become equally facile with all three treatment approaches, since each requires years of training and practice to master. However, therapists who are solidly grounded in one school of thought might master techniques from other models to employ with certain patients. For instance, a therapist trained in cognitive-behavioral marital therapy could use family systems theory to help conceptualize cases in terms of family symptoms and to identify patterns of dysfunction. A therapist

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who is rooted in family disease theory might want to use particular cognitive-behavioral techniques such as functional analysis to assess drinking patterns and consequences. Further work in this area, testing whether therapists can integrate treatment approaches successfully and whether such integration increases efficacy of the treatment, is encouraged. 9.13.6 REFERENCES Alcoholics Anonymous (1976). Alcoholics Anonymous: The story of how many thousands of men and women have recovered from alcoholism (3rd ed.). New York: Alcoholics Anonymous World Services. American Psychiatric Association (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. American Psychiatric Association (1987). Diagnostic and statistical manual of mental disorders (3rd ed. Rev.). Washington, DC: Author. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Annis, H. M. (1982). Inventory of Drinking Situations (IDS-100). Toronto, Canada: Addiction Research Foundation. Babor, T. F. (1992). Cross-cultural research on alcohol: A quoi bon? In J. E. Helzer & G. J. Canino (Eds.), Alcoholism in North America, Europe, and Asia (pp. 33±52). New York: Oxford University Press. Beattie, M. (1987). Co-dependent no more. Minneapolis, MN: Hazelden. Begun, A., & Zweben, A. (1990). Assessment and treatment of adjustment and coping capacities in children living with alcoholic parents. Alcoholism Treatment Quarterly, 7(2), 23±40. Berger, A. (1981). Family involvement and alcoholicsº completion of a multiphase treatment program. Journal of Studies on Alcohol, 42, 517±520. Bowen, M. (1978). Family therapy in clinical practice. New York: Aronson. Bucholz, K. K. (1992). Alcohol abuse and dependence from a psychiatric epidemiologic perspective. Alcohol Health and Research World, 16, 197±208. Canino, G. J., Burnam, A., & Caetano, R. (1992). The prevalence of alcohol abuse and/or dependence in two Hispanic communities. In J. E. Helzer & G. J. Canino (Eds.), Alcoholism in North America, Europe, and Asia (pp. 131±155). New York: Oxford University Press. Catalano, R. F., Morrison, D. M., Wells, E. A., Gillmore, M. R., Iritani, B., & Hawkins, J. D. (1992). Ethnic differences in family factors related to early drug initiation. Journal of Studies on Alcohol, 53, 208±217. Cermak, T. (1986). Diagnosing and treating co-dependence. Minneapolis, MN: Johnson Institute Books. Chassin, L., Rogosch, F., & Barrera, M. (1991). Substance use and symptomatology among adolescent children of alcoholics. Journal of Abnormal Psychology, 100, 449±463. Collins, R. L. (1990). Family treatment of alcohol abuse: Behavioral and systems perspectives. In R. L. Collins, K. E. Leonard, & J. S. Searles (Eds.), Alcohol and the family: Research and clinical perspectives (pp. 285±308). New York: Guilford Press. Collins, R. L. (1992). Methodological issues in conducting substance abuse research on ethnic minority populations. Drugs and Society, 6, 59±77. Cork, M. (1969). The forgotten children. Toronto, Canada: Addiction Research Foundation.

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treatment. Washington, DC: The White House. Laundergan, J. C., & Williams, T. (1993). The Hazelden residential family program: A combined systems and disease model approach. In T. J. O'Farrell (Ed.), Treating alcohol problems: Marital and family Interventions (pp. 145±169). New York: Guilford Press. Legge, C., & Sherlock, L. (1991). Perception of alcohol use and misuse in three ethnic communities: Implications for prevention programming. The International Journal of Addictions, 25, 629±653. Leonard, K. E., & Jacob, T. (1988). Alcohol, alcoholism, and family violence. In V. B. Van Hasselt, R. L. Morrison, A. S. Bellack, & M. Hersen (Eds.), Handbook of family violence (pp. 383±406). New York: Plenum. Lewis, M. L. (1937). Alcoholism and family casework. Social Casework, 35, 8±14. Lex, B. W. (1987). Review of alcohol problems in ethnic minority groups. Journal of Consulting and Clinical Psychology, 55, 293±300. Liepman, M. R. (1993). Using family influence to motivate alcoholics to enter treatment: The Johnson Institute Intervention Approach. In T. J. O'Farrell (Ed.), Treating alcohol problems: Marital and family interventions (pp. 54±77). New York: Guilford Press. Love, C. T., Longabaugh, R., Clifford, P. R., Beattie, M., & Peaslee, C. F. (1993). The Significant-other Behavior Questionnaire (SBQ): An instrument for measuring the behavior of significant others towards a person's drinking and abstinence. Addiction, 88, 1267±1279. MacDonald, D. E. (1956). Mental disorders in wives of alcoholics. Quarterly Journal of Studies on Alcohol, 17, 282±287. Manson, S. P., Shore, J. H., Baron, A. E., Ackerson, L., & Neligh, G. (1992). Alcohol abuse and dependence among American Indians. In J. E. Helzer & G. J. Canino (Eds.), Alcoholism in North America, Europe, and Asia (pp. 113±130). New York: Oxford University Press. Margolin, G., Talovic, S., & Weinstein, C. D. (1983). Areas of Change Questionnaire: A practical approach to marital assessment. Journal of Consulting and Clinical Psychology, 51, 920±931. Martin, S. E. (1992). The epidemiology of alcohol-related interpersonal violence. Alcohol Health and Research World, 16, 230±237. McCrady, B. S. (1993). Alcoholism. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders. (2nd. ed., pp. 362±395). New York: Guilford Press. McCrady, B. S., & Epstein, E. E. (1995). Marital therapy in the treatment of alcohol problems. In N. S. Jacobson & A. S. Gurman (Eds.), Clinical handbook of couple therapy (pp. 369±393). New York: Guilford Press. McCrady, B. S., & Epstein, E. E. (1996). Theoretical bases of family approaches to substance abuse treatment. In F. Rotgers, D. S. Keller, & J. Morgenstern (Eds.), Treating substance abuse: Theory and technique (pp. 117±142). New York: Guilford Press. McCrady, B. S., Epstein, E. E., & Hirsch, L. S. (1996). Conducting research on Alcoholics Anonymous: A model for using the randomized clinical trial. Journal of Studies on Alcohol, 57, 604±612. McCrady, B. S., Kahler, C. W., Shraedley, P., Epstein, E. E., & Hirsch, L. (1995, June). Coping and psychopathology: Models of wives of alcoholics. Presented at the Annual Meeting of the Research Society on Alcoholism, Steamboat Springs, CO. McCrady, B. S., Miller, K., Epstein, E. E., & Van Horn, D. (1993, November). Spouses of alcoholics: Measurement of coping behaviors and self efficacy for coping. Presented at the Annual Meeting of the Association for Advancement of Behavior Therapy, Atlanta, GA. McCrady, B. S., Stout, R., Noel, N., Abrams, D., & Nelson, H. F. (1991). Effectiveness of three types of spouse-involved behavioral alcoholism treatment.

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Copyright © 1998 Elsevier Science Ltd. All rights reserved.

9.14 Families of Children with Chronic Medical Conditions ROBERT J. THOMPSON, JR. Duke University Medical Center, Durham, NC, USA and LAUREN B. RAEZER Duke University, Durham, NC, USA 9.14.1 INTRODUCTION

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9.14.2 CHRONIC MEDICAL CONDITIONS

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9.14.2.1 Nature 9.14.2.2 Prevalence 9.14.2.3 Assessment 9.14.2.4 Conceptual Models 9.14.2.4.1 Psychological adjustment of children with chronic illness 9.14.2.5 Psychological Adjustment of Siblings 9.14.2.6 Psychological Adjustment of Parents 9.14.2.7 Treatment 9.14.2.7.1 Psychosocial adjustment 9.14.2.7.2 Adherence 9.14.2.8 Pain Management

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9.14.3 FUTURE DIRECTIONS FOR RESEARCH AND PRACTICE

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9.14.3.1 Parenting 9.14.3.2 Family Systems Functioning 9.14.3.3 The Psychosocial Demands of Illness 9.14.3.3.1 The psychosocial demands of the family life cycle 9.14.3.3.2 The interface between the psychosocial demands of the illness and the family life cycle

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9.14.4 SUMMARY

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9.14.5 REFERENCES

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spondingly, many children and their families are engaged in the continuous process of adapting to the stresses and tasks associated with chronic medical conditions over substantial periods of their lives. This has led to a focus on enhancing quality of life in general, and psychosocial adjustment in particular, by

9.14.1 INTRODUCTION Advances in biomedical science and health care have prolonged the lives of children who previously might have died in early childhood. As a consequence, once acutely lethal illnesses have now become chronic conditions. Corre-

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fostering adaptation (Thompson & Gustafson, 1996). Concurrent with these advances in biomedical science, there have been advances in understanding about how biological and psychosocial processes act together in human development across the life course. The social±ecological systems theory perspective on human development has provided a basis for investigating the process of adaptation to chronic medical conditions (Bronfenbrenner, 1977, 1979). There are two major tenets of this theory: there is a reciprocal influence between the child and his or her environmental settings; and transitions, that is, successive shifts in role and setting across the life span have developmental significance. The setting of immediate importance to the child is the family system. Research on adaptation to chronic childhood medical conditions has moved to the analytic level in which various models have been proposed to delineate individual and family adaptational processes associated with quality of life. In general, these models have adopted a stress and coping framework based on cognitivebehavioral and social learning theories (Thompson & Gustafson, 1996; Wallander & Thompson, 1995). The development of these models has enabled application of the considerable body of knowledge regarding the role of cognitive processes, coping methods, and social support in managing stress to the specific situation of adapting to chronic childhood illness. In turn, new knowledge has been generated regarding adaptational processes, particularly in terms of developmental aspects. Dimensions of family functioning have been among the adaptational processes investigated. One of the purposes of this chapter is to summarize these findings. However, research in this area is just beginning to include more comprehensive family systems theory perspectives. Another purpose of this chapter is to integrate family system theories with cognitive-behavioral±social learning theories to formulate a conceptual framework to guide the next stage of research. This will provide the necessary basis for the development of intervention programs to enhance adaptation by fostering the goodness of fit of the special needs and characteristics of the child with a chronic medical condition with his or her family setting. 9.14.2 CHRONIC MEDICAL CONDITIONS 9.14.2.1 Nature Chronic conditions of childhood include developmental disabilities and chronic diseases. The primary focus of this chapter is on chronic childhood illness. A generally accepted defini-

tion of a chronic illness has been provided by Mattsson (1972): a disorder with a protracted course which can be progressive and fatal, or associated with a relatively normal life span despite impaired physical or mental functioning. Such a disease frequently shows periods of acute exacerbation requiring medical attention. (p. 801)

There are a large number of specific chronic childhood illnesses. It is essential to understand the impact of disordered biological processes that result in specific symptoms and functional impairments and treatment regimens. It is also essential to recognize that the impact of chronic childhood illness is dynamic because it occurs within the context of ongoing developmental processes reflecting the mutual and continuous influence of the child on his or her environment (Thompson & Gustafson, 1996). Thus, an appreciation of multiple dimensions of chronic childhood medical conditions requires a biopsychosocial framework (Thompson & Gustafson, 1996). In terms of biomedical dimensions, there is considerable diversity among the chronic illnesses of childhood in etiology and manifestation. Many conditions have a genetic component that affects the functioning of key biological processes, for example, hemophilia and muscular dystrophy, which are sex-linked recessive disorders, and cystic fibrosis and sickle cell disease, which are autosomal recessive disorders. Other conditions, such as cancer, have less clear etiologies and may reflect a combination of environmental factors and genetic predispositions. Chronic conditions also vary in structural and functional manifestations. This variability has been the basis for classification systems that group conditions according to the body system affected such as endocrine, metabolic, hematologic, respiratory, digestive, and musculoskeletal systems (Newacheck, Budetti, & Haflon, 1986). Illnesses have also been categorized according to functional impact which includes both biomedical and psychosocial dimensions such as activity limitations and social roles. For example, Stein and Jessop (1982) developed a measure of functional status which assesses behavioral responses to illness, including communication, mobility, mood, sleeping, and eating, that interfere with the performance of normal social roles for infants, toddlers, preschoolers, and school-age children. In terms of psychosocial dimensions, chronic childhood illness is associated with an increased risk of psychosocial adjustment difficulties for the child and his or her parents and siblings.

Chronic Medical Conditions However, good adjustment is the norm. This variability in psychosocial adjustment has prompted the investigation of processes associated with risk and resiliency in the face of the adversity of chronic childhood illness (Thompson & Gustafson, 1996). Not only does chronic childhood illness impact on biomedical and psychosocial functions, but it also brings a number of challenges that have been conceptualized by Moos and Tsu (1977) in their life crises model as adaptive tasks. Three adaptive tasks are illness-related: (i) dealing with the symptoms; (ii) dealing with the treatment procedures and environments; and (iii) developing and maintaining adequate relationships with the health care team. Four adaptive tasks are related to general life crises: (i) preserving reasonable emotional balance by managing feelings and maintaining hope; (ii) preserving self-image, sense of competence, and mastery and readjusting goals and expectations; (iii) preserving relationships with family and friends; and (iv) preparing for an uncertain future. This delineation of illness tasks and general adaptive tasks has fostered a biopsychosocial approach to psychological adjustment that has included psychosocial perspectives without losing the advantages of the biomedical perspective. Although each chronic illness is characterized by distinct biological processes, symptoms, and specific therapies, the early history of the study of adaptation to chronic childhood illness did not reveal illness-specific patterns of adjustment. There was as much variability in adjustment patterns within illness subgroups as there was between illness subgroups. This led to a focus on commonalities confronting children and their families who are dealing with different chronic illnesses. For example, Pless and Pinkerton (1975) identified the chronicity of the illness and the impact on the family as factors likely to be more important for adjustment than specific characteristics of their illness. This emphasis on similarities across chronic illnesses became known as the noncategorical approach. Subsequently, Stein and Jessop (1982) suggested dimensions of particular importance to psychological adjustment, including whether the condition is visible or invisible, life-threatening or not, stable or unpredictable, involves the central nervous, sensory, or motor systems, or requires an intrusive or demanding routine of care. In the efforts to foster adaptation, there are advantages to both the categorical, that is, illness specific, and noncategorical approaches to chronic childhood illness. What is needed are conceptual frameworks that delineate: (i) meaningful biomedical parameters within and across

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specific illness that elicit ªsignificantly distinct psychosocial demands for the ill individual and his or her familyº (Rolland, 1987, p. 204); and (ii) the specific pattern of individual and family adaptational processes that match or best fit these demands. The advent of systems theory perspectives in general, and family systems theories in particular, is an important tool in the effort to achieve this ªgoodness of fit.º 9.14.2.2 Prevalence Because of the large number and relative rarity of chronic illnesses in childhood, it is difficult to estimate prevalence. Estimates have been based on several epidemiological studies on children's health and development conducted in the USA and the UK (see Cadman, Boyle, Szatmari, & Offord, 1987; Gortmaker & Sappenfield, 1984; Pless & Douglas, 1971; Pless & Roghmann, 1971; Roghmann & Haggerty, 1970). Based on these data, it is estimated that one million children in the USA have a severe chronic illness that may impact their daily functioning (Perrin & MacLean, 1988a) and an additional 10 million children suffer from a less serious chronic disorder (Haggerty, 1984). Overall, 10±20% of children have a chronic disorder (Gortmaker & Sappenfield, 1984) and these children comprise approximately 50% of pediatric practice (Magrab & Calcagno, 1978). In terms of specific illnesses, asthma and other allergic disorders ranked first, sensory disorders ranked second, and nervous systems disorders ranked third (Pless & Roghmann, 1971). Whereas there is little evidence for significant change over time in the incidence of chronic childhood illness, the prevalence has increased. It has been estimated that from the 1960s to the 1980s there was a doubling from 1% to 2% of children with a severe chronic health condition (Gortmaker, 1985). There are three factors contributing to this increase in prevalence. First, advances in health care have increased the life expectancy and survival rates for many illnesses. For example, the median survival age for children with cystic fibrosis increased 2.5 fold, from 11 years in 1966 to 29.4 years in 1993 (Cystic Fibrosis Foundation, 1994). A second factor contributing to increased prevalence are new survivors. With advances in neonatal intensive care since the 1950s, there has been a progressive decline in mortality for infants born prematurely at very low birth weight (51 500 g) from 72% to 27% (McCormick, 1989). However, these new survivors have increased morbidity for respiratory, neurodevelopmental, behavioral, and learning problems. A third factor is new conditions, reflected in infants with prenatal drug exposure

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and children with AIDS who also have increased neurodevelopmental morbidity. Thus, children and their families are, in increasing numbers, confronted with the task of adapting to chronic illness over a substantial period of their lives. 9.14.2.3 Assessment Assessment issues regarding adaptation to chronic childhood illness have two foci: psychosocial adjustment and the correlates, that is, processes or factors, that contribute to or account for differences in psychosocial adjustment. The term adjustment implies a broad range of functioning that includes the clinical/ maladaptive level, and temporal and situational variability (Wallander & Thompson, 1995). Psychosocial adjustment is an umbrella term that encompasses three dimensions: psychological adjustment as reflected in emotional/ behavioral problems/disorders and self-esteem; social adjustment and peer relationships; and school performance. It is useful to adopt a developmental-normative definition of adjustment in which behavior is assessed in terms of age appropriateness and trajectory toward positive adult functioning (Wallander & Thompson, 1995). Because psychological adjustment has been conceptualized and operationalized in numerous ways, methods for assessing children's adjustment have been diverse and include checklists, questionnaires, and diagnostic clinical interviews completed by children or by parents, teachers, or clinicians about children. Classification systems for children's adjustment problems also vary by assessment methods, such as broad-band (e.g., internalizing and externalizing) and narrow-band (e.g., somatization or anxiety) behavior dimensions of the Child Behavior Checklist (Achenbach & Edelbrock, 1983) and the psychiatric diagnoses of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994). Research indicates that there is a range in level of agreement among different informants and alternative methods as a function of age of the child, symptom type, and mental state of the informant (see Thompson & Gustafson, 1996). Evidence indicates that comprehensive assessment of the psychological adjustment of children requires multiple informants and measures (Thompson & Gustafson, 1996). 9.14.2.4 Conceptual Models Research on adaptation to chronic childhood illness has reached the analytic, theory-driven stage and several conceptual models have

emerged. These models have in common the conceptualization of chronic illness as a potential stressor and the conceptualization of adaptation in terms of social-ecological systems. Each model presents variables and processes that are hypothesized to affect adaptation to the stress of chronic illness. Models serve the heuristic value of integrating findings across diverse studies and guiding subsequent investigative studies and initial intervention efforts to enhance adaptation. An early conceptual model, formulated by Pless and Pinkerton (1975), viewed adjustment as multiply determined by the individual's transactions with his or her environment. In addition to conceptualizing chronic illness as a stressor, seminal contributions of this model to subsequent efforts included viewing adaptation as a continuous process over time and the emphasis on the importance of coping methods in the process of adaptation. The life crisis model developed by Moos and Tsu (1977) emphasized the role of individual cognitive processes in appraisal of the significance of the crisis, perceptions of tasks involved, and the selection of coping skills. This model postulates that these processes are influenced by three factors: background and personal characteristics; illness-related factors; and features of the physical and sociocultural environment. In the disability±stress coping model developed by Wallander, Varni, Babani, Banis, and Wilcox (1989), factors hypothesized to play a role in adjustment to chronic illness are organized into a risk-resistance framework. The risk of psychosocial problems is elevated by stress emanating from disease parameters and associated functional limitations and from major life events, daily hassles, or transitions in the course of children's lives. Resistance factors include: intrapersonal factors of temperament, competence, effectance motivation, and problem-solving ability; stress processing factors of cognitive appraisal and coping behaviors; and social±ecological factors such as the family's psychosocial and practical resources. The transactional stress and coping model, developed by Thompson and Gustafson (1996), hypothesizes that the illness±outcome relationship is a function of the transactions among biomedical parameters that reflect the type and severity of illness; demographic parameters of age, sex, and socioeconomic status (SES); and psychosocial processes including appraisal of illness-related and daily stress, expectations of efficacy and locus of control, coping methods, and family functioning. Psychological adjustment is considered in terms of maternal and child adjustment and their interrelationship.

Chronic Medical Conditions In the following sections, what is known about the psychological and social adjustment of children with chronic illness and their siblings, and the psychological adjustment of their parents is summarized. Within each section, information on the correlates of adjustment is summarized in terms of the illness condition, individual, and social-ecological dimensions of concurrent conceptual models. 9.14.2.4.1 Psychological adjustment of children with chronic illness Several hundred studies have addressed the psychological adjustment of children with chronic illness. Reviews available include Wallander and Thompson (1995), Thompson and Gustafson (1996), and a meta-analysis (Lavigne & Faier-Routman, 1993). Two research strategies have been employed: epidemiological surveys and clinical studies. A review of three epidemiological surveys conducted in the late 1960s revealed that children with chronic medical conditions demonstrate a higher proportion of emotional and social problems than their healthy peers, with approximately 30% expected to be impaired by secondary psychological maladjustment by 15 years of age (Pless & Roghmann, 1971). A later epidemiological study reported similar findings, with 33% of children with a chronic physical condition diagnosed with at least one DSM-III disorder (Cadman et al., 1987). Children with chronic illness with and without disability had a risk of psychiatric disorder that was 3.4 times and 2.1 times that of healthy children, respectively. Children with chronic illness and disability were also at increased risk of social adjustment and school difficulties. Studies of adjustment of children with chronic illness, using samples obtained in clinical settings, have suffered from methodological problems. However, studies have been conducted across a number of specific chronic illnesses that have used psychometrically sound assessment methods with samples of patients with a single illness or pooled illnesses compared with healthy or psychiatrically impaired groups or with normative data. Several conclusions can be reached: children with chronic illness are at increased risk of behavioral and emotional problems; internalizing, anxiety-based disorders are most frequent, although milder forms of externalizing problems such as oppositional disorder are evident in some illness and age groups; children with disorders that affect the brain may be at particular risk of adjustment difficulties; and stability in adjustment is only moderate with considerable change across time at the individual level in the presence or absence

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of a behavioral problem or diagnosis, particularly in terms of specific diagnoses or behavioral patterns. Overall, based on epidemiological and clinical studies, it is estimated that children with chronic illness have a risk of adjustment problems that is 1.5±3 times as high as their healthy peers (Pless, 1984). However, major psychiatric disturbance is not common and good adjustment is possible. Thus, there is no simple or direct relationship between chronic childhood illness and psychosocial adjustment (Wallander & Thompson, 1995). This has led to a search for the processes and factors associated with good and poor adjustment. There is substantial literature on the processes and factors that mediate or moderate the psychosocial adjustment of children to the stress of chronic childhood illness. The search for correlates of psychological adjustment is being guided by conceptual models. An organizational framework comprised of condition, child, and social-ecological perspectives has provided a useful framework for integrating findings across studies (Lavigne & Faier-Routman, 1993; Thompson & Gustafson, 1996; Wallander & Thompson, 1995). Condition parameters have included condition type, severity, functional status, prognosis, and duration. Children with conditions involving the brain have more behavior problems and poorer social functioning than children with conditions not involving the brain among which no significant differences have generally been found. The findings of the meta-analysis (Lavigne & Faier-Routman, 1993) provide support for the contribution of condition severity, but numerous studies do not. There is emerging evidence for the relationship of functional status and illness duration with adjustment. Child parameters have included age, gender, temperament, coping methods, and cognitive processes. Whereas most studies report no significant difference in parent and/or teacher reported behavior problems as a function of gender, where differences were found, boys were reported to have more problems. In terms of selfreport, girls report more symptoms of distress than boys. Age effects on behavior/emotional problems and self-esteem have generally not been found but the evidence regarding age of onset is mixed. There is some support for the relationship of temperamental difficulty and mother-reported behavior problems. Children's pain coping strategies characterized by negative thinking have been associated with childreported psychological symptoms, as have been an array of cognitive processes including high levels of perceived stress and negative percep-

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tions of physical appearance and self-esteem. However, the findings regarding perceptions of health locus of control have been mixed. Social-ecological parameters have included life stress, SES, parental adjustment, marital adjustment, and family functioning. SES has been measured inadequately and used infrequently and the findings are inconsistent. Child adjustment is positively related to maternal adjustment. Marital adjustment has been investigated infrequently but there is strong support for the role of family functioning in child psychological adjustment. In general, high levels of cohesion and supportiveness and low levels of conflict are associated with better adjustment. In spite of efforts, the knowledge base is limited regarding the correlates of psychological adjustment of children with chronic illness. The focal points have been condition parameters and family functioning. The interrelationship among condition, child, and social-ecological parameters needs to be investigated longitudinally. To delineate salient intervention targets, there is a particular need for conceptually- and theoretically-driven studies.

9.14.2.5 Psychological Adjustment of Siblings Research on the siblings of children with medical conditions has focused on the negative impact of the child with a handicap on the healthy siblings (Senapati & Hayes, 1988). This is consistent with the commonly held belief that children with a chronic condition have a harmful effect on healthy siblings that is reflected in healthy siblings having a high rate of adjustment problems. This belief in harmful effects is based on considerations of the impact of increased parental stress associated with caring for the disabled child, decreased parental attention to the healthy child, decreased family resources, and pathological identification with the child with a disability (Dyson, 1989). However, the number of empirical studies has been relatively small (see review by Drotar & Crawford, 1985; Lobato, Faust, & Spirito, 1988). In general, there is wide variability in the findings on the frequency of sibling adjustment problems, with some studies reporting adverse psychological outcomes, no significant difference between siblings of children with disabilities and siblings of healthy children, and benefits to siblings of children with disabilities. The one extant longitudinal study reported an increase in depressive affect and social isolation over a five-year period in siblings of children with disabilities compared to healthy controls (Breslau & Prabucki, 1987). These diverse

findings have stimulated efforts to delineate the correlates of good and poor sibling adjustment (Thompson & Gustafson, 1996). Studies have not demonstrated a strong relationship between illness or disability and adverse psychological outcome among siblings (Thompson & Gustafson, 1996). Thus, investigations of the correlates of sibling adjustment have focused on sibling parameters including gender, birth order, and age spacing. In general, increased risk of sibling adjustment problems is associated with closer age spacing and older sisters and younger brothers in relation to the child with a disability (Lobato et al., 1988). Studies are investigating more dynamic processes such as the quality of sibling relations, especially sibling conflict (Hanson et al., 1992) and the impact of chronic illness on siblings' early functioning and interactions (McHale & Gamble, 1989). Again, to delineate specific processes likely to mediate or moderate sibling adjustment, theoretically- and conceptuallydriven studies are necessary.

9.14.2.6 Psychological Adjustment of Parents Psychological adjustment of parents is of concern as one of the impacts of chronic childhood illness because of the previously discussed role of parental adjustment in children's adjustment (Thompson & Gustafson, 1996). Assessment methods have been predominately self-report measures of psychological distress in terms of overall adjustment and specific symptom dimensions, particularly depression and anxiety. Studies have predominately been of mothers. The primary question addressed concerns the frequencies and types of adjustment problems. The search for correlates of parental adjustment is in its early stage. One epidemiological survey, the Ontario Child Health Study, included an assessment of parental adjustment in terms of affective balance in families with children with health problems and families of well children (Cadman, Rosenbaum, Boyle, & Offord, 1991). The findings indicated significantly higher maternal negative affect scores among parents of children with a chronic problem and rates of parentreported mental health treatment for nerves among mothers (29%) and fathers (8%) that was 2±3 times higher than that reported by parents of well children. However, there were no significant differences in other measures including social isolation and alcohol problems. It was concluded that ªcontrary to some clinical opinion, we found no evidence in this general community sample to support the belief that families of children with chronic health pro-

Chronic Medical Conditions blems function any differently than families in the general populationº (Cadman et al., 1991, p. 886). Clinical studies of single or pooled illnesses are the basis for most of what is known about parental adjustment. The results of parent studies that compare self-reported adjustment of chronically ill children with that of healthy children in terms of mean scores on a number of different assessment measures have yielded mixed results. Some studies have reported increased, but subclinical, levels of symptoms, compared to normative data. A research program at Duke University has addressed the questions of type and frequency of adjustment problems in mothers of children with chronic illness and changes in adjustment over time (see Thompson & Gustafson, 1996). Psychological adjustment has been assessed with the SCL-90-R (Derogates, 1977), which is a 90-item self-report measure of psychological distress along symptom dimensions including depression, anxiety, and hostility. The Global Severity Index combines information on numbers of symptoms and intensity of distress and is used as a measure of the overall level of psychological distress. Using nonpatient norms for females, T-scores greater than or equal to 63 (i.e., above the ninetieth percentile) are considered in the clinical range. Poor psychological adjustment is based on criteria for ªcaseness,º T-scores 4 63 on the Global Severity Index or any two of the nine symptoms dimensions. Across a number of separate studies of specific illness subgroups, the rates of poor maternal adjustment were relatively high: Duchenne muscular dystrophy (57%), spina bifida (44%), cystic fibrosis (34%), and sickle cell disease (36%). There was moderate stability in the individual classification of adjustment of mothers of children with cystic fibrosis and sickle cell disease across an 8±19 month period. A change in classification (between good and poor adjustment) was found in 21% and 25% of the mothers of children with cystic fibrosis and sickle cell disease, respectively. Although there have been few studies, the biopsychosocial framework is also useful for integrating findings regarding the correlates of parental psychological adjustment. In terms of illness parameters, maternal adjustment is generally found not to be related significantly to the child's medical status (Kupst & Schulman, 1988) or to the degree of the child's physical impairment (Wallander et al., 1989). However, strong support has been provided for the relationship of intrapersonal parameters, in terms of maternal psychological processes, and social±ecological parameters to maternal adjustment.

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Research guided by the transactional stress and coping model in the Duke University studies has demonstrated that maternal adjustment is associated with lower levels of appraisals of daily stress, less use of palliative methods of coping in general and in relation to adaptive methods of coping, and higher levels of family supportiveness and lower levels of family conflict (Thompson & Gustafson, 1996). Research guided by the disability±stress coping model (Wallander et al., 1989) has provided support for the role of utilitarian family resources (i.e., structural characteristics of the family) and psychosocial family resources (i.e., the family's characteristic mode of perceiving and interacting with the social world) in maternal adjustment. Support has also been provided for the contribution of family life stress to maternal distress (Mullins et al., 1991). 9.14.2.7 Treatment The biopsychosocial framework for adaptation to chronic childhood illness has implications for intervention. Health care services are directed at two outcomes: extending the duration of life and improving the quality of life (Kaplan & Anderson, 1988). With regard to quality of life, the focus of intervention is the adaptation of all children with chronic illness and their families, not just the relative few who experience psychological crises (Drotar, 1981). Thus, intervention includes treatment and prevention. Stein and Jessop (1984) have articulated that the goals of care are to confine the consequences of the biologic disorder to its minimum manifestations, to encourage normal growth and development, to assist the child in maximizing potential in all possible areas, and to prevent or diminish the behavioral and social consequences. (pp. 193±194)

In the situation of chronic childhood illness, both biological and psychosocial processes are mediators of quality of life. One way to improve outcome is to modify health behaviors to enhance functioning. In this regard, adherence to medical regimens and pain management are important. Another way to improve outcome is to limit the disruptive impact of the illness on the normal processes of child development and family functioning (Perrin & MacLean, 1988b). Important in this regard are stress reduction and coping skills and social support enhancement. In general, the research on intervention is based on cognitive-behavior± social learning theory approaches to enhancing adaptation and have focused on three targets:

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psychosocial adjustment, adherence, and pain management.

9.14.2.7.1 Psychosocial adjustment Because the normal development of children is influenced by the social and academic progression that occurs in school (Sexson & MadanSwain, 1993), preventing problems in these areas is integral to optimal adaptation to illness. With the onset of chronic illness, some children experience cognitive impairment, health-related absenteeism, and disruption of peer relationships. In response, multicomponent school reintegration programs have been developed and have been shown to enhance social competence and decrease behavioral adjustment problems (Katz, Rubenstein, Hubert, & Blew, 1988; Katz, Varni, Rubenstein, Blew, & Hubert, 1992). Research has demonstrated the importance of peer support over and above family support in the adjustment of children with chronic illness (Varni, Katz, Colegrove, & Dolgin, 1994; Wallander & Varni, 1989). Consequently, efforts have been directed to developing methods to improve children's social skills and peer relationships through social skills and cognitive problem-solving training. Representative of these efforts is the behavioral group approach for social skills training of elementary school children developed by La Greca and Santogrossi (1980) and the social skills training modules developed by Varni, Katz, Colegrove, and Dolgin (1993). Parenting processes have also been identified as salient intervention targets because of the firmly established contributions of parenting to behavioral adjustment and cognitive and social development (Thompson & Gustafson, 1996). A number of specific parent training programs have been developed and have been shown to be effective in teaching parents procedures for interacting with their children. With regard to behavioral adjustment, the program developed by Forehand (1993) is exemplary. With regard to cognitive and social development, The Partners for Learning Curriculum developed by Sparling and Lewis (1984) has been used successfully in early intervention efforts, such as the Infant Health and Development Program for low birth weight infants (Gross, 1990). The efforts to foster developmentally conducive parent±child interactions are being applied to the management of illness tasks, such as the multifamily group intervention program for children with diabetes and their families, that focuses on improving metabolic status and psychosocial functioning (Satin, La Greca, Zigo, & Skyler, 1989).

9.14.2.7.2 Adherence Noncompliance with medical regimens is relatively common. The median adherence rate for pediatric populations has been estimated to be 50% (Dunbar-Jacob, Dunning, & Dwyer, 1993). The biopsychosocial framework identifies factors affecting adherence (Thompson & Gustafson, 1996). Illness parameters are reflected primarily in treatment regimens. Treatments that are more complex produce negative side effects, interfere with normal activities, are oriented toward the future, and have a negative impact on adherence. In terms of individual processes, adherence is related positively to cognitive and social/emotional developmental level and coping skills. In terms of socialecological parameters, parenting, maternal functioning, and family functioning are related positively to adherence. Given the less than one-to-one relationship of treatment to outcome and the complexity of the interrelationships of illness tasks with developmental life course issues in quality of family life, views regarding compliance are changing. There has been a movement away from viewing noncompliance as an indicator of irresponsibility or forgetfulness to a more considered view in which noncompliance can be a well-reasoned, adaptive choice (Deaton, 1985). Haynes (1976) has classified strategies for improving compliance into three broad categories: educational, behavioral, and combined. Educational strategies provide information. Behavioral strategies focus on changing behavior involved in compliance through stimulus control techniques, self-monitoring of symptoms and self-regulation of medications, and reinforcement of symptom reduction, medication use, and health contacts. The evidence for the effectiveness of behavioral strategies is strong (see Epstein & Cluss, 1982). Corresponding to the change in the view of adherence, there is an increasing emphasis on the process of tailoring a consensual regimen to the specific needs and life situation priorities and realities of the family (Thompson & Gustafson, 1996). 9.14.2.8 Pain Management Pain is a multidimensional experience. It involves a sensory component, nociception, and the psychologic, physiologic, emotional, and behavioral responses to the nociception (McGrath et al., 1990). Approaches to pain management involve analgesics and behavioral intervention focused on cognition and socioenvironmental processes that influence the perception, interpretation, and behavioral responses to pain.

Future Directions for Research and Practice Children with chronic illness may face two types of pain: acute pain associated with invasive medical procedures and chronic and recurrent pain associated with illnesses such as sickle cell disease and arthritis. The efficacy of the cognitive-behavioral approach for both types of pain is well established (Thompson & Gustafson, 1996). These approaches are multicomponent and focus on pain perception regulation and pain behavior modification. Pain perception regulation includes the selfregulatory techniques of deep breathing, muscle relaxation, imagery and behavioral rehearsal; distraction; and active coping attempts. Pain behavior techniques identify and modify socioenvironmental factors that influence behavioral expressions of pain (for details regarding these techniques see Dahlquist, 1992; Jay, 1988; and Varni, Walco, & Wilcox, 1990). The role of the family environment in the reinforcement of pain-coping behaviors has been recognized and these multicomponent pain management programs have parent-training components as well as components to teach children pain-coping skills. For example, the efficacy of cognitivebehavioral family intervention has been demonstrated for children with recurrent abdominal pain (Sanders et al., 1989; Sanders, Shepherd, Cleghorn, & Woolford, 1994).

9.14.3 FUTURE DIRECTIONS FOR RESEARCH AND PRACTICE The next steps in the process of understanding and enhancing adaptation to chronic childhood illness involve further refinements at the analytic level of model development and movement to the experimental level of controlled interventions that would serve to increase quality of life and confirm relationships of processes to outcome. Although much remains to be learned, the next steps in the process must intentionally build on, refine, and extend the current knowledge base. In particular, ªthere is a compelling need to determine how psychosocial adjustment, mediating and moderating adaptational processes, and their interrelationship change over time relative to individual and family developmental phases and illness courseº (Thompson & Gustafson, 1996, p. 20). The experience gained from current models is that adaptation is a multicomponent process in which a large array of factors and processes account for relatively small portions of variance in psychological adjustment. Thus, one way in which advances could occur is by increasing the array. It is also clear that the interrelationship of processes and factors is important as reflected in the findings regarding goodness of fit, for

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example, between methods of coping and situational and adaptational processes. Thus, another way in which advances could occur is by delineating goodness of fit patterns among biomedical, psychosocial, and developmental processes. Goodness of fit patterns offer the potential for identifying at-risk and resilient families and salient intervention targets for treatment and prevention efforts. In considering both extending the array and goodness of fit, two processes are ripe for inclusion within a stress and coping framework: parenting and family system functioning. Both of these processes are within the social-ecological domain and are areas of theoretical and empirical activity in and of themselves. Inclusion of these processes would serve to enhance the sophistication of constructs and measures within the social-ecological domain of biopsychosocial models of adaptation to chronic childhood illness and expand the targets for intervention. 9.14.3.1 Parenting The impact of parents' child rearing strategies and behavior, that is parenting, on the child's cognitive and psychosocial development has been clearly established. ªParenting that is sensitively attuned to children's capabilities and to the developmental tasks they face promotes a variety of highly valued developmental outcomesº (Belsky, Lerner, & Spanier, 1984, p. 85). Thus, there has been a search for factors that influence parenting. Belsky (1984) has formulated a process model of parenting that includes three domains that influence parenting: parent personality, child characteristics, and contextual sources of stress and support. Other lines of research have delineated other parent factors that affect parenting. Parental cognitions, in terms of beliefs and causal attributions regarding child development and behavior, have been shown to influence parents' proactive and reactive responses to their children and their children's development (see Dix, Ruble, & Zambarano, 1989; Miller, 1988). Linkages among parental stress and distress, child-rearing practices, and children's cognitive and social development have also been established. ªGreater stress is associated with less optimal parent and family functioning, less optimal parent±child interactions, and lower child developmental competenceº (Crnic & Greenberg, 1990, p. 1628). Maternal psychological distress has been shown to influence maternal perceptions of, and behavioral interactions with, her children (Webster-Stratton, 1990). For example, maternal depression has been linked to increased

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levels of vague or interrupting commands to which children cannot comply (Forehand, Lautenschlager, Faust, & Graziano, 1986). An integration of these lines of research into a cognitive and stress processing model of parenting has been suggested previously (Thompson & Gustafson, 1996). The model is based on the premise that if parenting is the primary mechanism for reflecting the socialecological effects on children's development, then enhancing the goodness of fit of parenting with the child's special needs and characteristics would promote development and adaptation. In turn, parents' psychological functioning, in terms of stress and distress, and parent childrearing knowledge, beliefs, and attributions, are major influences on parenting. These processes become salient targets for intervention programs that combine educational and stressprocessing components. In these efforts, basic programs to enhance parent effectiveness can be modified to address the illness-specific and general adaptative tasks associated with chronic childhood illness. 9.14.3.2 Family Systems Functioning Family functioning has been one of the most frequently investigated correlates of psychological adjustment of children with chronic illness and their parents. Conceptual models afford family functioning a prominent role. However, for the most part, family functioning has been conceptualized and measured in terms of various dimensions such as cohesion, experiences, and conflict. The opportunity exists to go beyond such conceptualizations to employ the richer conceptualizations of family dynamics captured by family system theories. Although rich, these theories have been difficult to operationalize and evaluate empirically. However, with the formulation of the Family System Health Model, a basis for bringing family system theory approaches to bear in adaptation to chronic childhood illness is provided (Rolland, 1984, 1987, 1993). Rolland's (1984, 1987, 1993) conceptual model of the adaptation of families confronting chronic and life-threatening disorders is based on the premise that illness and family processes interact in a constantly evolving fashion. Categorizing illnesses according to their psychosocial demands on the family system provides a common link between illness and family processes. The goodness of fit between the psychosocial demands of the disorder and the family's style of functioning and resources is viewed as a prime determinant of successful vs. problematic family coping and adaptation (Rolland, 1993). Within this model, goodness

of fit is determined on the basis of a three-way congruence between the pull from the psychosocial demands of the illness, the pull from the demands of the family's life cycle stage, and the style of family functioning. Pull is conceptualized as either the need for family members to focus their energies inward and work together to perform family developmental tasks, termed centripetal pull, or the need for the family to work to support the development of individual members outside of the family system, termed centrifugal pull. Better family member adjustment is expected if the style of family functioning required (or pulled) by the family's current life cycle stage also fits that required by the illness. Rolland's (1993) model provides a detailed explanation of how to delineate the psychosocial demands of the illness and the family life cycle and how to relate those demands to the family's life structure and style of functioning. One advantage of Rolland's (1993) model is its comprehensiveness, but his model and its components have not yet been operationalized. Thus, an effort will be made to illustrate potential ways to operationalize key constructs so that these can be investigated empirically. 9.14.3.3 The Psychosocial Demands of Illness Rolland (1993) suggested that all illnesses elicit some degree of centripetal pull on the family system. However, the degree of pull varies as a function of the illness' psychosocial demands which arise out of the interaction between the biomedical parameters and the illness phase of the specific condition. Biomedical parameters which place psychosocial demands on the family system include onset (acute or chronic), course (constant, progressive, or relapsing), outcome (fatal, nonfatal, or potentially fatal), and degree of incapacitation (incapacitating or nonincapacitating). These parameters have been combined to form a grid which yields a psychosocial typology comprising 32 illness types (Rolland, 1993). Illness types range from those that are acute in onset, constant, incapacitating, but nonfatal, such as congenital malformations, to those that are acute in onset, relapsing, nonincapacitating, and possibly fatal, such as sickle cell disease, to those that are gradual in onset, progressive, increasingly incapacitating, and fatal, such as cystic fibrosis. The tendency for an illness to elicit centripetal pull increases with the level of incapacitation or risk of progression and/or death (Rolland, 1993). For example, progressive illnesses elicit a stronger centripetal pull over time than illnesses with a constant course. The continual addition of new demands

Future Directions for Research and Practice associated with progressive conditions keep the family's energy perpetually focused inward, often hindering the family's advancement through the life course developmental process (Rolland, 1993). In contrast, illnesses with a constant course (that are not severely incapacitating) require an initial period of readjustment, but then allow the family to regain its normal style of functioning. There are two disease phases of importance to psychosocial demands and the corresponding degree of centripetal pull on the family system: crisis and chronic. Crisis phases are periods marked by the onset or significant exacerbation of disease symptoms. The diagnostic and terminal periods of the illness process are considered crisis phases. The diagnostic period ranges from the period in which the family first notices illness symptoms to the initial period of readjustment after the diagnosis. Family psychosocial tasks associated with this period include beginning the process of coping with the illness symptoms, dealing with the treatment regimens, and becoming familiar with the hospital staff and environment. The terminal period of the illness process is the period during which the inevitability of the patient's death becomes apparent. During this period, the family must cope with issues of separation, death, grief, and resumption of normal life. Family members must shift their focus from trying to control the illness to coping with the process of letting go. Further, the family must remain open emotionally in order to deal with unfinished business, cope with practical tasks, and say their final goodbyes. Crisis phases, whether they are the diagnostic or terminal periods of the illness process or simply periods of symptom exacerbation during the chronic phase, typically place demands on the family system which require family integration and diffuse boundaries between family members. These phases are therefore viewed as eliciting a centripetal pull on the family system (Rolland, 1993). The chronic phase is the asymptomatic period or period of baseline illness symptoms that occurs between the family's initial readjustment after the diagnosis and the period in which symptoms of terminal disease first appear. This phase is variable in length and, depending on the illness type, is marked either by constancy, progressive decline, or episodic change. Further, this period can be disrupted by crisis phases whenever there is an acute increase in illness symptoms. Within this period, the family must learn to live day-to-day with the chronic condition, while maintaining as normal a life as possible. It is no longer critical that the family focuses all of its energy on the illness process.

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Family members can, instead, begin to concentrate on their own individual development as well as the family's development as a system. The demands associated with the chronic phase are therefore thought to elicit a weak centripetal pull on the family system (Rolland, 1993). The psychosocial demands associated with biomedical parameters and illness phases are combined to determine the degree of centripetal pull on the family system. For example, a severely incapacitating and/or fatal disease in the crisis phase of the illness process is thought to elicit a strong centripetal pull on the family system, whereas a nonincapacitating and nonfatal condition in the chronic phase of the illness process is thought to allow more individuation among family members. It is hypothesized that better family member adjustment is expected if the family's style of functioning (e.g., high or low cohesion) fits the demands of the illness (i.e., strong or weak centripetal pull). For example, since the demands associated with the onset or crisis phase of an illness elicit a strong centripetal pull, it is hypothesized that high family cohesion during these periods leads to better family member adjustment. This hypothesis could be tested empirically by comparing the relationship between high family cohesion and child adjustment during the crisis phase of an illness to the relationship between high family cohesion and child adjustment during the chronic phase of an illness that is not progressive, incapacitating, or fatal. 9.14.3.3.1 The psychosocial demands of the family life cycle The life cycle is a key determinant of the psychosocial demands on the family system. The family life cycle refers to the basic sequence and development of the life course within which family differences occur. The life cycle can be divided into a series of stages that progress from the stage during which the family bears children through the stage during which the family has adolescents to the stage during which the family launches young adults. The terms centripetal and centrifugal pull are also useful in conceptualizing the psychosocial demands of different family life cycle stages. The developmental tasks of the family life cycle shift from demanding interdependence and family teamwork (centripetal pull) during early stages of the life cycle, such as the childbearing stage, to emphasizing individuation and personal autonomy (centrifugal pull) among family members during later stages of the life cycle, such as the stage in which the family launches young adults (Rolland, 1993). In this way, stages of the life

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cycle can be defined in terms of the degree to which psychosocial demands reflect the relative need for family members to channel their energies and work together to perform those tasks. It is hypothesized that better family adjustment is expected if the family's style of functioning fits the demands of the family's current life cycle stage (i.e., centripetal or centrifugal). For example, since the demands of the early stages of the life cycle require interdependence among family members, it is hypothesized that high family cohesion during these periods leads to better family member outcomes. This hypothesis could be tested empirically by comparing the relationship between high family cohesion, which can be assessed using measures such as the Family Environment Scale (Moos & Moos, 1981) or the Family Adaptability and Cohesion Evaluation Scales III (Olson, Portner, & Lavee, 1985), and child adjustment during an early stage within the life cycle to the relationship between high family cohesion and child adjustment during a late stage within the life cycle. 9.14.3.3.2 The interface between the psychosocial demands of the illness and the family life cycle Combination of the key concepts regarding the family life cycle and the illness process provides a foundation for understanding family adaptation to chronic illness. Rolland (1993) proposed that the illness process and family life cycle interact, each placing their own demands on the family system. The goodness of fit between the pull from psychosocial demands of the illness and the pull from the developmental demands of the family's life cycle stage moderates family adaptation (Rolland, 1993). Better family member adjustment is expected if the pull of the demands associated with the family's life cycle stage is complementary, rather than conflicting, with the pull of the demands related to illness phase (Rolland, 1993). For example, if the crisis phase of an illness (which elicits a strong centripetal pull on the family) interfaces with the early childrearing years of the family life cycle (which also elicits a centripetal pull), better family member adjustment would be expected than if the crisis phase occurred during a centrifugal stage of family development (such as the period during which the family launches young adults). Specifically, illnesses that elicit a strong centripetal pull, those that are progressive, relapsing, severely incapacitating, and/or fatal, are thought to be particularly problematic to the family system if their onset coincides with a later stage of the family life

cycle since the pull of the demands of the illness does not fit the pull of the demands associated with the family's life cycle stage (Rolland, 1993). These hypotheses can be tested empirically by comparing child adjustment during a period in which a fit is thought to exist between the pull of psychosocial demands of the illness and that of the family life cycle demands (e.g., when the onset of a progressive, incapacitating, and/or fatal illness occurs during a stage early in the family life cycle) to child adjustment during a period in which a fit between demands is not thought to exist (e.g., when the onset of a progressive, incapacitating, and/or fatal illness occurs during a stage late in the family life cycle). It is hypothesized that child adjustment would be better in the fit rather than the nonfit condition. Based on the interaction between the pull of illness and family life cycle demands, it is also hypothesized that a goodness of fit exists if the style of family functioning required for the family to deal appropriately with the psychosocial demands of the illness is congruent with the style of family functioning needed to meet the demands of the family's current life cycle stage. Specifically, high family cohesion would be hypothesized to fit both illness and family demands during periods in which both the family's life cycle stage and illness process elicit a strong centripetal pull on the family system. Since a fit exists between these variables within this situation, better family member adjustment would be expected than if high family cohesion did not fit illness and family demands. The model is not limited to cohesion as the measure of family style. Other aspects of family functioning such as control, expressiveness, or support could be hypothesized as a fit between illness and family processes during different periods of illness and family development. It is the eventual hope that the information yielded from the operationalization of Rolland's (1993) model will enable investigators and clinicians to categorize families facing pediatric chronic illness as high or low risk for adjustment problems based on this three-way goodness of fit schema. Intervention efforts, appropriate to illness and family developmental demands, could then be developed and provided to atrisk families to enhance adaptation and prevent adjustment problems.

9.14.4 SUMMARY Chronic illness impacts on an increasing number of children and their families and is a significant stressor with an increased risk for psychological adjustment difficulties. However,

References most children and families adapt well to the stresses and tasks associated with chronic childhood illness and good adjustment is the norm. Research on adaptation to chronic childhood illness has progressed to the analytic level of conceptually- and theoretically-driven studies that seek to delineate the biomedical, intrapersonal, and social-ecological processes associated with varying degrees of adjustment. The findings from these analytic level of studies have provided a foundation for moving to the experimental level of controlled intervention studies to enhance adaptation and quality of life. More specifically, improved stress processing is a salient target for interventions designed to enhance coping skills and foster social support. In these efforts, it is recognized that adaptation is a multidimensional process. There is no one right way and the emphasis is upon achieving a good fit among illness demands and intrapersonal and social-ecological processes to enhance quality of life in general, and psychological adjustment, in particular, of all family members. While these intervention studies are underway, the proposed expansion of models to incorporate parenting processes and family system functioning will provide the foundation for the next wave of intervention targets. This expansion within the social-ecological domain of adaptative processes is particularly necessary to enable movement to another level of goodness of fit. That is, intervention programs can be tailored to diverse cultural beliefs and practices regarding health, illness, child development, and family functioning.

9.14.5 REFERENCES Achenbach, T., & Edelbrock, C. (1983). Manual for the Child Behavior Checklist and Revised Child Behavior Profile. Burlington, VT: Queen City Printers. American Psychiatric Association (APA) (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: APA. Belsky, J. (1984). The determinants of parenting: A process model. Child Development, 55, 83±96. Belsky J., Lerner, R., & Spanier, G. (1984). The child in the family. Reading, MA: Addison-Wesley. Breslau, N., & Prabucki, K. (1987). Siblings of disabled children. Archives of General Psychiatry, 44, 1040±1046. Bronfenbrenner, U. (1977). Toward an experimental ecology of human development. American Psychologist, 32, 513±531. Bronfenbrenner, U. (1979). The ecology of human development. Cambridge, MA: Harvard University Press. Cadman, D., Boyle, M., Szatmari, P., & Offord, D. R. (1987). Chronic illness, disability, and mental and social well-being: Findings of the Ontario Child Health Study. Pediatrics, 79, 805±813. Cadman, D., Rosenbaum, P., Boyle, M., & Offord, D. R. (1991). Children with chronic illness: Family and parent demographic characteristics and psychosocial adjust-

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ment. Pediatrics, 87, 884±889. Crnic, K. A., & Greenberg, M. T. (1990). Minor parenting stress with young children. Child Development, 61, 1628±1637. Cystic Fibrosis Foundation (CFC) (1994). Patient Registry 1993 annual data report. Bethesda, MD: CFC. Dahlquist, L. M. (1992). Coping with aversive medical treatments. In A. M. La Greca, L. J. Siegel, J. L. Wallander, & C. E. Walker (Eds.), Stress and coping in child health (pp. 345±376). New York: Guilford Press. Deaton, A. V. (1985). Adaptive noncompliance in pediatric asthma: The parent as expert. Journal of Pediatric Psychology, 10, 1±14. Derogatis, L. R. (1977). SCL-90-R manual. Baltimore, MD: Johns Hopkins University, Clinical Psychometrics Research Unit. Dix, T. H., Ruble, D. N., & Zambarano, R. J. (1989). Mothers' implicit theories of discipline: Child effects, parents effects, and the attribution process. Child Development, 60, 1373±1391. Drotar, D. (1981). Psychological perspectives in chronic childhood illness. Journal of Pediatric Psychology, 6, 211±228. Drotar, D., & Crawford P. (1985). Psychological adaptation of siblings of chronically ill children. Research and practice implications. Journal of Developmental and Behavioral Pediatrics, 6, 355±362. Dunbar-Jacob, J., Dunning, E. J., & Dwyer, K. (1993). Compliance research in pediatric and adolescent populations: Two decades of research. In N. P. Krasnegor, L. Epstein, S. B. Johnson, & S. J. Yaffe (Eds.), Developmental aspects of health compliance behavior (pp. 29±51). Hillside, NJ: Erlbaum. Dyson, L. L. (1989). Adjustment of siblings of handicapped children: A comparison, Journal of Pediatric Psychology, 14, 215±229. Epstein, L. H., & Cluss, P. A. (1982). A behavioral medicine perspective on adherence to long-term medical regimens. Journal of Consulting and Clinical Psychology, 50, 950±971. Forehand, R. (1993). Twenty years of research on parenting: Does it have practical implications for clinicians working with parents and children? The Clinical Psychologist, 46, 169±176. Forehand, R., Lautenschlager, G. L., Faust, J., & Graziano, W. G. (1986). Parent perceptions and parentchild interaction in clinic-referred children: A preliminary investigation of the effects of maternal depressive mood. Behavior Research and Therapy, 24, 73±75. Gortmaker, S. L. (1985). Demography of chronic childhood diseases. In N. Hobbs & J. M. Perrin (Eds.), Issues in the care of children with chronic illness: A sourcebook of problems, services, and policies (pp. 135±154). San Francisco: Jossey-Bass. Gortmaker, S. L., & Sappenfield, W. (1984). Chronic childhood disorders: Prevalence and impact. Pediatric Clinics of North America, 31, 3±18. Gross, R. T. (1990). Enhancing the outcomes of low birth weight, premature infants: A multisite, randomized trial. Journal of the American Medical Association, 263, 3035±3042. Haggerty, R. J. (1984). Symposium on chronic disease in children. Pediatric Clinics of North America, 31, 1±2. Hanson, C. L., Henggeler, S. W., Harris, M. A., Cigrang, J. A., Schinkel, A. M., Rodrigue, J. R., & Klesges, R. C. (1992). Contributions of sibling relations to the adaptation of youths with insulin-dependent diabetes mellitus. Journal of Consulting and Clinical Psychology, 60, 104±112. Haynes, R. B. (1976). Strategies for improving compliance: A methodologic analysis and review. In D. L. Sackett & R. B. Haynes (Eds.), Compliance with therapeutic regi-

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mens (pp. 69±82). Baltimore, MD: Johns Hopkins University Press. Jay, S. M. (1988). Invasive medical procedures: Psychological intervention and assessment. In D. K. Routh (Ed.), Handbook of pediatric psychology (pp. 401±425). New York: Guilford Press. Kaplan, R. M., & Anderson, J. P. (1988). The general health policy model: Update and application. Health Services Research, 23, 203±235. Katz, E. R., Rubenstein, C. L., Hubert, N. C., & Blew, A. (1988). School and social reintegration of children with cancer. Journal of Psychosocial Oncology, 6, 123±140. Katz, E. R., Varni, J. W., Rubenstein, C. L., Blew, A., & Hubert, N. (1992). Teacher, parent, and child evaluative ratings of school reintegration intervention for children with newly diagnosed cancer. Children's Health Care, 21, 69±75. Kupst, M. J., & Schulman, J. L. (1988). Long-term coping with pediatric leukemia: A six-year follow-up study. Journal of Pediatric Psychology, 13, 7±23. La Greca, A. M., & Santogrossi, D. A. (1980). Social skills training with elementary school students: A behavioral group approach. Journal of Consulting and Clinical Psychology, 48, 220±227. Lavigne, J. V., & Faier-Routman, J. (1993). Correlates of psychological adjustment to pediatric physical disorders: A meta-analytic review and comparison with existing models. Journal of Developmental and Behavioral Pediatrics, 14, 117±123. Lobato, D., Faust, D., & Spirito, A. (1988). Examining the effects of chronic disease and disability in children's sibling relationships. Journal of Pediatric Psychology, 13, 389±407. Magrab, P. R., & Calcagno, P. L. (1978). Psychological impact of chronic pediatric conditions. In P. R. Magrab (Ed.), Psychological management of pediatric problems (Vol. 1, pp. 3±14). Baltimore, MD: University Park Press. Mattsson, A. (1972). Long-term physical illness in childhood: A challenge to psychosocial adaptation. Pediatrics, 50, 801±811. McCormick, M. C. (1989). Long-term follow-up of infants discharged from neonatal intensive care units. Journal of the American Medical Association, 261, 1767±1772. McGrath, P. J., Beyer, J., Cleeland, C., Eland, J., McGrath, P. A., & Portenoy, R. (1990). Report of the subcommittee on assessment and methodologic issues in the management of pain in childhood cancer. Pediatrics, 86 (Suppl.), 814±817. McHale, S. M., & Gamble, W. C. (1989). Sibling relationships of children with disabled and nondisabled brothers and sisters. Developmental Psychology, 25, 421±429. Miller, S. A. (1988). Parents' beliefs about children's cognitive development. Child Development, 59, 259±285. Moos, R. H., & Moos, B. S. (1981). Family Environment Scale manual. Palo Alto, CA: Consulting Psychologists Press. Moos, R. H., & Tsu, U. D. (1977). The crisis of physical illness: An overview. In R. H. Moos (Ed.), Coping with physical illness (pp. 3±21). New York: Plenum. Mullins, L. L., Olson, R. A., Reyer, S., Bernardy, N., Husztic, H. C., & Volk, R. J. (1991). Risk and resistance factors in the adaptation of mothers of children with cystic fibrosis. Journal of Pediatric Psychology, 16, 701±715. Newacheck, P. W., Budetti, P. P., & Haflon N. (1986). Trend in activity-limiting chronic conditions among children. American Journal of Public Health, 76, 178±184. Olson, D. H., Portner, J., & Lavee, Y. (1985). FACES III manual. Unpublished manual. (Available from D. H. Olson, Family Social Science, University of Minnesota, 290 McNeal Hall, St. Paul, MN, 55108). Perrin, J. M., & MacLean, W. E., Jr. (1988a). Biomedical

and psychosocial dimensions of chronic illness in childhood. In P. Karoly (Ed.), Handbook of child health assessment: Biopsychosocial perspectives (pp. 11±28). New York: Wiley. Perrin, J. M., & MacLean, W. E., Jr. (1988b). Children with chronic illness: The prevention of dysfunction. Pediatric Clinics of North America, 35, 1325±1337. Pless, I. B. (1984). Clinical assessment: Physical and psychological functioning. Pediatric Clinics of North America, 31, 33±45. Pless, I. B., & Douglas, J. W. B. (1971). Chronic illness in childhood: Epidemiological and clinical characteristics. Pediatrics, 47, 405±414. Pless, I. B., & Pinkerton, P. (1975). Chronic childhood disorders: Promoting patterns of adjustment. Chicago: Year-Book Medical Publishers. Pless, I. B., & Roghmann, K. J. (1971). Chronic illness and its consequences: Observations based on three epidemiological surveys. Journal of Pediatrics, 79, 351±359. Roghmann, K. J., & Haggerty, R. J. (1970). Rochester Child Health Surveys: I. Objectives, organization and methods. Medical Care, 8, 47±59. Rolland, J. S. (1984). Toward a psychosocial typology of chronic and life-threatening illness. Family Systems Medicine, 2, 245±263. Rolland, J. (1987). Chronic illness and the life cycle: A conceptual framework. Family Process, 26, 203±221. Rolland, J. S. (1993). Mastering family challenges in serious illness and disability. In F. Walsh (Ed.), Normal family processes (2nd ed.). New York: Guilford Press. Sanders, M. R., Rebgetz, M., Morrison, M., Bor, W., Gordon, A., Dadds, M., & Shepherd, R. (1989). Cognitive-behavioral treatment of recurrent nonspecific abdominal pain in children: An analysis of generalization, maintenance, and side effects. Journal of Consulting Psychology, 57, 294±300. Sanders, M. R., Shepherd, R. W., Cleghorn, G., & Woolford, H. (1994). The treatment of recurrent abdominal pain in children: A controlled comparison of cognitive-behavioral family intervention and standard pediatric care. Journal of Consulting and Clinical Psychology, 62, 306±314. Satin, W. M., La Greca, A. M., Zigo, M. A., & Skyler, J. S. (1989). Diabetes in adolescence: Effects of multifamily group intervention and parent stimulation of diabetes. Journal of Pediatric Psychology, 14, 259±275. Senapati, R., & Hayes, A. (1988). Sibling relationships of handicapped children: A review of conceptual and methodological issues. International Journal of Behavioral Development, 11, 89±115. Sexson, S. B., & Madan-Swain, A. (1993). School reentry for the child with chronic illness. Journal of Learning Disabilities, 26, 115±125. Sparling, J., & Lewis, I. (1984). Partners for learning. Lewisville, NC: Kaplan Press. Stein, R. E. K., & Jessop, D. J. (1982). A noncategorical approach to chronic childhood illness. Public Health Reports, 97, 354±362. Thompson, R. J., Jr., & Gustafson, K. E. (1996). Adaptation to chronic childhood illness. Washington, DC: American Psychological Association. Varni, J. W., Katz, E. R., Colegrove, R., Jr., & Dolgin, M. (1993). The impact of social skills training on the adjustment of children with newly diagnosed cancer. Journal of Pediatric Psychology, 18, 751±767. Varni, J. W., Katz, E. R., Colegrove, R., & Dolgin, M. (1994). Perceived social support and adjustment of children with newly diagnosed cancer. Journal of Developmental and Behavioral Pediatrics, 15, 20±26. Varni, J. W., Walco, G. A., & Wilcox, K. T. (1990). Cognitive-biobehavioral assessment and treatment of pediatric pain. In A. M. Gross & R. S. Drabman

References (Eds.), Handbook of clinical behavioral pediatrics (pp. 83±97). New York: Plenum. Wallander, J. L., & Thompson, R. J., Jr. (1995). Psychosocial adjustment of children with chronic physical conditions. In M. C. Roberts (Ed.), Handbook of pediatric psychology (2nd ed., pp. 124±141). New York: Guilford Press. Wallander, J. L., & Varni, J. W. (1989). Social support and adjustment in chronically ill and handicapped children. American Journal of Community Psychology, 17, 185±201. Wallander, J. L., Varni, J. W., Babani, L., Banis, H. T., &

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Wilcox, K. T. (1989). Family resources as resistance factors for psychological maladjustment in chronically ill and handicapped children. Journal of Pediatric Psychology, 14, 157±173. Wallander, J. L., Varni, J. W., Babani, L., DeHaan, C. B., Wilcox, K. T., & Banis, H. T. (1989). The social environment and the adaptation of mothers of physically handicapped children. Journal of Pediatric Psychology, 14, 371±387. Webster-Stratton, C. (1990). Stress: A potential description of parent perceptions and family interactions. Journal of Clinical Child Psychology, 19, 302±312.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

9.15 Families of Children with Serious Emotional Disturbance CYNTHIA R. ELLIS and NIRBHAY N. SINGH Virginia Commonwealth University, Richmond, VA, USA 9.15.1 INTRODUCTION

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9.15.2 CHARACTERISTICS OF CHILDREN AND THEIR FAMILIES

236 237 237 239

9.15.2.1 Children in Restrictive Settings 9.15.2.2 Children in Community Settings 9.15.2.3 Families 9.15.3 FAMILY IMPACT

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9.15.3.1 Definition and Conceptualization 9.15.3.2 Research Findings 9.15.4 FAMILY SUPPORT

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9.15.4.1 Definition and Conceptualization 9.15.4.2 Research Findings 9.15.5 FAMILY EMPOWERMENT

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9.15.5.1 Definition and Conceptualization 9.15.5.2 Research Findings 9.15.6 FAMILY INVOLVEMENT

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9.15.6.1 Definition and Conceptualization 9.15.6.2 Research Findings 9.15.7 FAMILY±PROFESSIONAL PARTNERSHIP

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9.15.7.1 Definition and Conceptualization 9.15.7.2 Research Findings 9.15.8 FAMILY AND CULTURAL DIVERSITY

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9.15.8.1 Definition and Conceptualization 9.15.8.2 Research Findings 9.15.9 SUMMARY

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9.15.10 REFERENCES

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many children. Given a population of three million children with SED, this meant that over two million of them were either not receiving needed services or the services that they were receiving were inappropriate. Spurred by these findings, as well as by demands of advocacy groups for better services for these children, Congress appropriated funds that enabled the

9.15.1 INTRODUCTION The seminal work of Knitzer (1982) documented that at least two of every three children with serious emotional disturbance (SED) in the USA did not receive the services that they needed and, when they did receive services, the services were inappropriate for the needs of 235

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creation of the Child and Adolescent Service System Program (CASSP) through the National Institute of Mental Health in 1984. This initiative enabled states and communities to begin developing comprehensive systems of care for children with SED and their families. Within 10 years, the CASSP had assisted all 50 states to improve their services for these children (Davis, Yelton, Katz-Leavy, & Lourie, 1995). Most of the service systems developed by the states were based on a system-of-care concept that was advocated by CASSP (Stroul & Friedman, 1986). Although service delivery systems have taken new forms since the late 1980s, the major tenets of the system-of-care philosophy are still much in evidence today, both at local and state levels. The core values of this philosophy require that the system of care be child-centered and family focused, community-based, and culturally competent. In addition, Stroul and Friedman (1986, p. xxiv) provided a set of 10 philosophical guiding principles that is being used by communities and states in developing their systems of care, including: (i) Children with emotional disturbances should have access to a comprehensive array of services that address the child's physical, emotional, social, and educational needs. (ii) Children with emotional disturbances should receive individualized services in accordance with the unique needs and potentials of each child, and be guided by an individualized service plan. (iii) Children with emotional disturbances should receive services within the least restrictive, most normative environment that is clinically appropriate. (iv) The families and surrogate families of children with emotional disturbances should be full participants in all aspects of the planning and delivery of services. (v) Children with emotional disturbances should receive services that are integrated, with linkages between child-serving agencies and programs and mechanisms for planning, developing, and coordinating services. (vi) Children with emotional disturbances should be provided with case management or similar mechanisms to ensure that multiple services are delivered in a coordinated and therapeutic manner so that they can move through the system of services in accordance with their changing needs. (vii) Early identification and intervention for children with emotional disturbances should be promoted by the system of care in order to enhance the likelihood of positive outcomes. (viii) Children with emotional disturbances should be ensured smooth transitions to the adult service system as they reach maturity.

(ix) The rights of children with emotional disturbances should be protected, and effective advocacy efforts for children and youth with emotional disturbances should be promoted. (x) Children with emotional disturbances should receive services without regard to race, religion, national origin, sex, physical disability, or other characteristics, and services should be sensitive and responsive to cultural differences and special needs. Many communities and states have used these principles to develop local systems of care aimed at improving the outcomes for children and their families. Regardless of the details, all of the systems of care focus equally on the children and their families. Further, evaluation of these systems of care include family outcomes as an integral part of overall systems outcome. The focus of this chapter is on issues that families of children with SED face in their daily lives. We begin with a discussion of the characteristics of the children with SED and their families, and note that, because of the heterogeneity of the children with emotional and behavioral disorders, these families face multiple problems not only in the direct care of their children but also in accessing multiple services for them. Next, we consider the issues of family impact and family support. Obviously, caring for a child with SED affects the lifestyle of the children's families and, although not all of it is negative, some families will need social, financial, and mental health support to cope with having a child with SED. Issues of family empowerment and involvement with respect to their importance in accessing services are discussed, and family±professional partnerships in terms of having parents as full partners with professionals in determining the needs and nature of the services provided to their children are considered. Finally, some of the issues related to cultural diversity and how these may affect families, professionals, and service delivery systems are discussed.

9.15.2 CHARACTERISTICS OF CHILDREN AND THEIR FAMILIES Depending on the methodology and sample size used in epidemiological studies, the prevalence of children with SED ranges between 11% and 26%, with about 3±6% having serious psychopathology in need of treatment (Bird et al., 1988; Brandenberg, Friedman, & Silver, 1987; Costello et al., 1988). The impact of emotional disorders on these children's lives, as well as on their families and their communities, is immense. For example, because of their emotional and behavioral problems, these

Characteristics of Children and their Families children are very likely to have severe adjustment and psychological problems as they grow older (Wagner, Blackorby, Cameto, Hebbeler, & Newman, 1993). The school dropout rate of students educationally labeled as SED exceeds 50% (US Department of Education, 1994), which means that the majority of them will face major obstacles in obtaining and maintaining a well-paid job. Of those who complete high school, up to 40% of them do not seek further education, vocational training, or regular employment (Wagner et al., 1993). Further, children with SED are often at risk for outof-home and out-of-community placements because of their behavior and psychiatric problems.

9.15.2.1 Children in Restrictive Settings Although many communities provide a single, community-based system of care, families often find that their children with SED continue to be served in restrictive settings, such as psychiatric hospitals, day treatment centers, juvenile justice learning centers, and residential treatment centers (Institute of Medicine, 1989; Nelson & Pearson, 1991; Singh, Landrum, Donatelli, Hampton, & Ellis, 1994). Even though inpatient psychiatric services have been criticized as an overused and unnecessarily restrictive treatment option, it is an integral part of a responsive system of care for certain children with SED (Cohen et al., 1990; Lundy & Pumariega, 1993). However, very little is known about the characteristics of the children who need such services. In a study examining the characteristics of 250 children receiving partial hospitalization and inpatient psychiatric treatment, Singh et al. (1994) reported that, according to their educational status prior to admission, 46% had not been identified as handicapped for educational services, 36% were identified as SED, and another 18% had some other disabilities, such as mental retardation and learning disabilities. In the group of children with SED, boys outnumbered girls by a ratio of four to one. The mean age of the children with SED was about 12 years. About 77% of the children were Caucasian and the rest were African-American; 69% had lived at home prior to admission at a psychiatric hospital and 70% returned home at discharge from the hospital. A disproportionately higher percentage of children with SED had a prior history of psychiatric hospitalization. While only about 46% of children not having SED had previously been admitted to a psychiatric hospital, 73% of children with SED had a prior admission. This supports the

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findings of Mattison, Morales, and Bauer (1992) who reported significantly more children with SED receiving therapy for psychiatric problems than a control group of nondisabled children. In Singh et al. (1994), the majority of the children with SED had no history of alcohol (83%) or other drug (87%) abuse. Similarly, the majority of the children with SED had no criminal history (91%). However, it must be remembered that the average age of these children was about 12 years, an age when children are just beginning to experiment with drugs and alcohol, as well as engage in criminal activity. Indeed, research shows that up to 40% of children with SED in our schools will become involved with the criminal justice system soon after leaving school (Jay & Padilla, 1987). Referrals for psychiatric services in the Singh et al. (1994) study came from the courts, mental health professionals, family, or self, with the major reasons for referral being threat to self and others and behavior problems. The three most frequently diagnosed psychiatric disorders for children with SED included, in order of prevalence, disruptive behavior disorders, attention-deficit hyperactivity disorder (ADHD), and mood disorders. Further, 64% of these children were on psychotropic medication, with 41% of those on medication receiving two or more medications. In general, the findings of this study suggest that children and adolescents with SED and those without SED but who receive inpatient psychiatric treatment are similar in many respects, namely age, race, residential status at admission and discharge, type of referral (voluntary vs. involuntary) for psychiatric services, source and reason for psychiatric referral, self-reported amount of substance abuse, and criminal record. However, they differ in some significant ways as well. For example, more children with SED have a history of receiving inpatient and outpatient psychiatric services; need psychiatric services for ADHD; are prescribed medication, both at admission and at discharge; and are prescribed two or more medications, both at admission and at discharge. Singh et al. (1994) reported that although there were some significant differences between children with and without SED in their sample, the most important general finding was that the differences were more of degree than of kind.

9.15.2.2 Children in Community Settings There is a recent but growing literature on characteristics of children with SED who receive community-based services (e.g., Barber,

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Rosenblatt, Harris, & Attkisson, 1992; Duchnowski, Johnson, Hall, Kutash, & Friedman, 1993; Epstein, Cullinan, Quinn, & Cumbald, 1994; Evans, Dollard, & McNulty, 1992; Landrum, Singh, Nemil, Ellis, & Best, 1995; Rosenblatt & Attkisson, 1992). These studies provide a fairly comprehensive picture of children with SED that families and service agencies deal with on a daily basis. These children are typically between 10 and 17 years, with studies from different geographical locations and sample sizes showing average ages ranging from 12 to 15 years (Epstein et al., 1994; Landrum et al., 1995; Rosenblatt & Attkisson, 1992). These findings are comparable with those reported for children treated in a residential mental health program (Wells & Whittington, 1993), as well as those identified as SED by their respective schools (Silver et al., 1992). As with children seeking inpatient treatment, boys substantially outnumber girls in community-based services. For example, male prevalence rates between 75% and 80% have been reported in three studies (Epstein et al., 1994; Landrum et al., 1995; Quinn & Epstein, 1998), although slightly lower male prevalence rates (57±64%) were reported in other studies (Duchnowski et al., 1993; Rosenblatt & Attkisson, 1992). However, the higher male prevalence figures are in accord with national surveys of school children in special education programs who are identified as SED (e.g., Cullinan, Epstein, & Sabornie, 1992; Valdes, Williamson, & Wagner, 1990). The data on racial prevalence is somewhat mixed. In the majority of studies, whites outnumber children from all other races. For example, prevalence of white children ranged from 63% to 77% in four studies (Duchnowski et al., 1993; Epstein et al., 1994; Quinn & Epstein, 1998; Rosenblatt & Attkisson, 1992), although in one of three communities surveyed by Rosenblatt and Attkisson (1992), the prevalence was only 45%. Further, Landrum et al. (1995) reported a figure of 54% African-American in a state-wide sample in Virginia, suggesting an overrepresentation of minorities among children and adolescents with SED, a finding noted by others as well (e.g., Kauffman, 1997; Singh, Ellis, Oswald, Wechsler, & Curtis, 1997; US Department of Education, 1994). In terms of intellectual functioning, children and adolescents with SED score within the normal to low-normal range on standardized measures of intelligence (Duchnowski et al., 1993; Epstein et al., 1994; Quinn & Epstein, 1998). As for educational attainment, children and adolescents with SED have significant academic deficits in most content areas, are typically underachievers even when they have

high IQs, are often in self-contained classrooms or alternative schools, and miss more days of school than their peers without SED because of truancy, suspension, expulsion, or dropout (Duchnowski et al., 1993; Epstein et al., 1994; Landrum et al., 1995). Further, the majority of these children exhibit behavior problems at some time during their school career. The combination of behavioral/psychiatric problems and academic deficits is a major risk factor for their continued educational achievements. Children and adolescents with SED have a number of behavioral and psychiatric problems that can be generally characterized as externalizing disorders. Studies show that these children have significant disruptive behaviors or adjustment disorders, extreme noncompliance, physical aggression, and extreme verbal abuse, as well as mood disorders (Bruns, Burchard, & Yoe, 1995; Landrum et al., 1995; Rosenblatt & Attkisson, 1992). In one study, however, internalizing disorders were found to be twice as prevalent as externalizing disorders, a finding attributed by the investigators to a number of methodological differences between their study and the others that reported opposite findings (Quinn & Epstein, 1998). The use of prescribed medication as a treatment modality for these children ranges from 30% (Quinn & Epstein, 1998) to 56% (Landrum et al., 1995). This is a surprisingly high prevalence rate because the use of psychotropic medication by students with SED in the US school system is only about 11% (Cullinan, Gadow, & Epstein, 1987; Cullinan et al., 1992). A high proportion of children and adolescents with SED have interactions with law enforcement agencies. Between 35% and 59% of them have a history of involvement with law enforcement agencies, typically because of their own unlawful behaviors (Duchnowski et al., 1993; Landrum et al., 1995; Quinn & Epstein, 1998). Further, many are referred to family courts because of abuse and neglect. Quinn and Epstein (1998) found that 20% of their sample had histories of abuse and neglect, and ZeiglerDendy (1989) found that 33% had a history of abuse and 65% had experienced neglect. That children who are abused or neglected also have SED has been reported in other studies as well (e.g., Trupin, Tarico, Low, Jemelka, & McCellan, 1993). In addition, a majority of children and adolescents with SED have had out-of-home placements, typically in foster placements, psychiatric hospitals, or residential treatment centers (Epstein et al., 1994; Hawkins, Almedia, & Samet, 1989; Landrum et al., 1995; Wells & Whittington, 1993). The picture that emerges is of children with multiple problems, requiring multiagency

Family Impact involvement. Thus, these children place immense burdens on their families, often so much so that they tear their families apart. 9.15.2.3 Families Much less has been written about the characteristics of families of children with SED than about the children themselves. Less than a third of the nuclear families are intact, with 25±46% of parents being divorced (Landrum et al., 1995; Quinn & Epstein, 1998). Landrum et al. (1995) reported that 24% of the parents were single and another 21% of their sample of parents were either separated or widowed. Further, they found that AfricanAmerican children were significantly more likely than white children to be living with a parent who was not married. Quinn and Epstein (1998) reported that in their sample, over 50% of the families had their parental rights qualified through either the child welfare system or the juvenile courts. They also reported that only 60% of the fathers and less than 50% of the mothers had full-time employment, and about 40% of the families received public assistance. Further, a significant percentage of the families had a history of mental illness, drug or alcohol abuse, and criminal activity. More than one half of these families had a history of family violence. Similar findings were reported by Epstein et al. (1994). Given the multiple problems of the children, the majority of these families had contact with multiple service agencies, including special education, juvenile justice, mental health, and child welfare. Accessing the needed services adds much strain on families that are already burdened by the daily grind of containing and helping their children to survive under difficult circumstances. 9.15.3 FAMILY IMPACT 9.15.3.1 Definition and Conceptualization Having a child with mental health problems invariably affects the functioning of the family members (Donner et al., 1995; Friesen & Huff, 1996). This impact, which has traditionally been known as ªfamily burden,º can be defined as ªthe presence of problems, difficulties, or adverse events which affect the life of the . . . patient's significant other(s)º (Platt, 1985, p. 383). Family members experience a high level of ªobjectiveº impact (e.g., disruption in family routine, providing transportation) and ªsubjectiveº impact (e.g., stigma, health problems, stress, reduced family cohesiveness) (Hoenig & Hamilton, 1967; Montgomery, Gonyea, & Hooyman, 1985). Often, these

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effects are in addition to other family stressors, such as poverty and poor housing. Friesen and Huff (1996) have noted that having a child with SED affects the family's lifestyle and routines, increases parental stress, decreases family time, and may negatively affect nuclear and extended family relationships. Of course, the level of family impact is dependent on a number of factors, including the severity of the child's emotional and behavioral problems, family strengths, cultural acceptance of the child's difficulties, and the parents' social support systems.

9.15.3.2 Research Findings Although research on family impact has a long history, it has focused almost exclusively on assessing the effects that an adult family member with mental illness has on the rest of the family (Biegel, Sales, & Schulz, 1991; Clausen & Yarrow, 1955). In much of the research with adults, family impact was assessed using semistructured interviews or questionnaires; few psychometrically valid rating scales were used. Four new instruments have been developed to measure family impact of caring for a child with SED: the Impact on the Family Scale (IOFS; Stein & Riessman, 1980); the Impact of the Situation checklist (IOS; Regional Research Institute for Human Services, 1992); the Caregiver Strain Questionnaire (CGSQ; Brannan, Heflinger, & Bickman, 1997), and the Child and Adolescent Impact Assessment (CAIA; Patrick, Angold, Burns, & Costello, 1992). Some psychometric data are available for the IOFS, CGSQ, and the CAIA although much more work needs to be done to fully establish their psychometric properties. Brannan et al. (1997) reported the development and psychometric properties of the CGSQ based on a sample of 984 families from the Fort Bragg Evaluation Project. The CGSQ is a 21item self-report instrument that was developed specifically for assessing the impact of caring for a child with SED. Factor analyses revealed three related but distinct factors: objective burden, subjective internalized burden, and subjective externalized burden. The CSGQ has high internal consistency and convergent validity. The scale has been used in preliminary studies of family impact and the use of mental health services by children with SED (Bickman, Foster, & Lambert, 1996; Foster, Saunders, & Summerfelt, 1996). These studies found that high family impact is associated with the families using inpatient hospitalization and intermediate nonresidential services for their children, and lower family impact is associated

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with the families using traditional outpatient services alone. The suggestion is that family impact can be used as a predictor of the type of services that will be sought by the families of children with SED. The link between family impact and the receipt of services has also been investigated. For example, it appears that the greater the family impact of caring for a child with SED, the more likely it is that the child will receive services (Angold et al., in press; Messer et al., 1996). Farmer, Burns, Angold, and Costello (1997) used the CAIA to assess the relationship between family impact and the families' use of services for their children. The CAIA measures the degree to which their children's emotional and behavioral problems impact on 17 areas of family functioning (e.g., the parent's relationship with his/her spouse/partner, restricted personal and family activities, parent wellbeing). The CAIA has good internal consistency and substantial discriminant validity between general population and clinical samples. Farmer et al. found that there was a strong association between family impact and initiation into and continued use of services for children with SED. Further, severity of the children's problems and degree of family impact were strongly associated with families accessing services. In addition, families accessed services when the care of the children impacted parental well being (e.g., depression resulting from the children's problems) and when parents felt incompetent in handling their children's problems. These findings suggest that parents access services for their children when the impact of caring for them gets beyond the parent's capability, and that they may not seek services solely on the basis of the mental health needs of the children. Given that children themselves do not seek services, and that some parents may not seek services for their children until the family impact is very severe, there may be children in our communities with unmet mental health needs. 9.15.4 FAMILY SUPPORT 9.15.4.1 Definition and Conceptualization As the family impact literature shows, if families are to care for their children with SED at home and provide the context in which their children can grow and thrive in our society, we need to lessen their subjective and objective burdens. Caring for children exacts a toll on all parents, but more so on those parents who have children with disabilities because of the inadequacy of societal assistance available to them. Of course, caring for a child with SED is not inevitably a negative experience for most

parents; however, current research does suggest that when family impact increases, parents of children with SED are at greater risk for psychological distress than those who do not have children with SED. Parental stresses may include economic stress, social isolation, and disruption of family life, including high rates of divorce and lower rates of remarriage (Singer & Irvin, 1989). Families can overcome many of life's hurdles if they have access to a service system that supports their social, emotional, and tangible needs. Family support can be defined as, a constellation of formal and informal services and tangible goods that are defined and determined by families. It is ªwhatever it takesº for a family to care for and live with a child or adolescent who has an emotional, behavioral, or mental disorder. It also includes support needed to assist families to maintain close involvement with their children who are in an out-of-home placement, and to help families when their children are ready to return home. (Federation of Families for Children's Mental Health, 1992, p. 1)

It is important to note that this definition stresses the fact that the family members determine what their needs are and the nature of the assistance they seek to overcome these needs. Further, the ªwhatever it takesº approach means that family supports will vary among families and over time. The Federation of Families for Children's Mental Health (1992, p. 1) has provided examples of family supports for those with a child with SED: (i) Family self-help, support, and advocacy groups and organizations. (ii) Information and referral. (iii) Education that will support families in becoming active, informed decision-makers on behalf of their family and the child. (iv) Advocacy with and on behalf of the family, if needed. (v) The capacity to individualize, provide flexible support services, and meet unplanned needs quickly and responsively. (vi) In-home and out-of-home respite care, with an emphasis on neighborhood and community participation for the child and conceptualized not as a clinical service but as a support for the whole family. (vii) Cash assistance. (viii) Assistance with family survival needs (housing, food, transportation, home maintenance). (ix) Other supports, as determined by the family. These examples suggest that family supports are society's responsibility, because it must be

Family Support provided not only by the state and local agencies but also by families, friends, churches, and other social networks, such as parentgroups. 9.15.4.2 Research Findings There are many studies showing that joining a support group reduces psychological and social distress in families. For example, Telleen, Herzog, and Kilbane (1989) enrolled mothers from low-income families in a family support program and found that, after three months, these mothers experienced less social isolation and parenting stress than mothers in a control group. This finding is in accord with others that show families who care for children with SED find family support programs to be supportive and rewarding (Rowe, 1991). Further, joining parent support groups enables parents to network with other parents with similar needs, identify other needs, and access services for these needs (Koroloff & Friesen, 1991). Respite care is another source of family support because it enables families to be less socially isolated and to undertake family activities that may not always be possible because of the emotional and behavioral problems of a family member. While the research literature on the impact of respite care is limited, the vast research base on families with children with developmental disabilities shows that respite care produces positive outcomes for the parents as well as the siblings of the child with disabilities (Singer & Irvin, 1991). With the movement to providing familycentered services, service providers have begun including clusters of supports in their programs. For example, Armstrong and Evans (1992) included intensive case management, access to respite care, family support groups and other family support services, the services of a paid family advocate, and recreational activities in their family-centered intensive case management services. While it is difficult to tease out the contributions of the various aspects of the support services, their program showed that a cluster of support services was more beneficial than therapeutic foster care services. In the 1990s, there has been a paradigm shift in the provision of services to children and adolescents with SED. A substantial number of states and local communities have begun using what is loosely called wraparound services. One of the eight key elements of this type of service states that ªServices and supports must be individualized to meet the needs of the children and families . . . º (VanDenBerg & Grealish, 1996, p. 9). This key element has been included a number of research-based wraparound services in the USA (e.g., Clark, Lee, Prange, &

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McDonald, 1996; Eber, Osuch, & Redditt, 1996; Hyde, Burchard, & Woodworth, 1996; Yoe, Santarcangelo, Atkins, & Burchard, 1996). Program evaluation data from these service programs indicate that family support is vital to positive outcomes for children with SED. However, cross-program comparisons are not possible as each included different combinations of family supports. VanDenBerg and Grealish (1996, pp. 14±15) have suggested that the following domains should be considered when providing clusters of family support in community-based services: (i) Residence. Do the current living arrangements meet the child's and family's needs? (ii) Family. Who is in the family, by their definition? Do all family members have appropriate access to each other? What do the members of the family need to stay together or in touch with each other? Are there serious, unmet needs for any family members that impair family functioning? (iii) Social. Do family members have friends and access to their friends? Does this family have the opportunity to socialize with each other? (iv) Emotional/Psychological. Does the referred individual or family have any unmet needs in these areas? Are there unresolved issues which impede normal interactions within the family or in the community? (v) Educational/Vocational. What will it take to ensure a viable education for the children, particularly the identified client? Do older children have access to employment opportunities? Are their rights to an appropriate education being enforced? (vi) Safety. Is everybody in the family safe? Are there dangers to individual family members? Are clients potentially dangerous to themselves or to the community? (vii) Legal. Are any family members involved in the judicial system, on probation, or parole? Do they have representation? Are there issues around custody of the children? (viii) Medical. Are health care needs met? Does the family have access to any specialist services they may need? (ix) Spiritual. Does this family identify unmet spiritual needs? Do all family members have access to spiritual leadership if they desire it? (x) Cultural. Are cultural differences present and being considered? (xi) Behavioral. Are any family members exhibiting behaviors which must be addressed if the quality of life for the family is to improve? (xii) Financial. Does the family have pressing financial needs which are not being met through employment or public support?

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Clearly, as this list shows, the development of a solid support system is a critical aspect of the care of children and adolescents with SED. Singer and Irvin (1991) have noted that respite care, child-focused education, parent training, and fiscal support are critical variables in reducing parental stressors. Supportive interventions that focus on helping families to use cognitive and behavioral coping strategies, such as cognitive reframing, have been found to be very helpful to families. Other supports that have been found to be effective include strengthening intrafamily support (Hawkins & Singer, 1989), strengthening informal social ties outside the family (Lehman, Ellard, & Wortman, 1986), and strengthening formal ties between parents and professionals (Singh, 1995). There is a growing literature on the need for family support services which shows that supportive interventions produce effective and lasting change in a family's ability to care for a child with SED. 9.15.5 FAMILY EMPOWERMENT 9.15.5.1 Definition and Conceptualization Empowerment has been defined in a number of different ways and, in the broadest sense, it implies a process which enables individuals to gain control over their lives by influencing their interpersonal and social environments (Hasenfeld, 1987; Parsons, 1991; Rappaport, 1981; Zimmerman & Rappaport, 1988). The results of this process for the individual may be many, depending on the specific context in which the process occurs. For example, psychological empowerment has been shown to be associated with greater participation in community activities and organizations (Zimmerman & Rappaport, 1988). In general, however, the goal of individuals in becoming empowered is to bring about a positive change that improves their quality of life or achieves a lifestyle change that they desire (Curtis & Singh, 1996). More recently, empowerment has been conceptualized within the framework of mental health service delivery systems. Although children and individuals with disabilities are frequently the recipients of mental health services, they are typically unable to advocate for themselves. Thus, increasing attention is being paid to the empowerment of their families needing access to the services on their children's behalf. The traditional paradigm of service providers and professionals ªknowing allº and being directive in their prescription of treatments, regardless of the unique nature, expectations, and outcomes desired by a family, is no longer acceptable (Singh, 1995). Furthermore,

the concept that empowerment involves a professional actively directing or compelling individuals or families to become a meaningful and influential participant in their own care has similarly fallen out of vogue because it is now generally accepted that one person cannot empower another. While professionals can encourage families to take more active roles in the care provided to their children, only the families can empower themselves to do so. In the context of mental health service delivery systems, family empowerment has been conceptualized as ªa process by which the families access knowledge, skills and resources that enable them to gain positive control of their own lives as well as improve the quality of their life-stylesº (Singh, 1995, p. 13). Although mental health service providers and professionals cannot empower a family, there is growing support for the notion that they serve a vital role in facilitating or assisting families to empower themselves within this system. For example, professionals can assist families to increase their level of empowerment by making structural changes in the way they deliver services to these families and their children (Singh et al., 1995). It is now recognized that, along with the more traditional goals, providers of mental health services to families and children with disabilities should facilitate the empowerment of the recipients of such services (Freund, 1993; Parsons, 1991; Singh et al., 1995; Sluyter, 1994; Staples, 1990). There is ample evidence that formalized efforts by service providers to facilitate the empowerment of families involved in the mental health service delivery system are generally successful and lead to positive perceptions and outcomes (Battaglino, 1987; Dunst, Trivette, Davis, & Cornwell, 1988; Hasenfeld & Chesler 1989; Kopp, 1989). 9.15.5.2 Research Findings Helping families to increase the level of their empowerment is a priority activity for service providers and professionals in the mental health system. Furthermore, in order to evaluate the impact of interventions designed to facilitate family empowerment, it is important that we assess families' perceptions of their empowerment status and empirically derive and validate the dimensions of the empowerment construct. To this end, Koren, DeChillo, and Friesen (1992) developed the Family Empowerment Scale (FES), a rating scale to assess family empowerment in the context of mental health service delivery systems. This scale was developed within a conceptual framework of empowerment that accounts for three levels of empowerment (Family, Service System, and

Family Involvement Community/Political) and three modalities for expressing empowerment (Attitudes, Knowledge, and Behaviors). A factor analysis by Koren et al. (1992) confirmed the validity of the three levels of empowerment, while only minimally confirming the three modalities for expressing empowerment. Another factor analysis of the FES resulted in the identification of four components of empowerment measured by the scale: Systems Advocacy, Knowledge, Competence, and Self-efficacy (Singh et al., 1995). These four components corresponded to four major areas of empowerment identified in the literature and represented a more atheoretical approach to the validation of the FES than that taken by Koren et al. (1992). Simply defining the dimensions of the empowerment construct, however, is not useful on a practical level for service providers and professionals who want the families that they serve to increase their ability to empower themselves. In addition, an understanding of the nature of families with various levels of empowerment is important in the implementation of strategies designed to increase the effectiveness of mental health service delivery systems. As part of their validation study of the FES, Koren et al. (1992) assessed whether or not the FES was able to differentiate between those parents who participated in activities indicative of empowerment and those who did not. Koren et al. grouped these activities into six types, advisory, political, legal, assistance, organizing, and participant. Participation in these activities was postulated to be a behavioral indicator of empowerment, primarily at the Community/Political level. The results indicated that parents who participated in these activities did, in fact, score higher on the three subscales of the FES than parents who were not involved in these activities. Other than for the work of Koren et al. (1992), there have been no further investigations of the relationship between family empowerment and theoretically proposed correlates of this construct. Singh, Curtis, Ellis et al. (1997) examined some of the demographic correlates of family empowerment in a sample of parents of children with SED alone and parents of children with SED as well as ADHD. Utilizing the FES as a measure of family empowerment and the four factors derived by Singh et al. (1995) as subscales, the empowerment status of this sample of parents across several family and demographic characteristics was investigated. The results indicated statistically significant correlations between family empowerment and membership in a parent support group, mental health status of the child, gender of the respondent (mother or father), and the parent's education level.

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Case studies and anecdotal family reports have suggested that empowerment of families through the use of support groups yields positive results for their children (Battaglino, 1987; Friesen & Wahlers, 1993; Kopp, 1989). However, Singh, Curtis, Ellis et al. (1997) provided the first set of empirical data confirming the overriding positive impact of parent groups on the empowerment status of families. In this study, membership in the parent support group was the variable that most influenced a family's level of empowerment. In a study discussed in the next section, Curtis and Singh (1996) found a correlational link between family empowerment and family involvement with services for their children with SED. However, the study did not deal with the issue of causality; that is, it did not determine whether greater involvement with the service system increased parental empowerment or if greater empowerment resulted in increased family involvement. Curtis and Singh suggested that the relationship between involvement and empowerment is reciprocal and inseparable. They noted that family involvement is strongly influenced by the level of parental empowerment and, at the same time, parental empowerment is strongly influenced by parental involvement. Our view, which is analogous to a constructivist position, focuses on the active role of parents in creating their cognitive, social, and political worlds in an effort to access the best services for their children. (p. 515)

9.15.6 FAMILY INVOLVEMENT Families are the primary socialization and change agents for their children. They play a critical role in enhancing the quality of life of their children through direct care as well as through advocacy. Thus, it is to be expected that families will be closely involved in every aspect of the care of their children, including the formulation, planning, and evaluation of services. Regardless of whether they are heavily involved or not, families are the consumers of mental health services and, as such, they need to have a voice in determining what and how the services should be provided. Family members understand the context and nature of their children, so they are in a better position than most professionals in identifying their children's service needs. Further, because family members are often the ones who carry out interventions with their children, they need to be involved both in choosing and in determining how the interventions will be implemented.

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9.15.6.1 Definition and Conceptualization There is no single, empirically derived definition of family involvement in the child mental health services literature. However, it is important that the term be defined in terms of how the families perceive their own involvement in the care of their children, as well as their interactions with the mental health services system generally. Clearly, the concept of family involvement is multidimensional and includes a variety of activities that facilitate the process and ultimate achievement of involvement. Of course, it is not a state that can be achieved but a process along a continuum of involvement. The components of family involvement have been identified through research, focus groups, and interviews with families receiving mental health services. These include, (i) involvement of families in all aspects of services at all times, with professionals genuinely encouraging this involvement; (ii) education of the family about the nature of services and how the service system works; (iii) involvement of the family in all decision-making; and (iv) keeping the family informed on the process and progress of treatment (Brotherson & Goldstein, 1992; Collins & Collins, 1990; DeChillo, 1993; Tarico, Low, Trupin, & Forsyth-Stevens, 1989). Generally, family involvement is thought to occur at multiple levels within the service delivery system, and may take different forms (Fullan, 1982). At the person level, family involvement can be used to enhance the quality of care provided to the child with SED. At this level, family members may act as the child's therapist, collaborate with professionals in developing the child's educational and treatment plans, advocate for additional services that can be purchased in the community, evaluate the services being provided, and educate professionals about the family's world view of systems and services. At the program level, family involvement can be used to enhance the nature, quality, and quantity of services provided to the child with SED. Family members work closely with professionals in assessing the needs of their child and matching the services to these needs. At the community level, family involvement is focussed at more general outcomes, such as working with service delivery agencies and making them more responsive to the needs of children with SED generally rather than just to their own child. At this level, family members are involved in educating the community about children with SED and in holding the community responsible for serving all children in their catchment area. Finally, at the society level, family involvement takes on the most global

level of commitment. At this level, family members encourage change in the larger society that they live in and work with volunteer agencies, such as with local and national organizations, that advocate for and serve children with SED. Family members form alliances with other advocacy groups, educate legislators and other key government officials, and encourage greater advocacy for their children with SED at a national and international level. Clearly, families can be involved, and should be encouraged by professionals to be involved, at the level that best suits them.

9.15.6.2 Research Findings The philosophical concept of family involvement was developed primarily within the context of human service delivery systems, particularly in the general area of services for children with developmental disabilities. Family involvement encompasses a conceptually narrower territory than family empowerment, relates specifically to involvement in service delivery systems, and does not carry the broader political and social ramifications that empowerment does. It reflects an ongoing process in mental health service delivery that is facilitated by service providers, and is characterized by a partnership or collaboration among families and service providers, with power and responsibility being shared among them (DeChillo, 1993; DeChillo, Koren, & Schultze, 1994; Friesen & Koroloff, 1990). There is a paucity of studies on family involvement in child and adolescent mental health services. One of the major reasons for this state of affairs has been the lack of a wellvalidated instrument for assessing the construct of family involvement. Two versions of a selfreport rating scale have been developed recently to describe empirically and quantify family involvement (Curtis, Singh, & Cohen, 1996). The Family Involvement Scale-Family Version (FIS-F) assesses the families' perceptions of their involvement in mental health services for their children with SED (Singh et al., 1996a) and the Family Involvement Scale-Professional Version (FIS-P) assesses professionals' perceptions of family involvement in mental health services (Singh et al., 1996b). These instruments can be used to investigate the relationship between parent-rated family involvement and selected demographic variables. Curtis and Singh (1996) investigated the sociodemographic correlates of family involvement in mental health services for children with SED, as well as the relationship between family involvement and family empowerment. The

Family Involvement FIS-F was used to measure involvement of families in the provision of mental health services for their children, and the FES was used to measure family empowerment. The results showed that mothers reported greater involvement in services for their children than fathers, and those respondents (mothers and fathers) who had less formal education were more involved than those who had more formal education. Further, the knowledge subscale of the FES was moderately correlated with all three subscales of the FIS-F, suggesting that parents who perceive themselves as being knowledgeable about their local mental health delivery systems also perceive themselves as being involved in the services provided to their children within this system. This finding reinforces our intuitive belief that knowledge of mental health service delivery systems is a moderator of parental participation. There are a number of barriers to a family's involvement in their child's mental health care, including resources, knowledge, and skills. Resource barriers that hinder family involvement include poverty; lack of adequate transportation, time, and opportunity; and limited family supports. Families that live in poverty, work long hours for minimum pay, or are in jobs that will withhold pay for time spent taking a child for a mental health appointment cannot be expected to be fully involved with the mental health system. Families that cannot find adequate child care for siblings of the child with SED do not have the luxury of becoming involved even if they so desired. Further, some families live in areas that are not served by public transportation or live at such a distance from the mental health facility that travel is a major barrier to closer involvement. Service delivery agencies can make accommodations in their planning for greater family involvement by scheduling meetings after work hours, providing child care services during the meetings, and arranging transportation for those who need it. Indeed, with some thought, service agencies can vastly increase family involvement at a personal and program level through skillful use of social supports and friendliness of the services they provide (Singh, Curtis, Ellis et al., 1997). Knowledge barriers include those variables that limit the family's involvement either because they do not understand the service system or the skills needed to deal with professionals in an assertive manner. For example, families often do not have adequate knowledge of the agency's individualized planning process (e.g., individualized education programs in schools) or the political structure of the mental health system in their locality to become useful advocates for their children.

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Given the cultural diversity of our society, some ethnic minority families may need assistance in learning how to assert themselves with professionals in conflictual situations, gather necessary information so that they can fully participate in the educational and treatment planning process, and access the necessary community supports for their children. In such cases, family involvement can be increased by providing comprehensive learning opportunities to both the families as well as the professionals. It is crucial that professionals learn how to be sensitive to the families' cultural nuances regarding their preferred level of involvement. Further, the Family Barriers Checklist (Elliott, Koroloff, Koren, & Friesen, 1998), a scale that families can use to rate the degree to which each of 13 variables pose a barrier to service involvement, can be used by professionals to assess barriers to involvement by individual families. In many cases, by carefully assessing family needs and actively listening to the family's views regarding their role in their child's care, professionals will be able to negotiate with the family regarding their level of involvement. Further, because of the vast tapestry of families that professionals deal with, it is important that they carefully examine their own and the families' assumptions, understanding, expectations, and level of involvement (Adams et al., 1997). Many advocates have suggested that families take an active role in shaping the policies and practices of their local and national mental health agencies. In this regard, Adams et al. (1997, pp. 35±36) have provided the following guidelines for families that should make them more effective in bringing about meaningful policy change at the local level: (i) learn about the agency, (ii) examine the agency's written and stated goals, (iii) examine the agency's motivation, (iv) examine the agency's mission statement, (v) identify a common vision for yourself and the agency, (vi) develop a formal agreement with the agency, (vii) develop a reporting mechanism, (viii) define communication links, (ix) define the scope of work and time line in writing, and (x) secure financial support for family participation. These are very practical suggestions that provide the framework for initiating family involvement both at the personal and program levels. However, we need further research to show whether these tactics do indeed work, and how well they work in current mental health service delivery systems. Family involvement is critical in the overall quality of services provided to children and adolescents with SED. Although conceptual work on family involvement has been available

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and empirical work on the topic has been abundant in the field of developmental disabilities, little has been done on it with regard to child mental health services. We suspect that with the development of appropriate assessment instruments, such as the FIS-F, FIS-P, and the Family Barriers Checklist, we will see much more research on the construct of family involvement. 9.15.7 FAMILY±PROFESSIONAL PARTNERSHIP Parent±professional relationships have received considerable attention in the general area of childhood disabilities, especially in developmental disabilities (e.g., Mittler, Mittler, & McCanachie, 1987). The literature on parent± professional partnership in child mental health, however, is much more limited. 9.15.7.1 Definition and Conceptualization There are a number of good reasons why child mental health professionals should involve parents as partners in the care of their children with SED. For example, it has been suggested that involving parents has intrinsic value (Friesen, 1989) and that it leads to improved outcomes for both the children and their parents (Burns & Friedman, 1989). Parent±professional partnership can be defined as parents and professionals having an active and equal role in making decisions about the needs and services for the child. It assumes that parents and professionals will have a collaborative working relationship, with each educating the other about the needs and services of the child, and both assuming responsibility for the process and outcome of the services. Parent±professional partnerships have been conceptualized in several ways. For example, Hobbs et al. (1984) proposed a needs-based framework for providing services in which both the child and the family benefit; the child is the direct recipient of services and the family members increase their knowledge and competence. Parent±professional partnership in this model assumes that professionals will assist the families (i) to learn how to care better for their children, (ii) to access more of the available services, (iii) to develop competencies which will enable them to reduce their psychological and other stressors, and (iv) to network their social supports in the community. Other models include the ªreflection in actionº model (SchoÈn, 1983), ªfamily consultationº model (Bernheim, 1989), ªenablement model of helpingº (Dunst & Paget, 1993), ªfamily allianceº

model (Lefley, 1989), and ªperson-centered planningº model (Singh, 1997). At the core of these models is the premise that families are critical to the process of service delivery because they provide the context in which the child and family function. As noted by numerous professionals, the parents are the experts on their children and no professional can ever rival their knowledge of their children and the contexts in which their children need to enhance their functioning. 9.15.7.2 Research Findings There is little research on parents' perceptions of professional behaviors and on parent± professional partnerships. In one study, Friesen, Koren, and Koroloff (1992) investigated parents views of the importance and frequency of professional behaviors in mental health services. Regardless of the professionals that the parents sought services from, they considered the following as very important to them: parent± professional relationship, honesty, nonblaming attitude, supportiveness, and inclusion in decision-making. Further, parents indicated that professionals only partly met their expectations. These findings are not surprising given that parents have been telling professionals that they wish to assume a more active role in decision-making regarding the services provided to their children (Collins & Collins, 1990). They strongly object to being excluded from decision-making or, worse, being blamed for their children's problems (Bernheim, 1989; Collins, & Collins, 1990; Lefley, 1989). There is a growing feeling in the mental health field that the traditional service delivery system which assumes the primacy of the professional is not only ineffective in the long-term but also dehumanizing to children with SED and their families. The way services have been provided in the past are not in the best interests of the families and their children. The traditional model assumes that professionals, by their training and experience, know best how to assess, diagnose, and treat all manner of problems in children, regardless of the diversity of contexts that these children may come from. However, there is little data to support the efficacy of a service delivery system that revolves around professionals and excludes the families from full partnership in the treatment process. The tradition model creates a duality, a distinction between the professional as the knower and the provider of services and the family as the receiver of the services. There is little oneness between the professional and the family, and no oneness of vision of what may be best for the family.

Family and Cultural Diversity In response, new service delivery models are emerging, such as wraparound (VanDenBerg & Grealish, 1996) and person-centered planning (Singh, 1997), and these need to be tested for their alignment with family values, expectations, and outcomes (Singh, Curtis, Wechsler, Cohen, & Ellis, 1997). Clearly, the process of paradigm shift is underway in child mental health service delivery systems. Professionals cannot equivocate on the changes that they must make if they are to be successful participants in the emerging paradigm. Singh (1995) has discussed what professionals can do to produce service delivery systems that are compassionate and sensitive to the needs of the families and their children. For example, above everything else, they need to learn to be one with the families and their children. They need to liberate themselves from the bondage of outdated theories, and from judging families in terms of their own mental constructs of a ªhealthyº or normative family. Professionals cannot facilitate family growth, empowerment, and involvement if they cannot see the world from the eyes of the family. They need to take a posture of mutual respect and reciprocity with families that will bring them closer to the world view of the families.

9.15.8 FAMILY AND CULTURAL DIVERSITY A tapestry of families, rich in linguistic, racial, ethnic, and socioeconomic diversity, have children with SED who need mental health services. The cultural heritage and diversity of these families almost guarantees that none of them will fully fit the service provider's mental model of a healthy family, a model typically based on white, middle-class families. However, all families share some characteristics that are universal, regardless of diversity. For example, they may have a sense of loss of self-respect when they visit a professional because of the feeling that they have failed as parents. Nontraditional and culturally diverse families may have added problems because of their feeling that they are not understood by mental health professionals who are unaware of the structural aspects of their families and therefore, unable to fully comprehend the nature of their problems. While they believe that professionals may have a family's best interests at heart, they also know that families and professionals often view the same problem and its solutions differently. The changing cultural demographics of our society is reflected in the demographics of children with SED and their families in systems

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of care. As the numbers of children from culturally diverse families increases in systems of care, it means that the context in which services are being delivered is also changing. This change has immense implications for the nature and effectiveness of the services delivered in systems of care.

9.15.8.1 Definition and Conceptualization Differences in the culture of the families and mental health professionals can have a profound impact on the outcome of services. Cultural differences in values, approaches to child rearing and education, views of mental illness, and the seeking of services for their children undoubtedly influence many aspects of the involvement of families in systems of care (Harry, 1992; Julian, McKenry, & McKelvey, 1994; Kalyanpur & Harry, 1997; Lee, 1997). Further, the cultural competence and sensitivity of the professionals will impact not only the nature of the services sought and received by these families, but also the level of their involvement with different sectors of the service system. Although no single definition of culture is likely to be universally accepted, it can be broadly defined as the shared values, traditions, arts, history, folklore, and institutions of a group of people that are unified by race, ethnicity, nationality, language, religious beliefs, spirituality, socioeconomic status, social class, sexual orientation, politics, gender, age, disability, or any other cohesive group variable (Singh, 1996). Clearly, this definition recognizes that all of us simultaneously belong to more than one cultural group and that each person is in a complex dynamic relationship with others from overlapping cultural traditions. As with the term culture, there are many definitions of cultural awareness, sensitivity, and competency. Cultural awareness is a general term used to indicate that a person is conscious of the similarities and differences within, between, and among cultures. Awareness is a necessary but not sufficient condition for a person to behave in a culturally appropriate manner towards others from different cultures. Cultural sensitivity is a more specific term used to indicate that a person not only has an awareness of the nuances of one's own culture as well as those of other cultures, but also that he or she does not assign a negative or positive value to the differences within, between, and among cultures. Sensitivity means that the person accepts cultural differences nonjudgmentally. Cultural competency is a term used to indicate that a person has ªknowledge and skills

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that enable him or her to appreciate, value and celebrate similarities and differences within, between, and among culturally diverse groups of peopleº (Singh, 1996, p. 124). Competency is a dynamic concept and does not imply that a person ever reaches a state of being universally culturally competent; rather, it implies that the person has the knowledge and skills for displaying and increasing his or her understanding and appreciation of the changing nature and nuances of his or her own culture as well as those of others.

9.15.8.2 Research Findings According to Kauffman (1997), 3±6% of children in our schools probably have emotional and behavioral disorders that require some form of intervention. Although the data are limited, there is a good general indication that children with SED form a culturally diverse group. For example, an analysis of nine recent studies on the characteristics of children in systems of care shows that, on average, the age of the children ranges from about 8 to 16 years, about 70±75% of them are boys, and between 50% and 75% are Caucasians, followed by about 25±30% African-Americans, 10% Hispanic Americans, and others, including native Americans, Asians, Pacific Islanders, and those of mixed races (Barber et al., 1992; Cullinan, Epstein, & Quinn, 1996; Epstein, Cullinan, Quinn, & Cumbald, 1994, 1995; Landrum et al., 1995; Quinn et al., 1996; Quinn, Newman, & Cumbald, 1995; Silver et al., 1992; Singh et al., 1994). These data indicate that even when only three indicators of cultural diversity (age, gender, and ethnicity/race) are taken into account, there is a broad spectrum of children with SED who are being served in various systems of care in this country. Of course, virtually no data are available on some of the other aspects of cultural diversity in these children and their families, such as their nationality, language, religious beliefs, spirituality, socioeconomic status, social class, sexual preference, politics, and disability, among others. The reporting of these data are crucial in future research because it may well be that some of these variables will be found to be highly correlated not only with the nature of the services needed or sought by children with SED and their families, but also with the types of services that are most appropriate. A related issue is the lack of similar data reported in outcome studies from various systems of care. Such data provide an indication of cultural diversity of the sample that is being provided with services. In addition, the report-

ing of these data indirectly indicates that mental health professionals are aware of the unique needs of children and families from different cultural groups. For example, it is well established that clinical psychologists may need to use assessment instruments and diagnostic methods that are culturally appropriate for children from different racial and ethnic groups. Further, children from diverse cultural backgrounds may need additional interventions that are different from the generic programs used with white, middle-class children and their families (Singh, Ellis, Oswald et al., 1997; Singh, Williams, & Spears, in press). Current research suggests that professionals have culturally laden interactions with families and their children throughout the process of providing psychological, educational, and mental health services (Harry, 1992; Kalyanpur & Harry, 1997; Singh, 1995). Singh (1998) has detailed the nature and extent of these interactions and the pitfalls that professionals should be aware of. These interactions range from collecting sociodemographic and intake information, assessment, cultural formulation of the presenting problems, and interventions to the evaluation of treatment outcome, cultural influences on data analysis and interpretation, and family satisfaction. Space precludes a detailed discussion and interested readers are referred to this source for further information. Finally, there is the issue of whether mental health professionals, such as clinical psychologists, can ever be competent enough to deal with the cultural nuances of the myriad of culturally diverse families who will seek their services. Although this question has not been subjected to rigorous research, intuitively we feel that the answer is no. However, we believe that sensitivity, understanding, and compassion will bridge the gap between culturally sensitive professionals and families who seek their services. Above all, good listening skills and understanding the issues from the perspective of the families are critical skills that all professionals should have. Fortunately, Kleinman, Eisenberg, and Good (1978) have provided us with a list of eight simple questions that professionals can ask, and the family's answers provide the professionals with the family's explanatory model of their problems. When professionals do not appreciate the cultural underpinnings of their own actions and that of the families, at best, their efforts will be only partially effective and, at worst, they will have to assume some of the responsibility for the tragic outcomes that can occur (see Fadiman, 1997). Given the pervasive effects of culture on human behavior, mental health professionals will find it difficult to be cognizant of and

References respond appropriately to all cultural variables in every facet of service provision to families with a child with SED. Obviously, the effects of even the major cultural variables can neither be assessed fully nor controlled with any one family. Our research efforts and clinical practice should focus on finding assessment and intervention principles and methods that are universal and would apply across cultures, as well as those that are specific to different cultural groups. 9.15.9 SUMMARY Families play a critical role in the care of children and adolescents with SED; they, not professionals, are the experts who know the children best. They determine if and when their children enter mental health services, and what services are accessed. In addition, recent research is making clear that caring for a child with SED has its own set of joys and rewards, above and beyond raising children in general. This has brought to light the cultural, political, and practical issues that these families have to face on a daily basis. These issues have spawned conceptual, philosophical, and research papers and books since the 1980s; obviously, enough material that cannot be summarized in one chapter. This chapter covers a selected set of issues that are still in their formative stages, both in terms of concepts and research, and presents some ideas regarding areas of future research and intervention with these families. 9.15.10 REFERENCES Adams, J., Gora, K., Huff, B., Burrell-Muhammad, V., Rivera, M., & Slaton, E. (1997). Defining family involvement. Reaching Today's Youth, 1(4), 35±36. Angold, A., Messer, S. C., Stangl, D., Farmer, E. M. Z., Costello, E. J., & Burns, B. J., (in press). Perceived parental burden and service use for child and adolescent psychiatric disorders. American Journal of Public Health. Armstrong, M. I., & Evans, M. E. (1992). Three intensive community-based programs for children and youth with serious emotional disturbance and their families. Journal of Child and Family Studies, 1, 61±74. Barber, C. C., Rosenblatt, A., Harris, L. M., & Attkisson, C. C. (1992). Use of mental health services among severely emotionally disturbed children and adolescents in San Francisco. Journal of Child and Family Studies, 1, 183±207. Battaglino, L. (1987). Family empowerment through selfhelp groups. In A. B. Hatfield (Ed.), Families of the mentally ill: Meeting the challenges (pp. 43±51). San Francisco: Jossey-Bass. Bernheim, K. F. (1989). Psychologists and families of the severely mentally ill: The role of family consultation. American Psychologist, 44, 561±564. Bickman, L., Foster, E. M., & Lambert, E. W. (1996). Who gets hospitalized in a continuum of care? Journal of the American Academy of Child and Adolescent Psychiatry, 35, 74±80.

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& A. Duchnowski(Eds.), Outcomes for children and youth with behavioral and emotional disorders and their families: Programs and evaluation best practices (pp. 425±454). Austin, TX: Pro-Ed. Singh, N. N., Curtis, W. J., Cohen, R., Nicholson, M. W., Villani, T. M., & Wechsler, H. A. (1996a). Measuring perceptions of family involvement. I: The Family Involvement Scale-Family Version. Richmond, VA: Commonwealth Institute for Child and Family Studies, Virginia Commonwealth University. Singh, N. N., Curtis, W. J., Cohen, R., Nicholson, M. W., Villani, T. M., & Wechsler, H. A. (1996b). Measuring perceptions of family involvement. II: The Family Involvement Scale-Professional Version. Richmond, VA: Commonwealth Institute for Child and Family Studies, Virginia Commonwealth University. Singh, N. N., Curtis, W. J., Ellis, C. R., Villani, T., Nicholson, M. W., & Wechsler, H. A. (1995). Psychometric analysis of the Family Empowerment Scale. Journal of Emotional and Behavioral Disorders, 3, 85±91. Singh, N. N., Curtis, W. J., Ellis, C. R., Wechsler, A. H., Best, A. M., & Cohen, R. (1997). Empowerment status of families whose children have serious emotional disturbance and attention-deficit hyperactivity disorder. Journal of Emotional and Behavioral Disorders, 5, 223±229. Singh, N. N., Curtis, W. J., Wechsler, H. A., Cohen, R., & Ellis, C. R. (1997). Family friendliness of communitybased services for children and adolescents with emotional and behavioral disorders: An observational study. Journal of Emotional and Behavioral Disorders, 5, 82±92. Singh, N. N., Ellis, C. R., Oswald, D. R., Wechsler, H. A., & Curtis, W. J. (1977). Addressing and valuing diversity. Journal of Emotional and Behavioral Disorders, 5, 24±35. Singh, N. N., Landrum, T. J., Donatelli, L. S., Hampton, C., & Ellis, C. R. (1994). Characteristics of children and adolescents with serious emotional disturbance in systems of care. Part I: Partial hospitalization and inpatient psychiatric services. Journal of Emotional and Behavioral Disorders, 2, 13±20. Singh, N. N., Williams, E., & Spears, N. (in press). Value and address diversity: From policy to practice. In US Department of Education, OSEP (Ed.), Improving results for children and youth with serious emotional disturbance. Washington, DC: Chesapeake Institute. Sluyter, G. V. (1994). Creating a vision for mental health services: A survey of states. Administration and Policy in Mental Health, 21, 247±250. Staples, L. H. (1990). Powerful ideas about empowerment. Administration in Social Work, 14, 29±42. Stein, R. E. K., & Riessman, C. K. (1980). The development of an Impact-on-Family Scale: Preliminary findings. Medical Care, 18, 465±472.

Stroul, B., & Friedman, R. M. (1986). A system of care for children and adolescents with severe emotional disturbances. Washington, DC: Georgetown University Child Development Center, National Technical Assistance Center for Children's Mental Health. Tarico, V. S., Low, B. P., Trupin, E. & Forsyth-Stevens, A. (1989). Children's mental health services: A parent perspective. Community Mental Health Journal, 25, 313±326. Telleen, S., Herzog, A., & Kilbane, T. L. (1989). Impact of a family support program on mother's social support and parenting stress. American Journal of Orthopsychiatry, 59, 410±419. Trupin, E. W., Tarico, V. S., Low, B. P., Jemelka, R., & McCellan, J. (1993). Children on child protective service caseloads: Prevalence and nature of serious emotional disturbance. Child Abuse and Neglect, 17, 345±355. US Department of Education. (1994). Sixteenth annual report to Congress on the implementation of Individuals With Disabilities Education Act. Washington, DC: US Government Printing Office. Valdes, K. A., Williamson, C. L., & Wagner, M. M. (1990). The national longitudinal transition study of special education students: Statistical almanac. Vol. 3: Youth categorized as emotionally disturbed. Menlo Park, CA: SRI International. VanDenBerg, J. E., & Grealish, E. M. (1996). Individualized services and supports through the wraparound process: Philosophy and procedures. Journal of Child and Family Studies, 5, 7±21. Wagner, M., Blackorby, J., Cameto, R., Hebbeler, K., & Newman, L. (1993). The transition experiences of youth with disabilities: A summary of findings from the National Longitudinal Transition Study. Palo Alto, CA: SRI. Wells, K., & Whittington, D. (1993). Characteristics of youths referred to residential treatment: Implications for program design. Children and Youth Review, 15, 195±217. Yoe, J. T., Santarcangelo, S., Atkins, M., & Burchard, J. D. (1996). Wraparound care in Vermont: Program development, implementation, and evaluation of a statewide system of individualized services. Journal of Child and Family Studies, 5, 23±37. Zeigler-Dendy, C. A. (1989). The invisible children project: Methods and findings. In A. Algarin, R. M. Friedman, A. J. Duchnowski, K. M. Kutash, S. E. Silver, & M. K. Johnson (Eds.), Second annual conference proceedings of the Research and Training Center for Children's Mental Health: Children's mental health services and policy: Building a research base (pp. 360±366). Tampa, FL: Florida Mental Health Institute. Zimmerman, M. A., & Rappaport, J. (1988). Citizen participation, perceived control, and psychological empowerment. American Journal of Community Psychology, 16, 725±750.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

9.16 Family Lives of Lesbians and Gay Men CHARLOTTE J. PATTERSON University of Virginia, Charlottesville, VA, USA 9.16.1 INTRODUCTION

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9.16.2.1 Estimates of the Lesbian and Gay Population 9.16.2.2 Diversity Among Lesbians, Gay Men, and Their Families 9.16.2.3 Legal and Public Policy Issues 9.16.3 RESEARCH ON LESBIAN AND GAY COUPLE RELATIONSHIPS 9.16.3.1 9.16.3.2 9.16.3.3 9.16.3.4 9.16.3.5

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Descriptions of Lesbian and Gay Couples Love and Commitment Power and Division of Labor Sexual Behavior Problems and Conflict in Couples

9.16.4 RESEARCH ON LESBIAN MOTHERS AND GAY FATHERS 9.16.4.1 Lesbians and Gay Men Who Became Parents in the Context of Heterosexual Relationships 9.16.4.1.1 Divorced lesbian mothers 9.16.4.1.2 Divorced gay fathers 9.16.4.2 Lesbians and Gay Men Choosing to Become Parents 9.16.5 RESEARCH ON CHILDREN OF LESBIAN AND GAY PARENTS 9.16.5.1 Research on Children Born in the Context of Heterosexual Relationships 9.16.5.1.1 Sexual identity 9.16.5.1.2 Other aspects of personal development 9.16.5.1.3 Social relationships 9.16.5.2 Diversity Among Children With Divorced Lesbian or Gay Parents 9.16.5.3 Research on Children Born to or Adopted by Lesbian Mothers

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9.16.6 RESEARCH ON OTHER FAMILY RELATIONSHIPS

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9.16.7 IMPLICATIONS OF RESEARCH FINDINGS

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9.16.8 DIRECTIONS FOR RESEARCH

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9.16.9 REFERENCES

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denied, they filed a lawsuit asking the State of Hawaii to grant them a marriage license. (Adapted from Bull & Gallagher, 1996, pp. 197±200)

9.16.1 INTRODUCTION In 1990, Ninia Baehr went on a blind date with another young woman, Genora Dancel. It was love at first sight. Later that year, they applied for a marriage license in Honolulu, where they were living. They were denied. Joining with a gay couple and another lesbian couple who had been similarly

Thus began the case that has become known as Baehr v. Miike, which is often called the Hawaii same-sex marriage case. In 1993, the Hawaii Supreme Court declared that the denial 253

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of marriage licenses to the three couples appeared to violate the state's prohibition on gender-based discrimination, and remanded the case to a lower court. In order to maintain the ban, the state would be required to prove that it served a compelling state interest. When the case was heard in 1996, the state's attorney argued that if same-sex couples could form legal marriages, then they would be likely to have more children, and this would harm children. Same-sex marriages would thus have an adverse impact on the welfare of children, the state's attorney argued, and this justified the ban. The trial judge's decision rejected the state's argument, holding that sexual orientation and parental fitness are not related, and struck down the prohibition on same-sex marriage. At the time of this writing, in 1997, the case is on appeal to the Hawaii Supreme Court. The Baehr case has generated enormous controversy, not only in Hawaii, but also across the USA and around the world. Conservatives argued that legal marriages between same-sex couples would undermine the institution of marriage, and introduced into the US Congress a ªDefense of Marriage Actº (DOMA) which said that states were not required to recognize as legal same-sex marriages contracted in another state. The bill passed, and was quickly signed into law. Meanwhile, a 1994 survey of a large group of gay men found that 85% said they would marry a same-sex partner if they were legally able to do so (Bull & Gallagher, 1996, p. 214). Religious groups also entered the debate. On one side, the Vatican declared that same-sex marriages would ªundermine the foundation of the family model upon which human civilization was builtº and would legitimize ªmoral disordertates.º At the same time, other religious groups, such as the Central Conference of American Rabbis, voted to support legalization of same-sex marriages (Dunlap, 1996). What is it that makes a lawsuit like Baehr v. Miike so controversial? This chapter addresses three inter-related reasons. First, the Baehr case involves controversies about the legitimacy of families formed by lesbians and gay men. Second, although widespread prejudices suggest that lesbians and gay men live outside the reach of family pleasures and responsibilities, the actual reality as illuminated by research is quite different. Third, if the family lives of lesbians and gay men are deemed acceptable under the law, the challenge to deeply held ideas about families and about child development is undoubtedly significant. Thus, when considering whether marriages like the one sought by Ninia Baehr and Genora Dancel are legitimate, much is at stake.

What are the findings of social science research about lesbian and gay family life? In this chapter, information about the prevalence and diversity of lesbian and gay family life, as well as about the legal context in which lesbian and gay families currently live, are first reviewed. The results of research on lesbian and gay couples, parents and their children, and other family members are then described and the implications of research findings for psychological theory as well as public policy are discussed. A discussion of directions for further research concludes the chapter. 9.16.2 FAMILIES OF LESBIANS AND GAY MEN TODAY How many lesbian and gay people are there in the USA, and how many people are included in their families? What are important sources of diversity among these families? What is the nature of the legal context in which lesbians, gay men, and their families are living today? 9.16.2.1 Estimates of the Lesbian and Gay Population For many reasons, no accurate count of lesbian and gay adults, much less of their families, is available. The numbers of lesbian and gay adults in the USA cannot be estimated with confidence. Because of fear of discrimination, many take pains to conceal their sexual orientation (Blumenfeld & Raymond, 1988). It is especially difficult to locate gay and lesbian parents. Fearing that they would lose child custody and/or visitation rights if their sexual orientation were to be known, many lesbian and gay parents attempt to conceal their gay or lesbian identities (Pagelow, 1980). It can also be difficult to locate other relatives of lesbians and gay men (e.g., siblings), because some may not be aware of having a lesbian or gay relative, and because others may not wish to acknowledge this aspect of their family life. One approach to making estimates of this kind is to extrapolate from what is known or believed about base rates in the population. For example, there are approximately 260 million people in the USA (US Bureau of the Census, 1995). Based on data collected by the National Health and Social Life Survey (Laumann, Gagnon, Michael, & Michaels, 1994), 1.4% of women and 2.8% of men identified themselves to an interviewer as lesbian or gay. Using these numbers, one can estimate that there are approximately 5.5 million people who identify as lesbian or gay in the USA. If, on average, each one has five relatives (e.g., two parents, one

Families of Lesbians and Gay Men Today sibling, and two grandparents), then there are at least 27 million heterosexual people with a lesbian or gay relative. That would mean that more than 32 million Americans either identify as lesbian or gay, or have a close relative who identifies in this way. The accuracy of such estimates is, of course, no better than the accuracy of the numbers on which they are based. Laumann et al. (1994) also reported that 4.1% of women and 4.9% of men reported at least one same-sex sexual partner since 18 years of age. If estimates are based not on self-identification as lesbian or gay, but on numbers of adults who reported at least one same-sex sexual partner, then population estimates for lesbians, gay men, and their families will of course become larger. Whatever the precise numbers, it is clear that, when one considers the families of lesbians and gay men, very substantial numbers of people are under discussion. 9.16.2.2 Diversity Among Lesbians, Gay Men, and Their Families Although lesbians, gay men, and their family members are often stereotyped in very specific ways, there is tremendous diversity among individuals and families. Just as other families embrace many variations, so the families of lesbians and gay men vary in many different ways from one another. Some of the variation is similar to that among heterosexual families, and some is more specific to the families of lesbians and gay men. As is true for heterosexual families, the families of lesbians and gay men vary considerably on demographic characteristics. Lesbians, gay men, and their families may be of any racial or ethnic group, any cultural background, and they may or may not have had the benefit of extensive educational opportunities. Lesbians and gay men can be found in all economic strata (Badgett, in press), and in many different occupations. Although evidence suggests that men who identify as gay are more likely to live in urban than in suburban or rural environments, the geographic dispersal of lesbian women seems to be less pronounced (Laumann et al., 1994). Family members may live near their lesbian or gay relatives, or may live at some distance. Much of this type of variation is held in common with the families of heterosexual individuals. Among lesbian and gay families with children, one important distinction concerns the sexual identity of parents at the time of a child's birth or adoption. Probably the largest group of children with lesbian and gay parents today are those who were born in the context of

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heterosexual relationships between the biological parents, and whose parent or parents subsequently identified as gay or lesbian. These include families in which the parents divorce when the husband comes out as gay, the wife comes out as lesbian, both parents come out, and one or both of the parents comes out and the parents decide not to divorce. Gay or lesbian parents may be single, or they may have samesex partners. A gay or lesbian parent's same-sex partner may or may not assume step-parenting relationships with the children. If the partner also has children, the youngsters may assume step-sibling relationships with one another. In short, gay and lesbian families with children born in the context of heterosexual relationships are themselves a relatively diverse group. In addition to children born in the context of heterosexual relationships between parents, lesbians and gay men are believed increasingly to be choosing parenthood (Martin, 1993; Patterson, 1994a, 1994b; Pies, 1985, 1990). The majority of such children are conceived by means of donor insemination (DI). Lesbians who wish to bear children may choose a friend, relative, or acquaintance to be the sperm donor, or they may choose to use sperm from an unknown donor. When sperm donors are known, they may take parental or avuncular roles relative to children conceived via DI, or they may not (Martin, 1993; Patterson, 1994a, 1994b; Pies, 1985, 1990). Gay men may also become biological parents of children whom they intend to parent, whether with a single woman (who may be lesbian or heterosexual), with a lesbian couple, or with a gay male partner. Options pursued by gay men and lesbians also include both adoption and foster care (Ricketts, 1991). Thus, children are today being brought up in a diverse array of lesbian and gay families. In addition to differences in parents' sexual identities at the time of a child's birth, another distinction among the families of lesbians and gay men is the extent to which family members are related biologically to one another (Pollack & Vaughn, 1987; Riley, 1988; Weston, 1991). Although biological relatedness of family members to one another in heterosexual families is probably less often taken for granted than it once was, it is often even more prominent as an issue in lesbian and gay families with children. When children are born via DI into lesbian families, they are generally related biologically only to the birthmother, not to her partner. Similarly, when children are born via surrogacy to a gay couple, only the father who served as a sperm donor is biologically related to the child. In adoption and foster care, of course, the child will probably have no

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biological relation to any adoptive or foster parent. Another distinction of particular importance for lesbian and gay families concerns custodial arrangements for minor children following the break-up of heterosexual marriages. As in heterosexual families, children generally live with one of their biological parents, or they spend part of their time in one biological parent's household, and part of their time in the other's home. Many lesbian mothers and gay fathers have, however, lost custody of their children to heterosexual spouses following divorce, and the threat of custody litigation almost certainly looms larger in the lives of most divorced lesbian mothers than it does in the lives of divorced heterosexual ones (Lyons, 1983; Pagelow, 1980). Although no authoritative figures are available, it seems likely that a greater proportion of gay and lesbian than heterosexual parents lost custody of children against their will. Probably for this reason, more lesbians and gay men are noncustodial parents (i.e., do not have legal custody of their children) and nonresidential parents (i.e., do not live in the same household with their children) than might otherwise be expected.

9.16.2.3 Legal and Public Policy Issues The legal system in the USA has long been hostile to lesbians and gay men, and especially to those who are or who wish to become parents (Editors of the Harvard Law Review, 1990; Falk, 1989; Patterson & Redding, 1996; Polikoff, 1990; Rivera, 1991; Rubenstein, 1991, 1996). Same-sex marriages are currently not legal in any jurisdiction in the USA. Lesbian mothers and gay fathers have often been denied custody and/or visitation with their children following divorce from heterosexual marriages. Although some states now have laws stipulating that parental sexual orientation as such cannot be a factor in determining child custody following heterosexual divorce, in other states gay or lesbian parents may be regarded as unfit. Regulations governing foster care and adoption in many states have also made it difficult for lesbians or gay men to adopt or to serve as foster parents (Ricketts, 1991; Ricketts & Achtenberg, 1990). One of the central issues underlying judicial decision-making in custody litigation and in public policies governing foster care and adoption has been questions about the fitness of lesbians and gay men to be parents (Patterson, 1995c; Patterson & Redding, 1996). Specifically, policies have sometimes been constructed and judicial decisions have

often been made on the assumptions that gay men and lesbians are mentally ill and hence not fit to be parents, that lesbians are less maternal than heterosexual women and hence do not make good mothers, and that lesbians' and gay men's relationships with sexual partners leave little time for ongoing parent±child interactions (Editors of the Harvard Law Review, 1990; Falk, 1989). Because these assumptions have been important ones in limiting gay and lesbian parental rights, and because they are open to empirical evaluation, they have guided much of the research on lesbian and gay parents that is discussed below. In addition to judicial concerns about parents themselves, three principal kinds of fears regarding the effects of gay and lesbian parents on children have also been reflected in judicial decision-making about child custody and in public policies such as regulations governing foster care and adoption (Patterson, 1992, 1995c; Patterson & Redding, 1996). One of these concerns is that development of sexual identity among children of lesbian and gay parents will be impaired. For example, judges may fear that children will themselves grow up to be gay or lesbian, an outcome which they generally view as negative. Another is that gay and lesbian parents will have adverse effects on other aspects of their children's personal development. For example, judges may fear that children in the custody of gay or lesbian parents will be more vulnerable to behavior problems or to mental breakdown. A third concern is that these children will have difficulties in social relationships. One version of such concern is the fear that children will be teased or stigmatized by peers because of the sexual orientation of their parents. Because such concerns have often been explicit in judicial determinations when lesbian or gay parentsº custody or visitation rights have been denied or curtailed, and because these assumptions are open to empirical test, they have provided an important impetus to research.

9.16.3 RESEARCH ON LESBIAN AND GAY COUPLE RELATIONSHIPS Research on lesbian and gay couples is a phenomenon of the last 25 years, and has addressed a number of interrelated issues. In this section, descriptive information from a large-scale survey of lesbian and gay couples is first summarized, then research findings on love and commitment, power and the division of labor, sexual behavior, problems and conflict in relationships, and the ending of couple relationships are described.

Research on Lesbian and Gay Couple Relationships 9.16.3.1 Descriptions of Lesbian and Gay Couples The earliest large-scale study of lesbian and gay couples was conducted by Blumstein and Schwartz (1983). In their study, 1576 lesbian, 1938 gay, 3656 heterosexual married, and 653 heterosexual cohabiting (but unmarried) couples completed extensive questionnaires about topics ranging from money and jobs to love and sexual behavior. Despite the large sample, carefully drawn from diverse geographic areas in the USA, the lesbian and gay respondents were almost all white, between 21 and 40 years of age, mostly well educated, and mostly employed in professional or managerial occupations. Similar demographics have characterized other large-scale studies of lesbian and gay couples as well (Bryant & Demian, 1994; McWhirter & Mattison, 1984). Bryant and Demian's (1994) study of lesbian and gay couples involved questionnaires completed by 709 lesbian and 557 gay couples who were drawn from 48 of the 50 states, Puerto Rico, and the District of Columbia. This group of respondents averaged about 35 years of age, had on average more than 16 years of education, and was heavily Caucasian. The average couple had been together more than five years, and lived together full-time. Most respondents reported having had one or two major lesbian/gay relationships before the one in which they were currently involved. Bryant and Demian (1994) reported a number of interesting differences between lesbian and gay couples. For example, lesbian couples were more likely than gay couples to have incorporated ritual and symbolism into their relationships by having a commitment ceremony or by wearing rings to symbolize their commitment to one another. Gay couples reported having sexual relations more frequently than did lesbian couples. Most couples of both genders reported that their relationships were sexually exclusive or monogamous, and very few couples reported sex with partners outside their primary relationships. However, men were over-represented among those who were not monogamous or who reported sex outside the relationship. Further, men were more likely than women to call the person with whom they were involved their ªlover,º and women were more likely than men to call this person their ªpartnerº; not one person of either gender mentioned using the term ªlongtime companionº to describe their lover or partner. When asked to whom they looked for support, couples reported that friends and coworkers were more supportive than relatives (Bryant & Demian, 1994; Kurdek & Schmidt,

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1987). Among relatives, siblings were considered most supportive, followed by mothers, and other relatives. Fathers were considered the least supportive among the couplesº relatives. Overall, relatives were rated as the third most important challenge to couple relationships, after ªcommunicationº and ªcareer.º A minority of couples reported acting in parental or other caregiving roles for children. Altogether, 21% of lesbian and 9% of gay couples reported caring for children. Most (75% of lesbians and 79% of gay men) had children from a previous marriage, and only 13% of lesbian mothers had children who had been conceived via DI. Interestingly, however, children were planned or under consideration by fully a third of all respondents under 35 years of age. In summary, couples who participated in large-scale surveys have been largely well educated, relatively young, mainly Caucasian, and usually living together full-time. They were likely to regard friends and co-workers (rather than relatives) as their principal sources of support, and unlikely to have children living with them in the home. In addition, some differences between lesbian and gay couples have been described, notably in the couplesº use of ritual and symbolism, sexual behavior, and in their names for one another. The extent to which these findings would be true of a more general cross-section of the population of lesbian and gay couples is unknown. 9.16.3.2 Love and Commitment Many, if not most, lesbians and gay men express the desire for an enduring love relationship with a partner of the same gender. Indeed, research findings suggest that many are successful in creating such relationships. Survey data suggest that 40±60% of gay men and 45±80% of lesbians are currently involved in steady romantic relationships (see Peplau & Cochran, 1990; Peplau, Veniegas, & Campbell, 1996). Because most surveys involve many young adults, who may not have yet committed to stable romantic relationships, these numbers may underestimate the true figures. When asked about their current relationship, lesbians and gay men report as much satisfaction with their relationships as do heterosexual couples; the great majority describe themselves as happy (Cardell, Finn, & Maracek, 1981; Kurdek & Schmidt, 1986a, 1986b; Peplau, Padesky, & Hamilton, 1982). For example, Peplau and Cochran (1990) surveyed 50 lesbians, 50 gay men, 50 heterosexual women, and 50 heterosexual men who were currently involved in romantic relationships. Both lesbians

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and gay men reported very positive feelings about their partners and rated their relationships as very satisfying. There were no differences as a function of sexual orientation on any of the measures of relationship quality (Peplau & Cochran, 1990). Of course, not every lesbian or gay couple is happy together, and research has also focused on factors related to differences in relationship satisfaction. The correlates of relationship quality for lesbian and gay couples include feelings of having equal power, perceiving many attractions and few alternatives to the relationship, endorsing few dysfunctional beliefs about the relationship, placing a high value on the relationship, and engaging in shared decisionmaking (Blumstein & Schwartz, 1983; Kurdek, 1994, 1995). 9.16.3.3 Power and Division of Labor How should power be allocated in a couple? The great majority of lesbian and gay couples feel that an equal balance of power would be desirable (Peplau & Cochran, 1990), but not all report that they achieve this ideal state. In Peplau and Cochran's study, only 59% of lesbians, 38% of gay men, 48% of heterosexual women, and 40% of heterosexual men reported that the balance of power in their current relationship was exactly equal. Others have found that majorities of gay as well as lesbian couples report equal power (see Peplau et al., 1996). When power is unequal in a relationship, which partner has more power in an intimate relationship, and why? Social exchange theory predicts that the partner with greater personal resources (e.g., income, education) should have greater power (Peplau, 1991), and results of a number of studies have supported this view. For example, Harry (1984) found that older, wealthier men tended to have more power in their intimate relationships, and Caldwell and Peplau (1984), in a study of young lesbians, reported that wealthier and better educated women tended to have more power than their partners. Blumstein and Schwartz (1983) found that the partner with greater financial resources had more power in money management issues in gay, married heterosexual, and unmarried (but cohabiting) heterosexual couples, but not in lesbian couples. Whether or not relative financial resources affect the balance of power in lesbian couples remains an open question (see Peplau et al., 1996). Other predictions from exchange theory have also received support from empirical research (Kurdek, 1995; Peplau, 1991; Peplau et al., 1996). In social exchange theory, the principle of

least interest states that when one person is more dependent or involved than the other, the more dependent partner is expected to have less power (Peplau, 1991). In other words, the person who is less interested in continuing the relationship has more power. Consistent with this view, Caldwell and Peplau (1984) found correlations between unequal involvement and unequal power among lesbian couples. Overall, as predicted by social exchange theory, the woman who was less involved in the relationship had more power. Although many people who are unfamiliar with lesbian and gay couples assume that, in same-sex couples, one partner plays a male and one a female role, research has consistently found that this is only rarely the case (Kurdek, 1995; Peplau et al., 1996). For example, Bell and Weinberg ( 1978) reported that the majority of lesbians and gay men they studied reported that they shared domestic tasks equally. When they were asked whether one partner does the feminine tasks while the other does the masculine tasks, about 90% of lesbians and gay men said that this was not the case in their households. Kurdek (1993) reported egalitarian divisions of labor among lesbian and gay couples, and Patterson (1995d) reported that in a sample of lesbian couples with children, most family and household tasks were shared equally. 9.16.3.4 Sexual Behavior Sexual behavior among lesbian and gay couples has been found to be strongly shaped by gender. First, the frequency of genital sexual behavior has been reported to decline with the duration of a relationship, and this is true of reports given by lesbian, gay, heterosexual married, and unmarried (but cohabiting) heterosexual couples (Kurdek, 1995). These declines are less pronounced among gay and more pronounced among lesbian couples than among heterosexual couples, whether married or not. The frequency of genital sexual relations, as reported in surveys, thus appears to increase with the number of men in a couple. Critics of these findings have suggested that lesbian couples may have different definitions of sexual behavior than do gay men or heterosexual couples. As Blumstein and Schwartz (1983) reported, lesbians may place greater value on non-genital expressions of love, such as hugging and other affectionate behaviors. Another area in which strong gender differences emerge is in the degree of a couple's desire for and accomplishment of sexual exclusivity. Lesbians and heterosexual couples have generally been found to be more supportive than

Research on Lesbian and Gay Couple Relationships gay men of monogamy in their relationships, and their reported behavior corresponds to these views. For example, Blumstein and Schwartz (1983) reported that, among couples who had been together between 2 and 10 years, most lesbian and heterosexual couples preferred and experienced monogamous sexual relationships, whereas most gay couples did not. These data were collected before the HIV/AIDS epidemic had attracted attention. However, data collected during 1988±89, after HIV infection and AIDS had become widespread in the USA, revealed the same pattern of results (Bryant & Demian, 1994). Despite differences in preferences and in actual behavior, however, lesbian, gay, heterosexual married, and unmarried (but cohabiting) heterosexual couples all reported similar satisfaction with their sexual relationships (see also Bryant & Demian, 1994). Blumstein and Schwartz (1983) reported that, in each of the four couple types they studied, satisfaction with sex was associated with a perception of equality in initiating and refusing sexual overtures. Thus, although gender differences in sexual attitudes and sexual behavior would appear to be substantial, reported sexual satisfaction within couple relationships has not varied as a function of sexual orientation or gender of partners (Kurdek, 1995; Peplau, 1991). 9.16.3.5 Problems and Conflict in Couples When lesbian and gay couples experience problems in their relationships, some of these stem from the same roots as those from which difficulties in heterosexual relationships also arise. As in heterosexual relationships, problems can arise due to different religious, racial, ethnic, or socioeconomic backgrounds of partners, and due to the different values that these backgrounds may have inculcated. Relationship difficulties can also arise as a result of problems at either partner's job, financial pressures on the couple, friction with members of extended family networks, and so forth, just as they do in heterosexual relationships. Kurdek (1992) found that the top five areas of conflict for lesbian and gay couples were finances, driving style, affection/sex, being overly critical, and division of household tasks. There are some conflicts that are probably unique to lesbian and gay couples, and prominent among these are problems generated by negative social attitudes toward homosexuality. Because of prejudice and discrimination directed toward lesbians and gay men, many are unwilling to disclose their sexual identities to family members, neighbors, co-workers, and even to friends. When a couple disagrees about

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the extent to which they should disclose the lesbian or gay nature of their relationship, real difficulties in the couple relationship can ensue. Resolution of such conflicts may be central to the success of the couple relationship over time (Peplau et al., 1996). The longevity of lesbian and gay relationships has also been a topic of some research. Blumstein and Schwartz (1983) found that for couples who had already been together 10 years, break-up rates over the 18 months of their study were low; only 6% of lesbian couples, 4% of gay couples, and 4% of married couples separated during this period. For couples who had been together less than 2 years, 22% of lesbian couples, 16% of gay couples, 17% of cohabiting (but unmarried) heterosexual couples, and only 4% of heterosexual married couples had separated. Thus, being married was associated with low break-up rates, but otherwise there were no significant differences. A later study (Kurdek, 1992, cited in Kurdek, 1995) also found no differences in break-up rates between lesbian and gay couples. In this study, break-up rates over a four-year period were 22% for lesbians and 12% for gay men, and this difference was not significant. Kurdek and Schmidt (1986a) compared the attractions that a relationship held for the partners and also the barriers to exiting a relationship for lesbian, gay, unmarried (but cohabiting) heterosexual, and married heterosexual couples. They found no differences among these four types of couples in the strength of attractions toward their relationships, but did find significant differences in barriers to leaving the relationships. Specifically, married heterosexual spouses reported more obstacles to exiting the relationship than did members of the other three types of couples. In addition to all the usual ways in which relationships can end, gay relationships in particular have, since the early 1980s, been subject to unusual stresses due to the HIV/ AIDS epidemic (Mattison & McWhirter, 1994; Paul, Hays, & Coates, 1995). In particular, the severe illnesses and premature deaths suffered by many gay men have precipitated relationship losses for surviving partners, who may themselves be relatively young. A study of a large group of gay men in New York City found that nearly one-third had suffered the loss of a close friend or lover to AIDS (Martin & Dean, 1993). Such men may not only have cared for a dying partner through a long illness, but also suffer bereavement without the institutionalized supports that would be available to surviving members of heterosexual couples. Despite such stresses, gay communities have responded with tremendous energy by creating volunteer service

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agencies and memorials such as the AIDS Quilt, which have supported those suffering with illness and helped survivors to keep memories of loved ones alive (D'Augelli & Garnets, 1995; Paul et al., 1995). In summary, research has begun to describe various characteristics of lesbian and gay relationships. Most lesbians and gay men want to have intimate romantic relationships, and most do in fact create such relationships. The majority of couples surveyed have reported a desire for egalitarian relationships, although many acknowledge that their current relationship may not attain that ideal. What inequalities in power do exist in lesbian and gay couple relationships can often be traced to differences in the personal resources and/or commitment of each partner to maintaining the relationship. Rarely do lesbian or gay couples rely on gendered divisions of labor in their relationships; they are more likely to divide family and household labor in more flexible and egalitarian ways. Although sexual practices diverge to some degree as a function of gender, both lesbian and gay couples are likely to express satisfaction with their sexual relationships. Many lesbian and gay relationships endure for a period of years, and there are no significant differences in break-up rates between lesbian, gay, and unmarried (but cohabiting) heterosexual couples. When problems arise, these are likely to be in areas common to heterosexual couples as well, although a few areas of special concern to lesbian and gay couples also exist due to the effects of societal prejudice and discrimination. Many gay relationships have been terminated prematurely because of the illness and death of a partner from HIV/AIDS, but other gay and lesbian relationships endure. Despite notable advances, research on lesbian and gay couples is still quite new, and much remains to be learned.

9.16.4 RESEARCH ON LESBIAN MOTHERS AND GAY FATHERS Systematic research on lesbian mothers, gay fathers, and their children is a phenomenon of the last 25 years. Despite the diversity of lesbian and gay parenting communities, however, research has with few exceptions been conducted with relatively homogeneous groups of participants. Like research on couples, research on parents has generally employed samples composed of white, middle or upper middle class, well-educated individuals, generally living in the USA. In this chapter, any studies that provide exceptions to this rule are specifically

noted. In this section, research on those who became parents in the context of heterosexual relationships, before coming out as lesbian or gay, is presented first, followed by a description of studies of lesbians who became parents after coming out. 9.16.4.1 Lesbians and Gay Men Who Became Parents in the Context of Heterosexual Relationships One important impetus for research in this area has come from extrinsic sources, such as judicial concerns about the psychological health and well-being of lesbians compared with heterosexual mothers. Other work has arisen from concerns that are more intrinsic to the families themselves, such as what and when children should be told about their parentsº sexual orientation. 9.16.4.1.1 Divorced lesbian mothers Because it has often been raised as an issue by judges presiding over custody disputes (Falk, 1989), a number of studies have assessed the overall mental health of lesbians compared with heterosexual mothers. Consistent with data on the mental health of lesbians in general (Gonsiorek, 1991), research has revealed that divorced lesbian mothers score at least as high as divorced heterosexual mothers on assessments of psychological health. For instance, studies have found no differences between lesbian and heterosexual mothers on self-concept, happiness, overall adjustment, or psychiatric status (Falk, 1989). Another area of judicial concern has focused on maternal sex-role behavior and its potential impact on children (Patterson, 1995a, 1995b). Stereotypes cited by the courts suggest that lesbians might be overly masculine and/or that they might interact inappropriately with their children. However, neither lesbian mothersº reports about their sex-role behavior nor their self-described interest in child-rearing have been found to differ from those of heterosexual mothers. Reports about responses to child behavior and ratings of warmth toward children have been found not to differ significantly between lesbian and heterosexual mothers. Differences between lesbian and heterosexual mothers have also been reported. Among the most straightforward of these are the reports by Lyons (1983) and Pagelow (1980) that divorced lesbian mothers in their samples had more fears about loss of child custody than did divorced heterosexual mothers. Similarly, Green, Mandel, Hotvedt, Gray, and Smith (1986) reported that lesbian mothers were more likely than

Research on Lesbian Mothers and Gay Fathers heterosexual mothers to be active in feminist organizations. Given the environments in which these lesbian mothers were living, findings like these are not surprising. A few other scattered differences seem more difficult to interpret. For example, Miller, Jacobsen, and Bigner (1981) found lesbian mothers to be more child-centered than heterosexual mothers in their discipline techniques. In a sample of African-American lesbian and heterosexual mothers, Hill (1987) found that lesbian mothers reported being more flexible about rules, more relaxed about sex play and modesty, and more likely to have nontraditional expectations for their daughters. Pending confirmation and replication with different samples, these findings are best viewed as suggestive. Several studies have also examined the social circumstances and relationships of lesbian mothers. Divorced lesbian mothers have consistently been reported to be more likely than divorced heterosexual mothers to be living with a romantic partner (Harris & Turner, 1985/86; Kirkpatrick, Smith, & Roy, 1981; Pagelow, 1980). Whether this represents a difference between lesbian and heterosexual motherheaded families, or reflects nothing more than sampling biases of the research, cannot be determined from current research studies. Information is sparse about the impact of such relationships in lesbian mother families, but that which has been published suggests that, like heterosexual step-parents, coresident lesbian partners of divorced lesbian mothers can be important sources of conflict as well as support in the family. Relationships with the fathers of children in lesbian mother homes have also been a topic of study. Few differences in the likelihood of paternal financial support have been reported for lesbian and heterosexual families with children. Kirkpatrick et al. (1981) reported, for example, that only about one-half of heterosexual and about one-half of lesbian mothers in their sample received financial support from the fathers of their children. Findings about frequency of contact with the fathers are mixed, with some (e.g., Kirkpatrick et al., 1981) reporting no differences as a function of maternal sexual orientation and others (e.g., Golombok, Spencer, & Rutter, 1983) reporting more contact among lesbian than among heterosexual mothers. Although most research has involved assessment of possible differences between lesbian and heterosexual mothers, a few studies have reported other types of comparisons. For instance, in a study of divorced lesbian mothers and divorced gay fathers, Harris and Turner (1985/86) found that gay fathers were likely to

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report higher incomes and that they encouraged more sex-typed toy play among their children, whereas lesbian mothers were more likely to see benefits for their children (e.g., increased empathy and tolerance for differences) as a result of having lesbian or gay parents. In comparisons of relationship satisfaction among lesbian couples who did or did not have children, Koepke, Hare, and Moran (1992) reported that couples with children scored higher on overall measures of relationship satisfaction and of the quality of their sexual relationship. These findings are intriguing, but much more research will be needed before their interpretation will be clear. Another important set of questions, as yet little studied, concerns the conditions under which lesbian mothers experience enhanced feelings of well-being, support, and ability to care for their children. Rand, Graham, and Rawlings (1982) reported that psychological health of lesbian mothers was associated with the mothersº openness about her sexual orientation with her employer, ex-husband, children, and friends, and with her degree of feminist activism. Kirkpatrick (1987) found that lesbian mothers living with partners and children had greater economic and emotional resources than those living alone with their children. Much remains to be learned about determinants of individual differences in psychological well-being among lesbian mothers. Many other issues that have arisen in the context of divorced lesbian mother families are also in need of study. For instance, when a mother is in the process of coming out as a lesbian to herself and to others, at what point in that process should she address the topic with her child, and in what ways should she do soÐif at all? And what influence ought the child's age and circumstances to have in such a decision? Reports from research and clinical practice suggest that early adolescence may be a particularly difficult time for parents to initiate such conversations, and that disclosure may be less stressful at earlier or later points in a child's development (Patterson, 1992, 1995a), but systematic research on these issues is just beginning. Similarly, many issues remain to be addressed regarding step-family and blended family relationships that may emerge as a lesbian mother's household seeks new equilibrium following her separation or divorce from the child's father. 9.16.4.1.2 Divorced gay fathers Although considerable research has focused on the overall psychological adjustment of lesbian mothers as compared with that of

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heterosexual mothers, no published studies of gay fathers make such comparisons with heterosexual fathers. This may be attributable to the greater role of judicial decision-making as an impetus for research on lesbian mothers. In jurisdictions where the law provides for biases in custody proceedings, these are likely to favor female and heterosexual parents. Perhaps because, other things being equal, gay fathers are unlikely to win custody battles over their children after divorce, fewer such cases have reached the courts. Consistent with this view, only a minority of gay fathers have been reported to live in the same households with their children (Bigner & Bozett, 1990; Bozett, 1980, 1989). Research on the parenting attitudes of gay versus heterosexual divorced fathers has, however, been reported. Bigner and Jacobsen (1989a, 1989b) compared gay and heterosexual fathers, each of whom had at least two children. Their results revealed that, with one exception, there were no significant differences between gay and heterosexual fathers in their motives for parenthood. The single exception concerned the greater likelihood of gay than heterosexual fathers to cite the higher status accorded to parents as compared with nonparents in the dominant culture as a motivation for parenthood (Bigner & Jacobsen, 1989a). Bigner and Jacobsen (1989b) also asked gay and heterosexual fathers in their sample to report on their behavior when interacting with their children. Although no differences emerged in the fathersº reports of involvement or intimacy, gay fathers reported that their behavior was characterized by greater responsiveness, more reasoning, and more limit-setting than heterosexual fathers. These reports by gay fathers of greater warmth and responsiveness, as well as greater control and limit-setting, are strongly reminiscent of findings from research with heterosexual families, and would seem to raise the possibility that gay fathers are more likely than their heterosexual counterparts to exhibit authoritative patterns of parenting behavior (Baumrind, 1967; Baumrind & Black, 1967). Caution must be exercised, however, in the interpretation of results which stem entirely from paternal reports about their own behavior. In addition to research comparing gay and heterosexual fathers, a handful of studies have made other comparisons. For instance, Robinson and Skeen (1982) compared sex-role orientations of gay fathers with those of gay men who were not fathers, and found no differences. Similarly, Skeen and Robinson (1985) found no evidence to suggest that gay men's retrospective reports about relationships with their own parents varied as a function of

whether or not they were parents themselves. As noted above, Harris and Turner (1985/86) compared gay fathers and lesbian mothers, reporting that while gay fathers had higher incomes and were more likely to report encouraging their children to play with sextyped toys, lesbian mothers were more likely to believe that their children received positive benefits such as increased tolerance for diversity from having lesbian or gay parents. Much research in this area has also arisen from concerns about the gay father identity and its transformations over time. For example, Miller (1978, 1979) and Bozett (1980, 1981a, 1981b, 1987) sought to provide a conceptualization of the processes through which a man who considers himself to be a heterosexual father may come to identify himself, both in public and in private, as a gay father. Based on extensive interviews with gay fathers in the USA and Canada, these authors emphasized the pivotal nature of identity disclosure itself and of the reactions to disclosure by significant people in a man's life. Miller (1978) suggested that while a number of factors, such as the extent of occupational autonomy and amount of access to gay communities, may affect how rapidly a gay man discloses his identity to others, the most important of these is likely to be the experience of falling in love with another man. It is this experience, more than any other, Miller argued, that leads a man to integrate the otherwise compartmentalized parts of his identity as a gay father. 9.16.4.2 Lesbians and Gay Men Choosing to Become Parents Although for many years lesbian mothers and gay fathers were generally assumed to have become parents in the context of previous heterosexual relationships, both men and women are believed increasingly to be undertaking parenthood in the context of pre-existing lesbian and gay identities (Crawford, 1987; Patterson, 1994a, 1994b). Although a substantial body of research addresses the transition to parenthood among heterosexuals, little research has explored the transition to parenthood for gay men or lesbians. While many issues that arise for heterosexuals also face lesbians and gay men (e.g., concerns about how children will affect couple relationships, economic concerns about supporting children), lesbians and gay men must also cope with many additional issues because of their situation as members of stigmatized minorities. These issues are best understood by viewing them against the backdrop of pervasive heterosexism and antigay prejudice.

Research on Lesbian Mothers and Gay Fathers Antigay prejudice is evident in institutions involved with health care, education, and employment that often fail to support and, in many cases, are openly hostile to lesbian and gay families (Casper, Schultz, & Wickens, 1992; Pollack & Vaughn, 1987). Lesbian and gay parents may encounter antigay prejudice and bigotry even from their families of origin. Many, if not most of, the special concerns of lesbian and gay parents and prospective parents stem from problems created by such hostility. A number of inter-related issues are often faced in particular by lesbians and gay men who wish to become parents (Crawford, 1987; Patterson, 1994b). One of the first needs among this group is for accurate, up-to-date information on how lesbians and gay men can become parents, how their children are likely to develop, and what supports are available to assist them. In addition to these educational needs, lesbians and gay men who are seeking biological parenthood are also likely to encounter various health concerns, ranging from medical screening of prospective birthparents to assistance with DI techniques, prenatal care, and preparation for birth. As matters progress, a number of legal concerns about the rights and responsibilities of all parties are likely to emerge. Associated with all of these will generally be financial issues; in addition to the support of a child, auxiliary costs of medical and legal assistance may be considerable. Finally, social and emotional concerns of many different kinds are also likely to emerge (Patterson, 1994b; Pies, 1985, 1990; Pollack & Vaughn, 1987; Rohrbaugh, 1988). The earliest studies of childbearing among lesbian couples were reported by McCandlish (1987) and Steckel (1987). Both investigators reported research based on small samples of lesbian couples who had given birth to children by means of DI. Their focus was primarily on the children in such families, and neither investigator provided much in the way of systematic assessment of mothers. McCandlish did, however, highlight events and issues that were significant among families in her sample. For instance, she noted that, regardless of their interest in parenting prior to birth of the first child, nonbiological mothers in each couple unanimously reported an ªunexpected and immediate attachmentº to the child (McCandlish, 1987, p. 28). Although both mothers took part in parenting, they reported shifting patterns of caretaking responsibilities over time, with the biological mother taking primary responsibility during the earliest months, and the nonbiological mother's role increasing in importance after the first year. Couples also

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reported changes in their relationships following the birth of the child, notably a reduction or cessation in sexual intimacy. Though the best interpretation of results from these pioneering studies is by no means clear, the work raises important issues and questions. A study by Hand (1991) examined the ways in which 17 lesbian and 17 heterosexual couples with children under two years of age shared childcare, household duties, and occupational roles. Her principal finding was that lesbian couples shared parenting more equally than heterosexual couples. Lesbian nonbiological mothers were significantly more involved in childcare and regarded their parental role as significantly more salient than heterosexual fathers. Lesbian biological mothers viewed their maternal role as more salient than did any of the other mothers, whether lesbian or heterosexual. Fathers viewed their occupational roles as more salient than any of the mothers, whether lesbian or heterosexual. Hand's major result was, however, that lesbian couples were more likely than heterosexual couples to share childcare relatively evenly. Another study (Osterweil, 1991) involved 30 lesbian couples with at least one child between 18 and 36 months of age. Consistent with Hand's (1991) results for parents of younger children, Osterweil reported that biological mothers viewed their maternal role as more salient than nonbiological mothers. In addition, although household maintenance activities were shared about equally, biological mothers reported somewhat more influence in family decisions and somewhat more involvement in childcare. Osterweil also reported that the couples in her study scored at about the mean for normative samples of heterosexual couples in overall relationship satisfaction. These studies suggest that lesbian couples who have chosen to bear children are likely to share household and childcare duties to a somewhat greater degree than heterosexual couples, and that lesbians are relatively satisfied with their couple relationships. Similar findings have also been reported by Patterson (1995d). Two studies of men who have become fathers after identifying themselves as gay have been reported. Sbordone (1993) studied 78 gay men who had become parents through adoption or through surrogacy, and compared them with 83 gay men who were not fathers. Consistent with Skeen and Robinson's (1985) findings for divorced gay fathers, Sbordone found no differences between fathers and nonfathers on reports about relationships with the men's own parents. Gay fathers did, however, report higher self-esteem and fewer negative attitudes about

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homosexuality than gay men who were not fathers. An interesting observation of Sbordone's (1993) study was that most gay men who were not fathers indicated that they would like to rear a child. The men who said that they wanted children were younger than those who said they did not, but the two groups did not differ on income, education, race, self-esteem, or attitudes about homosexuality. Given that fathers had higher self-esteem than either group of nonfathers, Sbordone suggested the possibility that the higher self-esteem of gay fathers might have been a result, not a cause or simple correlate, of parenthood. McPherson (1993) reported a study of gay couples who had chosen to become parents. He studied division of labor, satisfaction with division of labor, and satisfaction with couple relationships among 28 gay and 27 heterosexual parenting couples. Consistent with evidence from lesbian couples with children (Hand 1991; Osterweil, 1991; Patterson, 1995d), McPherson found that gay couples reported a more even division of responsibilities for household maintenance and childcare than did heterosexual couples. Gay couples also reported greater satisfaction with their division of childcare tasks than did heterosexual couples. Finally, gay couples also reported greater satisfaction with their couple relationships, especially in the areas of cohesion and expression of affection. In summary, studies of lesbians and gay men who have chosen to become parents are still sparse. Most research has been conducted on a relatively small scale and many important issues have yet to be addressed. Much remains to be learned about the determinants of lesbian and gay parenting and about its impact on lesbian and gay parents themselves.

9.16.5 RESEARCH ON CHILDREN OF LESBIAN AND GAY PARENTS Research on children in lesbian and gay families has, with few exceptions, been conducted with relatively homogeneous groups of white, well-educated, middle class, largely professional families living in or around urban centers in the USA or in other Western countries. Unless otherwise specifically noted, these characteristics apply to the research described in this section. Research on children born in the context of heterosexual relationships is presented first, followed by a description of work with children born to or adopted by lesbian and gay parents.

9.16.5.1 Research on Children Born in the Context of Heterosexual Relationships As with research on lesbian mothers, much of the impetus for research in this area has come from judicial concerns about the welfare of children residing with gay or lesbian parents. Research in each of three main areas of judicial concernÐnamely, children's sexual identity, other aspects of children's personal development, and children's social relationshipsÐis summarized here. 9.16.5.1.1 Sexual identity Following Money and Ehrhardt (1972), research on three aspects of sexual identity is considered. Gender identity concerns a person's self-identification as male or female. Genderrole behavior concerns the extent to which a person's activities and occupations are regarded by the culture as masculine, feminine, or both. Sexual orientation refers to a person's choice of sexual partners (e.g., heterosexual, homosexual, or bisexual). Research on gender identity has failed to reveal any differences in the development of children as a function of their parentsº sexual orientation. For example, Kirkpatrick et al. (1981) compared development among 20 children of lesbian mothers with that among 20 same-aged children of heterosexual mothers. In projective testing, most children in both groups drew a same-sex figure first, a finding that fell within expected norms. Of those who drew an opposite-sex figure first, only three (one with a lesbian mother, and two with heterosexual mothers) showed concern about gender issues in clinical interviews. Similar findings have been reported in projective testing by other investigators (e.g., Green et al., 1986) and studies using more direct methods of assessment have yielded similar results (e.g., Golombok et al., 1983). Research on gender-role behavior has also failed to reveal difficulties in the development of children with lesbian mothers. For instance, Green (1978) reported that 20 of 21 children of lesbian mothers in his sample named a favorite toy consistent with conventional sex-typed toy preferences, and that all reported vocational choices that fell within typical limits for conventional sex roles. In interviews with 56 children of lesbians and 48 children of heterosexual mothers, Green et al. (1986) found no differences with respect to favorite television programs, television characters, games, or toys. They reported that daughters of lesbian mothers were more likely to be described as taking part in rough and tumble play or as playing with masculine toys such as trucks or

Research on Children of Lesbian and Gay Parents guns, but found no comparable differences for sons. In all studies, the behavior of lesbian mothersº children was seen as falling within normal limits. Rees (1979) administered the Bem Sex Role Inventory to 12 young adolescent offspring of lesbian mothers and 12 same-aged youngsters of heterosexual mothers. Although children of lesbian and heterosexual mothers did not differ on masculinity or androgyny, adolescent offspring of lesbian mothers reported greater psychological femininity than their same-aged peers with heterosexual mothers. This result runs counter to expectations based on stereotypes of lesbians as lacking in femininity and, although provocative, it should be interpreted cautiously pending replication. Overall, research has failed to reveal any notable difficulties in the development of sex-role behavior among children of lesbian mothers. A number of investigators have also studied sexual orientation, the third component of sexual identity. For example, Huggins (1989) interviewed 36 teenagers, half of whom were the offspring of lesbian mothers and half of heterosexual mothers. No child of a lesbian mother identified as lesbian or gay, but one child of a heterosexual mother did. Generally similar results have been reported by other investigators (e.g., Golombok & Tasker, 1996; Gottman, 1990). Studies of the offspring of gay fathers have yielded similar results (Bozett, 1987). Based on the results of these studies, there is no reason to believe that the offspring of lesbian or gay parents are any more likely than those of heterosexual parents to become lesbian or gay themselves. As clear as these results are, it should be recognized that research on the development of sexual identity among the offspring of lesbian and gay parents has been criticized from a number of perspectives. For instance, many lesbian women do not self-identify as lesbians until adulthood (see Brown, 1995); for this reason, studies of sexual orientation among adolescents may count as heterosexual some individuals who will identify themselves as lesbian later in life. Concern has also been voiced that in many studies that compare children of divorced heterosexual mothers with children of divorced lesbian mothers, the lesbian mothers were more likely to be living with a romantic partner; in these cases, maternal sexual orientation and relationship status have been confounded. While these and other methodological issues await resolution, it remains true that no significant problems in the development of sexual identity among children of lesbian mothers have yet been identified.

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9.16.5.1.2 Other aspects of personal development Studies of other aspects of personal development among children of gay and lesbian parents have assessed a broad array of characteristics (Patterson, 1995a; Tasker & Golombok, 1995). Among these have been psychiatric evaluations and assessments of behavior problems, personality, self-concept, locus of control, moral judgment, and intelligence. Concerns about possible difficulties in personal development among children of lesbian and gay parents have not been sustained by the results of research (Patterson, 1992, 1995a, 1997). As was true for sexual identity, studies of other aspects of personal development have revealed no significant differences between children of lesbian or gay parents and children of heterosexual parents. On the basis of existing evidence, fears that children of gay and lesbian parents suffer deficits in personal development appear to be without empirical foundation. 9.16.5.1.3 Social relationships Studies assessing potential differences between children of gay and lesbian versus heterosexual parents have sometimes included assessments of children's social relationships. Because of concerns voiced by the courts that children of lesbian and gay parents might encounter difficulties among their peers, the most common focus of attention has been on peer relations. Studies have consistently found that children of lesbian mothers report normal peer relations, and that adult observers agree with this judgment (Patterson, 1992). Anecdotal and first-person accounts describe children's worries about being stigmatized as a result of their parentsº sexual orientation (e.g., Pollack & Vaughn, 1987), but research findings provide no evidence for the proposition that children of lesbian mothers have difficulties in peer relations (Tasker & Golombok, 1995). Research has also described children's relationships with adults, especially fathers. For instance, Golombok et al. (1983) found that children of lesbian mothers were more likely than children of heterosexual mothers to have contact with their fathers. Most children of lesbian mothers had some contact with their fathers during the year preceding the study, but most children of heterosexual mothers had not; indeed, almost a third of the children of lesbian mothers reported at least weekly contact with their fathers, whereas only 1 in 20 of the children of heterosexual mothers reported this. Kirkpatrick et al. (1981) also reported that lesbian mothers were more concerned than heterosexual

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mothers that their children have opportunities for good relationships with adult men, including fathers. Lesbian mothersº social networks have been found to include both men and women and, as a result, their children have contact with adults of both genders. Overall, research suggests that children of lesbian parents have satisfactory relationships with adults of both sexes. Concerns that children of lesbian or gay parents are more likely than children of heterosexual parents to be sexually abused have also been voiced by judges in the context of child custody disputes (Patterson, 1992). Research in this area shows that the great majority of adults who perpetrate sexual abuse are males and sexual abuse of children by adult women is extremely rare. Lesbian mothers are thus extremely unlikely to abuse their children. Existing research findings suggest that gay men are no more likely than heterosexual men to perpetrate child sexual abuse. Fears that children in custody of gay or lesbian parents might be at heightened risk for sexual abuse are thus without empirical foundation (Patterson, 1992, 1995a, 1995b).

9.16.5.2 Diversity Among Children With Divorced Lesbian or Gay Parents Despite the great diversity evident with gay and lesbian communities (Blumenfeld & Raymond, 1988), research on differences among children of lesbian and gay parents is, as yet, very limited. One important dimension of difference among gay and lesbian families concerns whether the custodial parent is involved in a romantic relationship, and if so what implications this may have for children. Pagelow (1980), Kirkpatrick et al. (1981), and Golombok et al. (1983) reported that divorced lesbian mothers were more likely than divorced heterosexual mothers to be living with a romantic partner. Huggins (1989) reported that self-esteem among daughters of lesbian mothers whose lesbian partners lived with them was higher than that among daughters of lesbian mothers who did not live with a partner. This finding might be interpreted to mean that mothers who are high in self-esteem are more likely to be involved in romantic relationships and to have daughters who are also high in selfesteem, but many other interpretations are also possible. In view of the small sample size and absence of conventional statistical tests, Hugginsº finding should be interpreted with great caution. Rand et al. (1982) found that lesbian mothersº sense of psychological well-being

was related to the extent to which they were open about their lesbian identity with employers, ex-husbands, and children. In their sample, a mother who felt more able to disclose her lesbian identity was also more likely to express a positive sense of well-being. In light of the consistent finding that, in heterosexual families, children's adjustment is often related to indexes of maternal mental health (Sameroff & Chandler, 1975), one might expect factors which enhance mental health among lesbian mothers also to benefit the children of these women, but this possibility has not yet been studied. Another area of great diversity among families with a gay or lesbian parent concerns the degree to which a parent's sexual identity is accepted by other significant people in children's lives. Huggins (1989) found a tendency for children whose fathers were rejecting of maternal lesbianism to report lower self-esteem than those whose fathers were neutral or positive. Due to small sample size and absence of conventional statistical tests, this finding should be seen as suggestive rather than definitive. Hugginsº results raise questions, however, about the extent to which reactions of important adults in a child's environment influence responses to discovery of a parent's gay or lesbian identity. Effects of the age at which children learn of parentsº gay or lesbian identities have also been investigated. Paul (1986) reported that those who were told either in childhood or in late adolescence found the news easier to cope with than did those who first learned of it during adolescence. Huggins (1989) reported that those who learned of maternal lesbianism in childhood had higher self-esteem than those who were not informed until they were adolescents. From a clinical standpoint, early adolescence is a particularly difficult time for children to learn of their parentsº lesbian or gay identities (Patterson, 1992). In summary, existing data favor early disclosure of identity to children, good maternal mental health, and a supportive milieu, but the available data are very limited. No information is yet available on differences attributable to race or ethnicity, family economic circumstances, cultural environments, or related variables. Because none of the published work has employed observational measures or longitudinal designs, little is known about the details of actual behavior in these families or about any changes over time. It is clear that much remains to be learned about differences among gay and lesbian families and about the impact of such differences on children growing up in these homes.

Research on Other Family Relationships 9.16.5.3 Research on Children Born to or Adopted by Lesbian Mothers In one of the first systematic studies of children born to lesbians, Steckel (1987) compared the progress of separation-individuation among preschool children born via DI to lesbian couples with that among same-aged children of heterosexual couples. Using parent interviews, parent and teacher Q sorts, and structured doll play techniques, Steckel compared independence, ego functions, and object relations among children in the two types of families. Her main results documented impressive similarity in development among children in the two groups. Similar findings, based on extensive interviews with five lesbian mother families were also reported by McCandlish (1987). Steckel (1987) did, however, report suggestive differences between the two groups. Children of heterosexual parents saw themselves as somewhat more aggressive than did children of lesbians, and they were seen by both parents and teachers as more bossy, domineering, and negativistic. Children of lesbian parents saw themselves as more lovable and were seen by parents and teachers as more affectionate, responsive, and protective toward younger children. In view of the small sample size, and the large number of statistical tests performed, these results must be interpreted with caution. Steckel's work was, however, the first to make systematic comparisons of development among children born to lesbian and to heterosexual couples. The first study to examine psychosocial development among preschool and school-aged children born to or adopted by lesbian mothers was conducted by Patterson (1994a). Thirtyseven four- to nine-year-old children were studied, using a variety of standardized measures. The Child Behavior Checklist was used to assess children's social competence and behavior problems; five scales from the Eder Children's Self-View Questionnaire were used to assess children's self-concepts, and openended interview techniques were used to assess preferences associated with sex-role behavior. Results showed that children scored in the normal range for all measures. On the Child Behavior Checklist (Achenbach and Edelbrock, 1983), for example, children of lesbian mothersº scores for social competence, internalizing behavior problems, and externalizing behavior problems differed significantly from the scores for a clinical sample, but did not differ from the scores for a large normative sample of American children. Likewise, children of lesbian mothers reported sex-role preferences within the ex-

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pected normal range for children of this age. On most subscales of the self-concept measure, answers given by children of lesbian mothers did not differ from those given by same-aged children of heterosexual mothers studied in a standardization sample. On two subscales of the self-concept measure, however, Patterson (1994a) found that children of lesbian mothers reported feeling more reactions to stress (e.g., feeling angry, scared, or upset), but a greater sense of well-being (e.g., feeling joyful, content, and comfortable with themselves) than did the same-aged children of heterosexual mothers in the standardization sample. One possible interpretation of this result is that children of lesbian mothers report greater reactivity to stress because, in fact, they experienced greater stress in their daily lives than did other children. Another possibility is that, regardless of actual stress levels, children of lesbian mothers were better able to acknowledge both positive and negative aspects of their emotional experience. Some additional findings from this study can be mentioned briefly. Contrary to stereotypes of these families as isolated from families of origin, most reported that children had regular contact with one or more grandparents, as well as with other adult friends and relatives of both sexes (Patterson, Hurt, & Mason, in press). In families headed by lesbian couples, the parents were likely to maintain egalitarian divisions of labor, but when differences occurred, biological lesbian mothers were likely to do somewhat more childcare and nonbiological lesbian mothers were likely to spend somewhat more time engaged in paid employment (Patterson, 1995d). Even within the relatively small range represented in this sample, families in which childcare was divided more evenly were also those in which children exhibited the most favorable adjustment (Patterson, 1995d).

9.16.6 RESEARCH ON OTHER FAMILY RELATIONSHIPS In addition to parent±child and couple relationships, lesbians and gay men are likely to maintain contacts with parents, siblings, and other members of their families of origin (Cohen & Savin-Williams, 1996; Laird, 1996; Patterson et al., in press). Although, as Laird (1996) has emphasized, many other issues are undoubtedly significant, the largest amount of research has focused on the concerns of young lesbians and gay men about disclosing their sexual identities to members of their families of origin, especially to parents.

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After acknowledging lesbian or gay identities, many people begin to wonder whether and how to share such identities with (i.e., ªcome out toº) those who are important to them. Most lesbians and gay men appear to come out first to close friends, and only laterÐif at allÐto family members (Savin-Williams, 1990). Young people are more likely to come out first to mothers rather than to fathers, perhaps because they expect more positive responses from mothers (Bryant & Demian, 1994; Cohen & SavinWilliams, 1996). For example, Remafedi (1987) studied a sample of gay and bisexual teenagers, and found that most were out to their mothers but not their fathers, and almost all were out to at least one friend. Although it is difficult to predict parental reactions to disclosure of a nonheterosexual orientation by their offspring, the most common initial reactions are usually negative (Cohen & Savin-Williams, 1996). Negative reactions are likely to be more pronounced among older parents, those with less education, and those whose parent±child relationships were troubled before the disclosure. Although interactions between lesbian and gay young people and their parents often suffer difficulties immediately after disclosure, they most often improve again over time, as families assimilate this new information into existing images of the lesbian or gay child. The best predictor of postdisclosure relationships between lesbian and gay young adults and their parents is the quality of their relationships before the disclosure (Cohen & Savin-Williams, 1996; Savin-Williams, 1990). What are the associations between disclosure of lesbian or gay identity to parents and young adultsº self-esteem? Because of the significance of parent±adolescent relationships, one might expect parental acceptance to be associated with favorable self-images among lesbian and gay youth. Consistent with this view, Savin-Williams (1990) found that teenaged and young adult lesbians who said that their parents were accepting of their sexual identities (or would be accepting if they knew) also reported feeling more comfortable with their sexual orientation. This was true for young men, however, only if they also described their parents as important to their self-image (Savin-Williams, 1990). Because the research has been correlational in nature, it cannot be determined whether parental acceptance makes lesbian and gay children feel better about themselves, whether youth who already have high self-esteem are more likely to disclose to parents, or whether a cyclical process may be involved. Identification of causal pathways in this area thus represents an important challenge for future research.

While some research has focused on young adultsº disclosure of lesbian and gay identities to parents, other studies have shown that, among samples of older lesbian and gay adults, sizeable proportions have not come out to parents or other family members. When a lesbian or gay identity has not been disclosed, any one of several coping strategies may be employed by the individual and the family (Brown, 1989). A common one is distancing, whether emotionally or geographically (or both) from the family of origin. Another is the unspoken agreement that nobody in the family will discuss the lesbian or gay individual's personal life; this has been termed the ªI know you knowº strategy. A third approach is to disclose to one family member, who is thought to be supportive, on the condition that no others be told. This approach appears to rely on and perhaps strengthen coalitions among subgroups within a family. Although these strategies may or may not be viewed as problematic by those who employ them, they all block the achievement of true intimacy and add to the stress experienced by lesbian and gay adults (Brown, 1989). When a family member's nonheterosexual orientation becomes known, Strommen (1989a, 1989b) has described the family's reaction as involving a two-stage process. First, the family members struggle to understand and assimilate this new information about one of its members. The family may then simply reject the lesbian or gay person, or it may reorganize itself over time to accommodate this shift in identity while still including the lesbian or gay person in family activities. Parents in particular often find that the process of reorganization can be difficult, often extending over substantial periods of time. In the end, many discover that the process has brought them unexpected gifts (Bernstein, 1995).

9.16.7 IMPLICATIONS OF RESEARCH FINDINGS Research on lesbian and gay couples and families with children, though relatively new, has nevertheless yielded results that are worthy of attention. Without denying the consistency of major research findings, it is important also to acknowledge that the research is subject to various criticisms. For instance, much of the research has involved small samples that are predominantly white, well educated, relatively affluent, and American; the degree to which results would hold with other populations is thus difficult or impossible to evaluate at this time. It would also be desirable to have data

Directions for Research based on observational methods, collected within longitudinal designs, but studies of this kind have not yet been reported. Despite shortcomings, however, central results of existing research on lesbian and gay couples and families with children are exceptionally clear. First, research has succeeded in bringing to light the fact that lesbian and gay parents as well as couples exist in large numbers. Given the relative invisibility of lesbian and gay couples, as well as that of parents and their children, this achievement is significant in itself, and should not be overlooked. Beyond their witness to the sheer existence of lesbian and gay family lives, the results of existing studies, taken together, also yield a picture of families thriving, even in the midst of discrimination and oppression. Certainly, they provide no evidence that psychological adjustment among lesbians, gay men, their children or other family members is impaired in any significant respect. Indeed, the available evidence suggests that relationships of lesbian and gay couples are just as supportive, and that home environments provided by lesbian and gay parents are just as likely as those provided by heterosexual parents to support and enable psychosocial growth among family members. Much research on lesbian and gay parenting has focused primarily on comparisons between lesbian and gay families, on the one hand, and heterosexual families, on the other. This approach presumably reflects the concern of researchers to address prejudices and negative stereotypes that have been influential in judicial decision-making and in public policies relevant to lesbian and gay couples, parents and their children in the USA. Now that results of research have begun to converge so clearly on answers to questions posed in this way, it would appear that the time has come also to address a broader range of issues in this area. Many important research questions arise from a focus on the interests of lesbian and gay families themselves. For example, many lesbian and gay couples with children are interested in distinctions between the experiences of biological and nonbiological parents. How important, they ask, is the biological link in influencing experiences of parenthood? Similarly, both lesbian and gay families can benefit from more information about diversity among lesbian and gay couples and families with children. It would seem likely that future scholarship will increasingly concern itself with the study of sources of strength and resilience in lesbian and gay couples as well as among parents and their children. In the meantime, however, the central results of research have important implications. If

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psychosocial development among children born to lesbian mothers and gay fathers is essentially normal, then traditional theoretical emphases on the importance of parental heterosexuality need to be reconsidered. Although many possible approaches to such a task are possible (Patterson, 1992), one promising approach is to focus on the significance of family process rather than structure. Thus, structural variables such as parental sexual orientation may ultimately be seen as less important in mediating children's developmental outcomes than the quality of family interactions, relationships, and processes. Results of research with lesbian and gay parents and their children also have implications for the politics of family life. If, as would appear to be the case, neither parents nor children in lesbian and gay families run any special risk of maladjustment or other psychosocial problems, then a good rationale for prejudice and discrimination is more and more difficult to provide. Without such a rationale, many legal precedents and public policies relevant to lesbian and gay families would require reconsideration. Ultimately, lesbian and gay couples and parents might come to be viewed as normal, and policies might be designed to protect their legitimate interests, as well as those of their family members.

9.16.8 DIRECTIONS FOR RESEARCH Because research on the family lives of lesbians and gay men is relatively new, there are many promising avenues for further research (Allen & Demo, 1995). From a substantive point of view, a number of issues have gone all but unexplored in the research literature on lesbian and gay family lives. For example, little attention has been devoted to assessment of sexual orientation over time, and the phenomena associated with bisexuality (Paul, 1996) have received little study. Ethnic, racial, and socioeconomic diversity of lesbian and gay family lives have yet to be systematically explored. Little research has been conducted outside of the United States. These gaps all provide important opportunities for future research. From a methodological perspective, it would be valuable to have more studies that follow couples or parents and their children over time. Longitudinal studies of the relationships between lesbians, gay men, and members of their families of origin over relatively long periods of time could also be helpful in describing predictable sequences of reactions to significant life events (e.g., coming out, having a child)

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among family members. To avoid the pitfalls associated with retrospective reporting, these studies should involve prospective designs that follow participants over time. Another methodological issue in the literature is the almost complete absence of observational data. Observational studies of couples, parents, and children, as well as of lesbian and gay adults with members of their families of origin, could provide valuable evidence about similarities and differences between family processes in the family lives of lesbian, gay, and heterosexual adults. Such observational data could be collected from dyads or triads or larger family groups, at home or in the laboratory, in a single visit or in repeated sessions over time; and it could add tremendously to knowledge in this area. Overall, the study of lesbian and gay family lives provides a context in which to explore the limits of existing theoretical perspectives, and an opportunity to develop new ones. Future research that addresses these challenges has the potential to improve understanding of lesbian and gay family life, increase inclusiveness of theoretical notions about family structure and process, and inform public policies and judicial rulings relevant to lesbian and gay family life. When lesbian and gay family lives are viewed in these terms, it serves to underline the tremendous signficance of historical factors in shaping both individual and familial experiences. Rapid change in attitudes, social climates, and even legal rulings relevant to lesbian and gay family lives in the USA has, in many ways, transformed the daily lives of lesbians and gay men, and those of their family members as well. Future events, such as decisions in cases like Baehr v. Miike, hold the potential to further transform the experiences associated with lesbian and gay family lives.

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tion in lesbian couples who are parenting their first child together. Unpublished doctoral dissertation, California School of Professional Psychology, Berkeley, CA. Pagelow, M. D. (1980). Heterosexual and lesbian single mothers: A comparison of problems, coping and solutions. Journal of Homosexuality, 5, 198±204. Patterson, C. J. (1992). Children of lesbian and gay parents. Child Development, 63, 1025±1042. Patterson, C. J. (1994a). Children of the lesbian baby boom: Behavioral adjustment, self-concepts, and sex-role identity. In B. Greene & G. M. Herek (Eds.), Contemporary perspectives on lesbian and gay psychology: Theory, research, and applications (pp. 156±175). Beverly Hills: Sage. Patterson, C. J. (1994b). Lesbian and gay couples considering parenthood: An agenda for research, service, and advocacy. Journal of Gay and Lesbian Social Services, 1, 33±55. Patterson, C. J. (1995a). Lesbian mothers, gay fathers, and their children. In A. R. D'Augelli & C. J. Patterson (Eds.), Lesbian, gay and bisexual identities over the lifespan (pp. 262±290). New York: Oxford University Press. Patterson, C. J. (1995b). Gay and lesbian parenthood. In M. H. Bornstein (Ed.), Handbook of parenting (pp. 255±274). Hillsdale, NJ: Erlbaum. Patterson, C. J. (1995c). Adoption of minor children by lesbian and gay adults: A social science perspective. Duke Journal of Gender Law and Policy, 2, 191±205. Patterson, C. J. (1995d). Families of the lesbian baby boom: Parentsº division of labor and children's adjustment. Developmental Psychology, 31, 115±123. Patterson, C. J. (1997). Children of lesbian and gay parents. In T. Ollendick & R. Prinz (Eds.), Advances in clinical child psychology (Vol. 19, pp 235±282). New York: Plenum. Patterson, C. J., & Chan, R. W. (1997). Gay fathers. In M. E. Lamb (Ed.), The role of the father in child development (3rd ed., pp. 245±260). New York: Wiley. Patterson, C. J., Hurt, S., & Mason, C. (in press). Families of the lesbian baby boom: Children's contacts with grandparents and other adults. American Journal of Orthopsychiatry. Patterson, C. J., & Redding, R. (1996). Lesbian and gay families with children: Public policy implications of social science research. Journal of Social Issues, 52, 29±50. Paul, J. P. (1986). Growing up with a gay, lesbian, or bisexual parent: An exploratory study of experiences and perceptions. Unpublished doctoral dissertation, University of California at Berkeley, Berkeley, CA. Paul, J. P. (1996). Bisexuality: Exploring/exploding the boundaries. In R. C. Savin-Williams & K. M. Cohen (Eds.), The lives of lesbians, gays and bisexuals: Children to adults (pp. 436±461). New York: Harcourt Brace. Paul, J. P., Hays, R. B., & Coates, T. J. (1995). The impact of the HIV epidemic on US gay male communities. In A. R. D'Augelli & C. J. Patterson (Eds.), Lesbian, gay and bisexual identities over the lifespan: Psychological perspectives (pp. 347±397). New York: Oxford University Press. Peplau, L. A. (1991). Lesbian and gay relationships. In J. C. Gonsiorek & J. D. Weinrich (Eds.), Homosexuality: Research implications for public policy (pp. 177±196). Newbury Park, CA: Sage. Peplau, L. A., & Cochran, S. D. (1990). A relationship perspective on homosexuality. In D. P. McWhirter, S. A. Sanders, & J. M. Reinisch (Eds.), Homosexuality/ heterosexuality: Concepts of sexual orientation (pp. 321±349). New York: Oxford University Press. Peplau, L. A., Padesky, C., & Hamilton, M. (1982). Satisfaction in lesbian relationships. Journal of Homosexuality, 8, 23±35.

Peplau, L. A., Veniegas, R. C., & Campbell, S. M. (1996). Gay and lesbian relationships. In R. C. Savin-Williams & K. M. Cohen (Eds.), The lives of lesbians, gays, and bisexuals: Children to adults (pp. 250±273). New York: Harcourt Brace. Pies, C. (1985). Considering parenthood. San Francisco: Spinsters/Aunt Lute. Pies, C. (1990). Lesbians and the choice to parent. In F. W. Bozett & M. B. Sussman (Eds.), Homosexuality and family relations (pp. 137±154). New York: Harrington Park. Polikoff, N. (1990). This child does have two mothers: Redefining parenthood to meet the needs of children in lesbian mother and other nontraditional families. The Georgetown Law Review, 78, 459±575. Pollack, S., & Vaughn, J. (1987). Politics of the heart: A lesbian parenting anthology. Ithaca, NY: Firebrand. Rand, C., Graham, D. L. R., & Rawlings, E. I. (1982). Psychological health and factors the court seeks to control in lesbian mother custody trials. Journal of Homosexuality, 8, 27±39. Rees, R. L. (1979). A comparison of children of lesbian and single heterosexual mothers on three measures of socialization. Berkeley, CA: California School of Professional Psychology. Remafedi, G. (1987). Male homosexuality: The adolescent's perspective. Pediatrics, 79, 326±330. Ricketts, W. (1991). Lesbians and gay men as foster parents. Portland, ME: National Child Welfare Resource Center, University of Southern Maine. Ricketts, W., & Achtenberg, R. (1990). Adoption and foster parenting for lesbians and gay men: Creating new traditions in family. In F. W. Bozett & M. B. Sussman (Eds.), Homosexuality and family relations (pp. 83±118). New York: Harrington Park. Riley, C. (1988). American kinship: A lesbian account. Feminist Issues, 8, 75±94. Rivera, R. (1991). Sexual orientation and the law. In J. C. Gonsiorek & J. D. Weinrich (Eds.), Homosexuality: Research implications for public policy (pp. 81±100). Beverly Hills, CA: Sage. Robinson, B.E., & Skeen, P. (1982). Sex-role orientation of gay fathers versus gay nonfathers. Perceptual and Motor Skills, 55, 1055±1059. Rohrbaugh, J. B. (1988). Choosing children: Psychological issues in lesbian parenting. Women and Therapy, 8, 51±63. Rubenstein, W. B. (1991). We are family: A reflection on the search for legal recognition of lesbian and gay relationships. The Journal of Law and Politics, 8, 89±105. Rubenstein, W. B. (1996). Lesbians, gay men, and the law. In R. C. Savin-Williams & K. M. Cohen (Eds.), The lives of lesbians, gays, and bisexuals: Children to adults (pp. 331±344). New York: Harcourt Brace. Sameroff, A. J., & Chandler, M. (1975). Reproductive risk and the continuum of caretaking casualty. In F. D. Horowitz (Ed.), Review of child development research (Vol. 4, pp. 187±244). Chicago: University of Chicago Press. Savin-Williams, R. C. (1990). Gay and lesbian youth: Expressions of identity. New York: Hemisphere. Sbordone, A. J. (1993). Gay men choosing fatherhood. Unpublished doctoral dissertation, Department of Psychology, City University of New York. Skeen, P., & Robinson, B. (1985). Gay fathersº and gay nonfathersº relationships with their parents. Journal of Sex Research, 21, 86±91. Steckel, A. (1987). Psychosocial development of children of lesbian mothers. In F. W. Bozett (Ed.), Gay and lesbian parents (pp. 75±85). New York: Praeger. Strommen, E. F. (1989a). ªYou're a what?º Family membersº reactions to the disclosure of homosexuality. Journal of Homosexuality, 18, 37±58.

References Strommen, E. F. (1989b). Hidden branches and growing pains: Homosexuality and the family tree. Marriage and Family Review, 14, 9±34. Tasker, F., & Golombok, S. (1991). Children raised by lesbian mothers: The empirical evidence. Family Law, 21, 184±187. Tasker, F., & Golombok, S. (1995). Adults raised as

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children in lesbian families. American Journal of Orthopsychiatry, 65, 203±215. US Bureau of the Census (1995). Statistical abstract of the United States, 1995. Washington, DC: US Department of Commerce. Weston, K. (1991). Families we choose: Lesbians, gays, kinship. New York: Columbia University Press.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

9.17 Families of Divorce ARNOLD L. STOLBERG, ELIZABETH MULLETT, and EUGENE V. GOURLEY Virginia Commonwealth University, Richmond, VA, USA 9.17.1 INTRODUCTION

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9.17.2 DIVORCE, HOSTILITY, AND CHILD ADJUSTMENT

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9.17.2.1 Gender Differences in Response to Marital Conflict 9.17.3 IMPLICATIONS FOR INTERVENTION

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9.17.4 MEDIATION

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9.17.5 COMMUNICATION

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9.17.6 DEFINING THE INTERVENTION

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9.17.6.1 9.17.6.2 9.17.6.3 9.17.6.4 9.17.6.5 9.17.6.6 9.17.6.7

The Conceptual and Empirical Underpinnings of the Therapeutic Process Understanding the Contributions of Each of the Parents Selecting the Intervention Targets Evaluating Client Motivation Increasing Client Motivation Resolving Disputes and Teaching Coparenting Skills Evaluating and Monitoring Therapeutic Gains

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9.17.7 CONCLUSIONS

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9.17.8 REFERENCES

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tive coparenting is obvious. The foci of this chapter are to clarify the processes underlying interparent hostility which lead to psychological problems in children, to suggest essential elements for a parent-focused intervention to reduce hostility and to promote coparenting, to review existing treatment strategies, and to suggest a clinical approach which will build on the strengths of existing programs and which will attend to psychopathogenic processes.

9.17.1 INTRODUCTION Approximately one and a half million US children experience their parents' divorce annually. Of this population, 250 000 children will experience serious adjustment problems attributable to this family event (Ellwood & Stolberg, 1993). Most of these families will take their conflict to the courtroom for resolution. The significance of the problem to mental health delivery systems is further dramatized by the fact that almost half of all children seeking public and private psychological counseling are from families of divorce. The size of the problem is apparent. The cause of the problem, interparent hostility, is clear. The need for an effective strategy to limit divorce-related hostility and to promote effec-

9.17.2 DIVORCE, HOSTILITY, AND CHILD ADJUSTMENT Marital conflict has been associated with a wide array of child behavior problems (Emery, 1982; Grych & Fincham, 1990). These problems 275

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include externalizing problems such as conduct disorder (Dadds, Sanders, Morrison, & Rebgetz, 1992; Emery & O'Leary, 1984; Jouriles, Barling, & O'Leary, 1989; Wierson, Forehand, & McCombs, 1988), delinquency/antisocial behavior (Emery, & O'Leary, 1984; Mann, Borduin, Henggeler, & Blaske, 1990; Vuchinich, Bank, & Patterson, 1992), and personality disorders (Porter & O'Leary, 1980) as well as internalizing problems such as anxiety, withdrawal (Porter & O'Leary, 1980; Wierson et al., 1988), and depression (Dadds et al., 1992). Other studies have found correlations between marital distress and cognitive functioning (Wierson et al, 1988), social functioning (Emery & O'Leary 1984; Jouriles et al., 1989; Wierson et al., 1988) and grade point average in the children (Wierson et al., 1988). Past research has focused primarily on correlations between marital conflict and behavior problems. The direct mechanisms through which conflict becomes detrimental to children have yet to be clearly identified (Katz & Gottman, 1993). However, three primary theories have each proposed different ways in which marital conflict affects children. These are social learning, socialization, and family systems theories. Social learning theory suggests that children may be learning ineffective problem solving and coping skills by modeling parents in conflicted marriages (Bandura, 1973). Hetherington, Cox, and Cox (1982) found that the degree to which children are exposed to marital conflict is directly related to levels of child behavior problems. Other studies have found that children who hear adults fighting were more likely to engage in aggressive play (Cummings, Iannotti, & Zahn-Waxler, 1985). Johnson and O'Leary (1987) examined girls with conduct disorder and the families of these girls were marked by higher levels of parental aggression and hostility. Furthermore, the girls' responses to conflict were closer to those of their mothers than their fathers, thus supporting social learning theory. It has also been proposed that the behavior of the parent of the same sex may be a more influential model for a child in dealing with conflict and aggression. There is some modest, but not always conclusive, support for this position (Turner, Gervai, & Hinde, 1993). Socialization theory suggests that marital conflict is detrimental to children because of its effects on parenting practices (Belsky, 1984). Marital conflict may have a ªspill over effect,º whereby the negative effect in marital disharmony carries over into parent±child relations. Christensen and Margolin (1988) found that in distressed families marital conflict was

not contained between spouses, but spread to parent±child relationships. Furthermore, parent±child aggression, which may be a consequence of marital conflict, has been related to higher rates of antisocial behavior (Patterson, 1982; Vuchinich et al., 1992) and behavior problems (Friedrich & Einbender, 1983). Jouriles et al. (1989) found that witnessing interspousal aggression was correlated with parent±child aggression, and that parent±child aggression was related to attention problems, anxiety/withdrawal, motor excess, and conduct problems in children. Much of the influence of marital conflict on children's adjustment has been found to be mediated by disrupted parenting practices in conflicted families (Belsky, 1984). Marital conflict may weaken unified parental alliances (Christensen & Margolin, 1988; Gilbert & Christensen, 1988) and may prevent parents from presenting a unified front to children (Stoneman, Brody, & Burke, 1989). Several investigators found weak unified parental alliances in maritally distressed families, resulting in inconsistency between parents' child rearing practices (Christensen & Margolin, 1988; Gilbert & Christensen, 1988). In turn, inconsistent discipline is related to conduct problems, aggression, and juvenile delinquency (Patterson, 1977, 1986; Patterson & Stouthamer-Loeber, 1984). Weak parental alliances have been repeatedly found in maritally distressed families (Christensen & Margolin, 1988; Gilbert & Christensen 1988) and are closely related to lower levels of effective family problem solving (Vuchinich, Vuchinich, & Wood, 1993). Family systems theory suggests that conflict is detrimental to children because of its effects on the functioning of the family system (Kerr & Bowen, 1988). Kerr and Bowen (1988) theorize that each person in the family is emotionally invested in keeping the family together and each person has a role or function in its maintenance. Consequently, all members are likely to be influenced by marital conflict because of the tremendous threat marital conflict poses to the integrity of the family. Individuals' responses to high levels of conflict may involve coping mechanisms aimed at reducing anxiety and tension among family members, even if it comes at a price for the individual. Grych and Fincham (1993) found that factors such as the intensity, content, and cause of the fight increased children's distress and their desire to intervene in the fight. Children proposed indirect intervention (e.g., distracting techniques) if they thought the marital fight would escalate. If the fight was child related, children reported increased shame and fear of being drawn into the conflict. These

Divorce, Hostility, and Child Adjustment children were also more likely to suggest that they would directly intervene in the fight. Children exposed to greater frequencies of marital conflict were also more likely to comfort their mother following an angry confrontation in an experimental session (Cummings, Vogel, Cummings, & El-Sheikh, 1989). Again, children were also more likely to propose that they would directly intervene in the fight. These studies suggest that children may intervene in marital conflict in attempt to decrease tension and anxiety. Hinde and Stevenson-Hinde (1988) suggested that a child may become involved in marital conflict in several ways. A child may enter the conflict and either mediate or side with one person and against another. A child may also reduce tension by distracting the other two from fighting. In addition, a child may also be drawn into the conflict when parents ally themselves and blame the child for the problem, in a process known as scapegoating (Hinde & StevensonHinde, 1988). A child's involvement in marital conflict may not only decrease a child's anxiety, but also benefit the parents. By entering a conflict, and siding with one parent, a child may provide support for a parent. Kerr and Bowen (1988) theorize that triads are inherently more stable relationship units than dyads. In the case of marital conflict, the same amount of anxiety or hostility is spread among three people instead of two. Scapegoating and third party manipulations are relationship patterns involving more than two people which clinicians often cite as families' attempt to divert attention away from the primary source of conflict, thereby reducing tension and stabilizing the family. A child's involvement in marital conflict may temporarily help decrease tension in the family, but, it may have detrimental long-term effects on the child. Minuchin (1974) suggested that a child's involvement in cross-generational alliance may have negative psychological effects on the child. A child who sides against a parent may experience anxiety because he/she also betrays the other parent. Furthermore, the parent's alliance with a child breaks the traditional family hierarchy, creating conflict and confusion for the child. Problems could also develop because parents may become over-involved in the child's life, undermining the development of autonomy and peer relationships. Katz and Gottman (1993) found that parents' coping styles with marital distress predicted types of behavior problems experienced by children three years later. A father's withdrawal from the family was associated with internalizing problems three years later, while mutual

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conflict and hostility between the parents predicted externalizing problems in children. Previous research also has found evidence for the existence of several coping mechanisms proposed by family systems theorists. Vuchinich, Emery and Cassidy (1988) examined third party interventions and patterns of interactions in families with adolescents. They found that in triadic interactions, family members intervened in conflict one-third of the time and alliances were formed approximately half of the time. These alliances were evenly spread between all members, however, parents rarely intervened in conflicts between their spouse and one child. Even more salient was the finding that parents rarely sided against each other. However, this study did not assess differences between conflicted and non-conflicted families. Unlike Vuchinich et al. (1988), Christensen and Margolin (1988) and Gilbert and Christensen (1988) examined both maritally conflicted and nonconflicted families for the presence of cross-generational alliances, and weak marital alliances. Using sequential analytic techniques, Gilbert and Christensen (1988) found significant levels of cross-generational alliances in maritally distressed families. Christensen and Margolin (1988) assessed cross-generational alliances and weak marital alliances using slightly different methods. Weak marital alliances were also found in maritally conflicted families. A study by Mann et al. (1990) found mixed support for the existence of cross-generational alliances. Delinquency in adolescents was moderately correlated with the presence of cross-generational alliances. In observations of family dyads, delinquent adolescents were more likely than nondelinquent adolescents to be disengaged from their fathers and aligned with their mothers. The parental dyads in families with delinquent adolescents were also more conflicted than those with well adjusted adolescents. However, within individual families, delinquent adolescents were not more aligned with their mothers and conflicted with their fathers. Also, within delinquent families, parental dyads were not more conflicted than the mother and child dyads. Therefore, Mann et al. suggested that cross-generational alliances may be more illusory than real. However, their results also revealed that in families which received multisystemic therapy, improvements in marital relations were linked to the amelioration of symptoms in both adolescents and their parents. These improvements were not found if adolescents received individual therapy only. Mann et al. stressed the need for researchers to go beyond observing family dyadic relations in order to understand family systems.

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9.17.2.1 Gender Differences in Response to Marital Conflict Gender differences have been found in children's psychological adjustment to marital conflict; however, the results have been inconsistent (Grych & Fincham, 1990). Conduct disorder has been found to be related to marital discord for boys but not for girls (Emery & O'Leary, 1984; Porter & O'Leary, 1980). However, other studies involving nonclinical families have found similar levels of pathology in boys and girls exposed to marital conflict (Emery & O'Leary, 1984; Jouriles et al., 1989). Although the response to conflict in boys and girls may differ, Emery and O'Leary (1984) found that both boys and girls accurately assessed the severity of marital conflict. Therefore, Grych and Fincham (1990) suggested that gender differences in behavior problems may be due to factors associated with marital distress other than marital conflict. A study by Kerig, Cowan, and Cowan (1993) suggested that gender differences in children's psychological adjustment may be related to the interaction styles of their parents. Overall, parents tended to negate daughters more than sons. However, when marital satisfaction was low, parent's interactions with their children were increasingly gender differentiated. In distressed marriages, fathers were more negative towards their daughters. Mothers were more likely to negate daughters in response to nontraditional behaviors (e.g., daughters' self assertion). The overall level of negative interactions between a mother and her son did not change according to levels of marital quality. However, mothers in distressed marriages were more likely to reciprocate their son's negative affect. These results suggest that, although overall levels of negativity may not differ in maritally distressed and nondistressed families, different patterns of interactions and behavior contingencies may emerge between parents and their sons and daughters under higher levels of marital conflict. Differences in boys' and girls' adjustment to marital conflict may also be association with gender differences in emotional responses and intervention in marital conflict. Cummings et al. (1989) found that boys and girls responded differently to marital conflict. After the age of 10, boys reported greater anger and girls reported greater fear in response to marital conflict (Cummings et al., 1985, 1989). Girls were also more likely to propose solutions to conflicts and were more likely to suggest direct intervention in the fight (Cummings et al., 1989; Vuchinich et al., 1988). Vuchinich et al. found that girls got more involved in all forms of

conflict, except marital conflict. Miller, Danaher, and Forbes (1986) found that girls were more likely to mitigate conflict than boys, although this was not supported in another study (Cummings et al., 1989).

9.17.3 IMPLICATIONS FOR INTERVENTION Several processes account for much of the deleterious impact of hostility on children's adjustment to divorce. Children may imitate their parents' poor problem solving and coping strategies and may display these aggressive behaviors with their peers. Hostility may also interfere with normal, unified parental alliances and may deteriorate the quality of the parenting which the child receives. Children may enter the conflict between parents. They may attempt to mediate the conflict between their parents and/ or may side with one against the other. They may also attempt to reduce the conflict by distracting their parents onto other activities and issues. In all cases, the unusual level of responsibility for marital harmony which children accept leads to significant emotional distress and may subsequently interfere with social, academic, and emotional adjustment. Interparent hostility associated with divorce appears to negatively impact children through five processes. First, children may model the inappropriate conflict resolution skills they see displayed by their parents and may use these strategies in the playground and in the classroom. Much of the peer and social problems common to children of divorce may result from these displays. Second, the hostility expressed between parents may deteriorate their parenting by redirecting their energies from the needs of the children onto the most pressing interspousal issue. Third, scapegoating, or blaming the children for marital problems, may lead the children to inappropriately accept blame for problems within the family. Poor self esteem common to some children of divorce may result from this process. Fourth, the emotional spillover from the anger conveyed by their parents may lead children to experience significant emotional distress. Finally, children often become engaged in the conflict, either by trying to distract parents from their discord or by joining in alliances with one parent against the other. Preventing and ameliorating children's adjustment problems associated with divorce and interparent hostility may be accomplished by efforts directly aimed at the parents and by attending to the pathogenic processes in the family. Such strategies include teaching parents

Communication effective conflict resolution skills. Mediation and alternative dispute resolution may provide a model for improving these skills. By providing a forum to keep the focus on resolving the primary divorce issues, residual deterioration of necessary parenting may not occur. Further, by providing strategies to develop effective and appropriate conflict resolution skills, children may not experience emotional distress resulting from the spillover from their parents' conflict. Helping parents to maintain their focus on the children's divorce-specific and ongoing developmental needs, with a particular emphasis on directing parents to maintain healthy family alliances, may help to preserve effective parenting roles of the conflicted adults. No programs exist which are aimed at reducing interparenting following divorce and concurrently promoting parenting effectiveness. Two or three existing strategies may be applied to promote healthy and essential aspects of a post-divorce, developmental environment. Mediation may provide strategies for enhancing conflict resolution skills, for resolving conflicts, and for keeping the attention on problem resolution and away from tangential and undeserved blame for parenting inadequacies. The most effective communication skill training package was probably that developed by Hendrix (1989) as a part of his marriage enhancement program.

9.17.4 MEDIATION Mediation is an increasingly popular alternative to traditional methods of resolving childrelated divorce and separation issues (Emery & Wyer, 1987). Proponents of mediation argue that cooperative, self-determined processes for resolving disputes minimize the reduction in family functioning that often follows divorce (Robinson & Parkerson, 1985). Mediation gives parents the rights and responsibilities to determine the nature of the post-divorce family (Trombatta, 1982). Despite support for mediation and the growth of court-sponsored programs, the disputes best suited for intervention and the impact of the process on the family are not well described in the literature (Emery & Wyer, 1987). Mediation is a task-oriented, problem solving activity that seeks to resolve clearly defined issues related to the on going relationship between divorcing couples (Coogler, 1978; Kressel & Deutsch, 1977). This short term, prevention oriented process seeks to minimize maladaptive outcomes typically associated with marital discord and divorce by directing parties in negotiations towards a fair agreement

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between themselves. Mediation differs from traditional methods of resolving disputes (either in court or through attorneys out of court) in that it is a cooperative and self-determined process. Parental status and parenting responsibilities are considered to be unalterable. Selfdetermined resolutions are considered better than those imposed by external forces (Neville, 1985). Mediation differs from traditional methods of resolving disputes in the manner in which decision-making power is distributed (Girdner, 1985). In traditional methods, couples relinquish their power to the judge or attorney when disputes are settled in the courtroom or in an attorney's office (Pearson & Thoennes, 1984). On the other hand, mediating couples maintain control over the process because they are required to present mutually determined and beneficial solutions to each other, and not to a judge (Neville, 1985). Research assessing the effectiveness of mediation in keeping couples out of court and in promoting family adjustment to divorce is encouraging but limited. Subjective reports following mediation indicate that couples are more likely to be satisfied with the outcome and to indicate that their lives have improved than those involved in the adversarial process (Emery & Wyer, 1987). A significant gender bias in outcomes has been found, with men reporting greater satisfaction with the process and a positive impact on all family members. Women reported less satisfaction and said that only the children benefited (Emery & Wyer, 1987). Court-based programs, which are the most often studied, have reported rates of agreement in men's and women's satisfaction with outcomes between 50% and 75% (Emery & Wyer, 1987; McIsaac, 1982; Pearson & Thoennes, 1984). These studies have failed, however, to examine the full range of couples who use mediation and have excluded noncustody disputes.

9.17.5 COMMUNICATION Communication is a bidirectional activity which requires both active listening and clear and intentional expression of ideas. Hendrix (1989) described a multistep procedure in which each of the participants takes turns articulating his or her concerns and, subsequently, listening to the other's ideas. In the first step, the conveyer states his or her ideas and articulates the content of and then the feelings about the message. In an effort to ensure that the receiver focuses on what is being said and is not preoccupied by formulating his or her response,

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the receiver is then asked to report the message they heard, the emotional import to the conveyer, and the extent to which the receiver understood and accepted the message. In the third step of the process, the conveyer evaluates the accuracy of the receiver's response and the extent to which he or she feels adequately heard. If an accurate exchange of the conveyer's ideas has not occurred, he or she clarifies what was heard and the receiver conveys his/her understanding of the clarified message. If a clear message has been conveyed and received, the participants change roles and activities. This process continues until both participants have communicated all of their ideas and concerns on the topic. This structured communication process ensures that communication is a bidirectional process; messages are stated clearly and are heard exactly as they were intended. Procedures are included which keep both participants' attention on the immediate activity and not on formulating their own ideas at the expense of hearing the concerns of the other. Because procedures are included which allow the conveyer to correct the misperceptions of the receiver and because each has a turn at explaining their thoughts, yelling and anger do not result. However, this approach has not been evaluated for its effectiveness.

9.17.6 DEFINING THE INTERVENTION Clinical experience dictates that any intervention to promote coparenting and to reduce hostility between divorcing parents must be built on a conceptual underpinning which puts the developmental needs of the children above most of the needs of their parents. Cooperation, compromise, objectivity, and confrontation of the parents with their contributions to their children's adjustment problems are essential for success. This is a significant departure from traditional approaches to working with divorcing parents. The therapist is required to be strong and directive. The therapist needs to be knowledgeable about the divorce literature, equally supportive of both parents, and, above all, to be able to gain an objective understanding of the dynamics of the family and the ways in which each of its members contributes to the children's adjustment. It is almost always the case that each parent contributes to the deterioration of the children and that, in most cases, each parent can substantially influence the effectiveness of the other parent and the welfare of the children. The role of the therapist may be construed as the superego for the divorcing familyÐas a

parent to the conflicting adults. Few outside relationships exist for the couple which require cooperative coparenting behaviors and which encourage for the psychological adjustment of the children. Attorneys, family members, and close friends are the strongest influences on parenting behaviors (Camplair & Stolberg, 1987). They often advocate for the needs of their clients, family members, or friends and promote adversarial stances. In fact, five years after the separation most divorcing parents view the influences of these professionals and friends as destructive of the parenting process. The clinician is required to convey an expectation which considers the long-term needs of each of the family members. When the therapist working with high hostility, divorcing couples must define the parameters of the parents' behaviors toward each other and with their children. The therapist must help the parents develop a perspective which sets as the priority the future adjustment of both of the parents and of the children, and not the immediate emotional needs of any individual. The manner in which the therapist responds to the clients as individuals, and the therapeutic relationship which is established, is essential to the success of the therapy. Support, validation, love, and respect are essential elements of this relationship. Divorce is one of the most difficult periods in an individual's life. Most divorcing adults feel worthless and unloved by their spouses, the most important people in their adult lives. The support for and validation of the client as a valued person, who can respond to demanding circumstances in competent and decent ways, and who is cared for by another person with societal esteem, facilitates the client to behave in a desirable and health promoting manner. Many therapists feel anger and frustration when spouses are engaged in meaningless conflict. This distress by the therapist must be conveyed in a way that promotes the best in the individuals and not with statements that make them feel foolish or dysfunctional. The therapist must act as the authoritative parent who can lovingly listen to the concerns of the children and can incorporate their concerns in the final decisions that the parent makes. The steps of this intervention process are discussed below. 9.17.6.1 The Conceptual and Empirical Underpinnings of the Therapeutic Process Working with children of divorce and their families requires a keen understanding of the clinical and empirical research literature describing this family event. A review of the

Defining the Intervention literature on divorce and child adjustment identifies factors within the child, parents, and the broader environment in which the child and parents live. The factors which appear to have the most significant influence on the development of the child include the child's age, the adults' abilities to parent the child and to work together without hostility, the life changes which the divorce brings about, the continued active involvement of both parents with the child, and the suggestions, directions, and demands of family members, close friends, and professionals working with the divorcing family. A review of these influences may be more clearly accomplished by categorizing them according to Bronfenbrenner's ecological model (Bronfenbrenner, 1977, 1979) and the elements of the child's environment to which they belong. The first level of analysis is the individual or ontogenic level (Belsky, 1980). This viewpoint looks at how divorce affects the individual, and how one's genetic predisposition combines with developmental events in personal and family history to affect available coping mechanisms. In this discussion, the children will always be the center of the analysis, thus the ontogenic system will always refer to the children. Divorce from this level focuses on how the children respond to the intense stressor of family separation. The children must deal with the changing demands this process will make on them over time. They will need to draw on available psychological coping resources, defense mechanisms, and behaviors in order to effectively deal with the demands of family transition. The effects of divorce on children's adjustment covary with their age, and age related developmental capacities and challenges make this an important variable to consider. Infants and toddlers require high levels of involvement in interaction because they are essentially helpless to care for themselves. Disruption in regular routines caused by instability in the household or parental conflict can often be stressful to many infants and toddlers, resulting in more distress and irritability even at an early age (Kalter, 1987, 1989). Initially, in instances where the father leaves the family home, his absence appears to have a surprisingly small effect on the children, primarily due to their inability to conceptualize relationship roles, and the fact that mothers are usually more involved at this early age. Children may benefit greatly from the father±child relationship in later development (Kalter, 1987, 1989). The research suggests that children require a stable, conflictfree environment where their demands can be met by parent figures. While father absence may not be evident in a child's behavior at this point,

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it is important that both parents remain involved if they are to form lasting attachments with their child. During the preschool years, children begin to develop more independent abilities including basic communication skills, increased locomotion, and some self care skills such as dressing, washing, and toileting. However, preschool children still have very limited individual resources for coping with divorce (Kalter, 1989). For example, their ability to understand cause±effect relationships is generally limited by a lack of perspective taking ability. This results in one of the most common problems associated with divorce: self blame (Hetherington, 1991; Kalter, 1989; Stolberg, Camplair, Currier, & Wells, 1987). The child perceives the parental separation as resulting from their lack of love for the child. During parental discussion of divorce or custody issues where the child hears his or her name mentioned contributes to this belief. Children may also harbor reunion fantasies for long periods of time due to their limited understanding and reality testing (Hetherington, 1979, 1991; Kalter, 1987, 1989; Wallerstein & Blakasee, 1989). Children at this developmental stage are more aware of their emotional states being able to label emotions such as mad, sad, or happy, but have limited ability to cope with these emotions, understand their causes, or communicate them to others (Kalter, 1989). Preschool children of divorce show significant differences in behavior from their peers from intact homes (Biller, 1981; Hetherington, 1979, 1991; Kalter, 1987). These children display more negative behavior including being more irritable, aggressive, complaining, and showing less social maturity. In addition, more anxiety, fear, and less imaginative play is observed in these children than those who do not experience parental separation (Hetherington, 1979; Kurdek, 1981; Wallerstein & Kelly, 1980). Consideration of developmental abilities, and the observed effects of divorce, have led researchers to conclude that preschoolers are a very vulnerable group because of their limited cognitive ability and the developmental importance of emerging social interactions (Kalter, 1989; Kurdek, 1981). Elementary school age children (6±12 years) make significant gains in abstract reasoning, communication, social maturity and their ability to fantasize about possible futures (Bjorklund & Green, 1992; Flavell, 1985). Children at this age will be better able to tolerate separation from a parent and have increased sources of support from teachers and peers outside the home. In the early elementary years (6±8 years), children may experience an

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intense longing for the noncustodial parent (most often the father), and this longing is based on fantasy and not related to the type of relationship that previously existed between the parent and child (Fry & Addington, 1985; Hetherington & Clingempeel, 1992). As children progress through the elementary years, they are vulnerable to conflictual feelings of loyalty to each parent. As they understand more about the divorce and their parent's lives after the divorce, they often begin to look for reasons to blame for the situation (Kalter, 1989; Wallerstein & Blakasee, 1989). In addition parents may exacerbate this by talking about the former spouse negatively, blaming the former spouse for current unhappiness or family difficulties, or by using the child as a source of information about the former spouse's behavior and life. Children at this age are likely to understand that the divorce is permanent, are able to tolerate separation, and have better coping skills. They will, however, have strong conflictual feelings for both parents, particularly when parental conflict is ongoing. Children have limited capacity to understand that mother and father are mutually unhappy, and this leads them to alternate blame from one parent to the other (Fry & Addington, 1985; Hetherington, 1991; Kalter, 1989; Wallerstein & Kelly, 1980). Divorce during adolescence is a large disruption occurring at a time of tremendous developmental change. Children in adolescence undergo the physical changes to adulthood, becoming acutely aware of their bodies and sexuality. Cognitive changes occur as adolescents develop formal operational thought and begin the development of long-term planning skills (Flavell, 1985). Emotionally, adolescents often experience anxiety concerning their future and in developing an adult identity. Social changes occur as adolescents become more independent from parents and develop adultlike relationships with peers of both genders, making them more vulnerable to peer pressure. The emotional experience of divorce for adolescents is often very intense as a result of their impulsivity and egocentric concern for their own feelings and development. Adolescents alternate between seeing parents in an idealized and deidealized light as they begin to integrate their positive and negative feelings towards them into a more mature and realistic view of the parent±child relationship (Forehand, Long, & Brody, 1988; Stinson, 1991). Divorce can disrupt this process as the child may experience many strong negative emotions toward both parents and create potentially long-lasting internal conflicts for the adolescent. Increased autonomy and an adult appearance may cause the parents to involve their adoles-

cent children in the divorce process, complain about the divorce, seek social support, and require them to be responsible for their siblings (Forehand et al., 1988). Adolescents of divorce frequently experience one or both parents being highly critical, vindictive, or vengeful when talking about the other parent to them. These events can result in feelings of responsibility and guilt in the adolescent. The Developmental Vulnerability Model, as described by Kalter (1987), speaks most directly to the child's evolving competencies which develop with age. In this model, developmental dimensions are viewed as continuously evolving sets of skills or capacities whose effectiveness is externally defined and at the time at which these skills are required. The progress of growth along these dimensions can be optimally or deleteriously affected by the five ecological system influences described in Bronfenbrenner's model and by the changing life circumstances brought about by acute transitional events. These developmental competencies are open to significant alterations if the ecological influences undergo substantial changes. Another major ontogenic factor contributing to children's divorce adjustment is the temperament/personality of the child. Thomas and Chess (1977) found that temperament is an important variable in the child±environment interaction. When a child's temperament is inconsistent with the demands of the environment, the child's psychological health is often threatened (Ainsworth, 1979, 1989). Children with a difficult temperament often have more difficult mother±child interactions and more psychological disorders later in life (Thomas & Chess, 1977). However, parents are often able to provide the high level of stability and consistency these children need. Divorce greatly decreases the parent's ability to provide such a stable environment. Children with easy temperaments may adjust the best to environmental inconsistency and less involvement from one or both attachment figures. Difficult children may require more care, and generate a negative interaction with the parent as their demands for care increase the stress on the primary caregiver (Thomas & Chess, 1977). As the child matures, more sophisticated behavioral and emotional coping strategies and defenses evolve as their personality develops. Because personality develops as an interaction between the person and the environment, parental separation will have a great effect on the child as they learn to cope with environmental and emotional demands. To the extent that divorce denies the child access to caring parental figures, the child may develop more problematic coping strategies which may result

Defining the Intervention in ineffective or self defeating methods for coping with stress and getting emotional needs met. Many children have special needs which require special attention or increased vigilance by the parents. Children with limited intellectual abilities, learning disabilities, attention-deficit hyperactivity disorder, or other developmental or psychological difficulties may require a consistent, safe, warm environment which can be threatened by divorce. In many cases, the parents working together may be able to relieve each other's stress and combine to provide a good child rearing environment, but are too overwhelmed or lack support to do so following divorce (Belsky, 1980). The microsystem is the next level of analysis in the ecological model. This system includes the immediate settings that the individual comes into contact with, such as family, friends, lovers, and coworkers. In the divorce process, this system is very much in flux. Obviously, the available coping resources among family members will change for children, with the loss of one parent and children seeing less of each parent. Children's relationships with peers may also change if they have to move, or visit the other parent away from their original neighborhood and peer network. Parents, friends, and in-laws may no longer be available while new dating partners may be introduced as sources of social support. The most significant microsystem factor in children's divorce adjustment is the amount of conflict and hostility between parents. Several studies have shown that children who become the focus of parental conflict fare the worst emotionally and behaviorally (Hetherington, 1991; Wallerstein & Kelly, 1980). Interparent conflict is a significant source of problems for children in both intact and divorced homes (Emery, 1982). Clearly, one major area where parents can help to buffer their children from negative effects of divorce are in limiting the amount of interparent conflict they are exposed to. This is most difficult in cases of adjudicated custody when children are involved in the custody dispute through legal and mental health professionals. Limiting the interparent conflict is of prime importance for buffering children from the deleterious effects of parental separation. Life change events in the child's life are an important microsystem influence for children's adjustment to divorce. Several clinical and research studies indicate that the number of life changes that occur during a parental divorce are associated with symptoms of psychological distress (Kalter, Pickar, & Lesowitz, 1984; Stolberg & Bush, 1985; Stolberg et al., 1987).

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In general, the more life changes that occur, the more vulnerable the child will be to negative psychological and health consequences. For some children divorce may constitute multiple life changes. When children remain in the same neighborhood and are able to maintain the same friends, school, and teachers, they also maintain a high level of stability. In contrast, the child who must move will face a series of stressful life events, such as changes in school, friends, neighborhood, or even a new city and state. These children are at higher risk for psychological disorders, as stress is increased and coping resources must be developed anew. One of the keys to the whole divorce process is the extent to which the parents are able to cope with the change and distress they are experiencing and are able to maintain their ability to be available to their children. The stress of divorce diminishes the emotional resources a parent has available for the child, often making a good parent marginal, and a marginal parent bad, at least on a temporary basis (Kalter, 1987). Even the most exceptional parent will have a difficult time maintaining their previous level of parenting competence. Divorced parents are less consistent in their discipline, make fewer maturity demands on their children, and lack control over their children's behavior when compared to intact parents (Bloom, Asher, & White, 1978; Emery, 1982). Fortunately, research points to a readjustment period following one year after divorce when most parents begin to regain their original equilibrium and achieve stability in their lives. The exosystem is the system into which the individual and microsystems are imbedded. This includes settings that often do not directly involve the individual but affect the person due to their influence on what resources are made available and how the community responds to divorce. These will often involve community resources available for divorcing families and may include school systems, local governments, and the availability of mental health services and other community programs (Fry & Addington, 1985). For example, a parent may not be immediately involved in allocating tax dollars for school-based interventions for children of divorce, but both the parent and children will be indirectly affected by the availability of these resources. As with children, adults experience life changes as stressful and will be more likely to report psychological symptoms, such as anxiety and depression, as the number of life changes increases. Children may not directly experience many life changes of the adults, such as getting a new job, returning to school, changing friends, or beginning to date again, but they are

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indirectly influenced by their parents' ability to cope with these changes. Thus, the number of life changes an adult is experiencing will be related to their psychological health and ability to provide stability, nurturance, and support to their children. A major exosystem factor influencing child adjustment is a drop in family income. Even with a financially supportive noncustodial parent, two incomes now go to support two households instead of one. This temporary drop in income often becomes permanent for the custodial parent, who must cope with increased child care demands while maintaining job performance (Weitzman, 1985). When the drop in income coincides with a change in residence, often the move is to a more impoverished neighborhood, and away from familiar friends, neighbors, and schools (Fry & Addington, 1985; Weitzman, 1985). Divorced parents have lost their spouse, often the main source of companionship and social support. In order to have social support needs met, kin networks, neighbors, churches, or friends must help to take up the slack and allow the parent to develop social support outside the home. Social support has been linked to increased ability to cope with stress, increased self esteem, and less physical and psychological illness (Sarason, Sarason, & Pierce, 1990; Vaux; 1988). This support is often essential for the parent to effectively adjust to the divorce and be an effective parent figure. Availability of babysitters, daycare, and single parent support groups are all important factors which can aid the divorced parent to recover from the stress of a major life change. Primary decision influencers, such as attorneys, pediatricians, mental health provides, clergy, and friends and family members, are exosystem influences on adjustment (Camplair & Stolberg, 1987, 1990; Davis & Stolberg, 1988). These individuals all indirectly affect the child's welfare by providing support, encouragement and advice to the divorcing parents. As previously mentioned, much of the direction given by these sources does not promote cooperative coparenting. The macrosystem which encompasses the ontogenic, microsystem, and exosystem includes the institutions and values of the greater society. These may include policies implemented by the state and federal governments as well as the values and attitudes of American society as a whole. Clearly, state and federal law can affect individual family members due to their impact on divorce laws, child custody awards and enforcement, and economic aid to families in transition (Deed, 1991). Society's cultural values also impact family members by helping

to determine how divorce is viewed by the community, society and the government. For example, when the social climate views divorce as a negative event and creates negative attitudes and stereotypes of divorcing families, reaction at each community level may be more negative. Macrosystem influences fluctuate with social, moral, and political changes in the culture. Divorced families are often pathologized as broken, abnormal, or disintegrated. Sex role attitudes often play a part in the ability of women to have access to the workplace and for men to be a primary caregiver (Hartup, 1989). Society's view of the status of children also plays an important role in divorce. As children's rights have become more accepted, their welfare has become more primary to the divorce and custody process. The final level of analysis, the mesosystem, concerns the interaction and connections among systems, settings, and people. Interaction between systems can help promote more flexibility and better solutions to problems. Perhaps most important is opening communication between the individuals and others in their microsystem. Children and parents both need to be able to communicate needs and feelings with each other and to friends, teachers, and sources of aid and support. Even though the parents may separate, they must be able to effectively communicate to provide for their children. Communication between individuals, families, teachers, school boards, and state governments can help inform policy makers of effective methods for helping children adjust to divorce. Policy makers and community leaders can make use of education and outreach programs to bridge gaps between the macrosystem and exosystem to help make families more aware of what resources are available and how to access them. 9.17.6.2 Understanding the Contributions of Each of the Parents Once therapists understand and accept their role in this constructive, therapeutic process and are thoroughly acquainted with the literature describing the influences on children's adjustment to divorce, they may begin the intervention process. The first intervention goal is to gain an understanding of each parent's view of the contributors to the hostility and poor coparenting, and each parent's emotional and parenting competencies. The therapist must gain each parent's trust and perception that the therapist is skilled and objective. This may be most effectively accomplished by meeting with each parent individually to gain the perspective they

Defining the Intervention hold and by conducting a thorough personality and parenting assessment of each of the adults. Parents are generally more aware of the weaknesses of the estranged spouse than they are of their own. Taking the time to gain the perspectives of both parents and to do so with a cautious acceptance of each of the parent's ªstoriesº will yield the breadth and objectivity that is required to proceed. In addition to understanding the parents' contributions to the children's adjustment problems, the therapist must also understand the extent to which the child's normal and extraordinary emotional, physical, social, and academic demands contribute to the observed difficulties and the extent to which they place demands on the parents which may be beyond their ability to respond. Traditional child and parenting assessment, as well as confirmation from outside sources, is necessary. 9.17.6.3 Selecting the Intervention Targets The third step of the process, or identifying the targets for the intervention naturally extend from the previous efforts. Before meeting with both parents together to convey the therapeutic goals, it is necessary for the therapist to develop a comprehensive conceptualization of the family dynamics which account for the child's present level of adjustment and which will help to foster his or her future development. The therapist must clearly, objectively, and supportively articulate the dynamic formulation and convey the essential steps that are necessary to promote the child's adjustment and the effective coparenting of the child. It is important that the therapist does not convey good guy and bad guy roles to the parents. Rather, it is necessary to communicate how each parent helps and hurts the child, and how each parent can help the other to be more effective. Honesty and support are essential. 9.17.6.4 Evaluating Client Motivation Determining each of the parent's willingness to participate in evolving cooperative problem solving is the fourth step in this therapeutic process. The most difficult aspect of working with high conflict divorces is getting the adults to acknowledge their own contributions to the hostility and to put aside their own deserved or unreasonable anger at their estranged spouse. Increasing each of the parent's motivation to put the developmental needs of the children above his or her own hurts and to actively and constructively work with the other parent is the most essential, and difficult, goal of the therapy.

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Many parents will express some skepticism about their ability to work cooperatively, although most will state that they are willing to try. The real test of the parents' willingness to compromise and to set aside differences comes when they are confronted with the changes they must make. The first opportunity for the therapist to observe this behavior comes in this stage of the process. The problem which has the greatest potential for resolution is the first to be brought up for discussion and resolution. It is generally most prudent to state the problem and ask each of the participants what steps they might individually take to resolve the problem. This gives the parents the opportunity to accept responsibility for the problem and to gain some experience in problem solving and in compromise. It also gives the therapist an opportunity to observe the commitment of each of the participants and to identify resistance. 9.17.6.5 Increasing Client Motivation Few parents involved in high hostility divorces reflect a willingness to actively cooperate with their former spouse and to view their parenting role in a truly generative light. The therapist will almost always be required to search for vehicles to bring parents to the table and to increase their motivation to behave in responsible ways. The therapist does, however, have considerable authority to influence client motivation beyond trying to enhance client insight or simple pleading. Interestingly, the professionals who most often exacerbate interparent tensions, the attorneys, can be called upon to promote cooperation and to exert some control over their client. Therapists can share their diagnostic formulations about the nature of the conflict and the observations of client commitment with the adult's attorney in an effort to impose some judicial reality. Most attorneys want their clients to win. The professional requirement of the attorney is to advocate for their client. Thus, conveying information to an attorney about the client's constructive or destructive behaviors in the therapy process and in coparenting efforts provides the attorney with information that can be used to help the client. If the client is actively working to promote cooperation, then that parent has a better chance of being viewed positively by the court if litigation occurs. If the parent being represented is poorly motivated to cooperate and emits destructive coparenting behaviors, then the attorney will be forced to exert some control over the client so they can avoid any negative, judicial evaluations.

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It is important to note that when working with high conflict, divorcing parents, the therapist is required to obtain signed release of information forms from each parent to discuss therapeutic progress with that parent's attorney. APA ethical guidelines prohibit sharing information gained in mediation with attorneys for the opposing party. Gaining permission in advance to talk with a parent's counsel should avoid any ethical restrictions. The potential that the therapists have to demand cooperative coparenting comes from the information that has been gained about parental behavior and the observations the therapist may be ordered to convey when called to testify. Attorneys can anticipate judges' reactions to professional testimony, particularly when the psychologist has had the opportunity to observe the relevant behaviors of both of the litigants. Attorneys can often bring to bear pressure on their clients to behave in constructive ways when they are able to help them anticipate the legal consequences of such actions. While a strong coercive aspect exists to this approach to clinical intervention, it is being done to achieve some healthy functioning in a family that is going through an acute and stressful transition. Many of their parenting behaviors have been impaired by outside influences and by their own distress. The therapist's efforts are made in an effort to help parents to grow into the new demands and circumstances which they face and to help them to develop into effective coparents who have healthy children and who enjoy their parenting roles.

9.17.6.6 Resolving Disputes and Teaching Coparenting Skills The sixth and seventh steps of the intervention are implemented simultaneously. They include: (i) resolving specific disputes between parents, (ii) teaching new skills (communication, compromise and conflict resolution, and parenting skills) and enhancing capacities in existing skills which will help parents work together after divorce, and (iii) teaching parents about the divorce adjustment process, helping them to understand their family dynamics, and helping them to understand the influence of these two processes on the development of their children. From a technical perspective, the therapist chooses one or two important, but solvable, problems for resolution. When choosing the target problem, the therapist will have three

goals. Resolving the dispute, identifying and enhancing capacities, and shaping the couple's views about parenting after divorce. The therapist first defines the problem and then asks each of the participants to convey what they might do to achieve resolution. The exact task is for each parent to identify what they do to contribute to the problem and to define what they may do to make the situation better. It is imperative that each of the participants respond with what they can do. The therapist must limit all discussion to what each parent can do and to accept personal responsibility for the current issue. The therapist's responsibility is to diagnose each of the parent's capacities to communicate clearly, to compromise, to set aside their own needs for those of their children, and to respect the importance of the other parent to their children. Once skill deficiencies are identified, the therapist adds the teaching of the absent skills and perspectives to dispute resolution. Directiveness is, again, required of the therapist. The therapist must set the standards for behavior, including both target skill levels as well as attitudes about mutual respect and the importance of both parents to the children. It is very helpful to resolve several specific disputes as quickly as possible during this stage as it will give parents some hope that improvement can occur. More important, however, is the fact that by helping parents to jointly resolve one issue, you are helping them to understand the processes involved in resolving future conflicts. Once the therapist has observed the parents' attempt to resolve a specific dispute issue and has drawn some important diagnostic conclusions about their strengths and weaknesses, he or she conveys observations about these capacities to the parents and targets skill areas in need of enhancement. Observations should include clear statements about what each of the parents is doing right and what is being done that either harms the children or interferes with resolution of the problems. In some cases, the therapist is required to comment on sources of resistance that may impair their ability to resolve disputes in mutually beneficial ways. Respect, objectivity, and honesty must characterize such statements. In the absence of directness one or both of the parents can not be expected to know how they are impairing the dispute resolution process. The therapeutic task is also to evaluate each of the parent's understanding of the impact of the divorce on their children. When the impediment to problem resolution is a lack of understanding of the divorce process and its impact on child adjustment, the therapist must be a conveyor of scientific data and

Conclusions developmental theory. It is also useful to relate the data to the specific and current needs to each of the couple's children. It is not the purpose of this paper to review all that has been written on training packages in these areas. Instead, refer to the writing of Hendrix (1989) or the vast literature on mediation and conflict resolution strategies. Teaching the requisite competencies as they are needed, rather than at the beginning of the therapy, may be a more efficient and effective process. In some cases, parents possess some of the required skills. Teaching what they already know adds substantial time to what is a very time consuming therapy. Ameliorating deficiencies as they appear increases parents' motivation to acquire the skills. They realize that without the specific capacities, they will be unable to reach the goals that either or both hold. Once requisite proficiencies have been taught and several problems have been resolved, the parents should be encouraged to initiate the resolution of some new problem with limited direction from the therapist. Three procedural points must be considered. First, many parents engaged in high conflict divorces do not acquire the level of skills, respect and motivation necessary to accomplish independent problem solving. Continued assistance from the therapist over time is generally required. It is important to note, however, that substantial reductions in hostility and increases in cooperative coparenting are achieved by helping parents to resolve their most significant disputes. Second, not all disputes are either resolvable or have to be resolved. Some issues are too difficult or too subtle to resolve, others simply do not matter to effective coparenting. It is necessary for the therapist to categorize issues along the dimensions of solvable and relevant so that sufficient attention can be given to reconcilable and relevant differences. Third, strict limits must be set by the therapist on any excessive expressions of anger or of efforts by one parent to control the other. Both parents must feel safe to participate in this process. If either feels threatened or controlled by the other, progress cannot be made. Strategies to insure a sense of safety include defining rules and consequences at the beginning of the therapeutic process. Short breaks during a session or, in some cases, early termination of a session may be required. Two disputes common to most divorces involving children are child support and flexibility in predetermined schedules. In many cases, parent and professionals involved with the family suggest unnecessarily complicated strategies to resolve these disputes. Child support is clearly defined by most state

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legislatures. One simple and fair strategy includes reviewing the most recent federal tax returns and using income statements on the returns for support calculations. Support can be recalculated annually, after federal taxes have been filed, using figures listed on the tax returns. This routine review of support insures that relevant figures are being used in the determination of support and that any inequity resulting from a change in the financial status of either parent lasts no more than one year. Too much flexibility in a previously defined schedule frequently results in unnecessary anger in the parents and confusion in the children. Parents frequently feel used and like ªbabysittersº to the other parent. Children cannot predict where they will reside. The most straightforward solution to such problems is one in which requests for changes are strictly limited to one, 24-hour alteration every three months. The priority of parenting commitments over work, social, and professional schedules is essential to the children's feeling of self-worth and to the other parent's feelings of respect. 9.17.6.7 Evaluating and Monitoring Therapeutic Gains As is the case with all structured interventions, evaluation of therapeutic effectiveness is necessary. Such evaluations should include the acquisition of specific and required skills, the immediate resolution of problematic and pathogenic processes, the current functioning of the children, and the long-term maintenance of skill and adjustive gains. Implementing a practical evaluation of therapeutic effectiveness should include some appraisal of parents' knowledge of the divorce adjustment process, particularly as it relates to their children. It should also include an assessment of the parents' skills in communicating, compromising, and parenting. Changes in observed interparent hostility and the ability to resolve specific disputes follow. Measures of child adjustment, such as the Child Behavior Checklist, must also be collected. In an effort to demonstrate the durability of the intervention, an evaluation of hostility, dispute resolution, and child adjustment should be conducted six months after the end of the therapy. 9.17.7 CONCLUSIONS The consequences of high hostility divorce on child adjustment is severe and long-lasting and impacts hundreds of thousands of children annually. Developing and evaluating a strategy to promote coparenting and to reduce hostility

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can substantially reduce the severe consequences of such dysfunctional parenting. A preliminary strategy to accomplish such goals has been suggested in the manuscript. Substantial work is still required in the development of such an intervention. First, more information is needed in understanding which specific coparenting behaviors exacerbate interparent hostility and deteriorate children's adjustment and which behaviors promote cooperation and children's mental health. Second, a formal evaluation of the existing strategy is required. Third, the experience of therapists experienced in working with hostile, divorcing parents must be accumulated to identify problems with the existing strategy and to suggest new procedures to ameliorate them. Finally, training at the graduate and professional level will be required so that a sufficient pool of competent therapists exists to meet the substantial demands of this emotionally taxing population.

9.17.8 REFERENCES Ainsworth, M. D. S. (1979) Infant±mother attachment. American Psychologist, 34, 932±937. Ainsworth, M. D. S. (1989). Attachments beyond infancy. American Psychologist, 44, 709±716. Bandura, A. (1973). Aggression: A social learning approach. Englewood Cliffs, NJ: Prentice-Hall. Belsky, J. (1980). Child maltreatment: An ecological perspective. American Psychologist, 35, 320±335. Belsky, J. (1984). The determinants of parenting: A process model. Child Development, 55, 83±96. Biller, H. B. (1981). The father and sex role development. In M. E. Lamb (Ed.). The role of the father in child development (2nd ed. pp. 319±358). New York: Wiley. Bjorklund, D. F., & Green, B. L. (1992). The adaptive nature of cognitive immaturity. American Psychologist, 47, 46±54. Bloom, B. L., Asher, S. J., & White, S. W. (1978). Marital disruption as a stressor: A review and analysis. Psychological Bulletin, 85, 867±894. Bronfenbrenner, U. (1977). Toward an experimental ecology of human development. American Psychologist, 32, 513±531. Bronfenbrenner, U. (1979). The ecology of human development. Cambridge, MA: Harvard University Press. Camplair, C. W., & Stolberg, A. L. (1987). Professionals' influences on child custody decisions. Journal of Divorce, 10, 43±56. Camplair, C. W., & Stolberg, A. L. (1990). Court sponsored divorce mediation: A description and evaluation of process and outcome. Mediation Quarterly, 7, 199±213. Christenson, A., & Margolin, G. (1988). Conflict and alliance in distressed and non-distressed families. In R. A. Hinde, & J. Stevenson-Hinde (Eds.), Relationships within families: Mutual influence (pp. 333±360). Oxford, UK: Oxford University Press. Coogler, O. J. (1978) Structural mediation in divorce settlement: A handbook for marital mediations. Lexington, MA: Lexington Books. Cummings, E. M., Iannotti, J. R., & Zahn-Waxler, C. (1985). The influence of conflict between adults on the emotions and aggressions of young children. Developmental Psychology, 21, 495±507.

Cummings, E. M., Vogel, D., Cummings, J. S., & ElSheikh, M. (1989). Children's responses to different forms of expression of anger between adults. Child Development, 60, 1392±1404. Dadds, M. R., Sanders, M. R., Morrison, M., & Rebgetz, M. (1992). Childhood depression and conduct disorder: II An analysis of family interaction patterns in the home. Journal of Abnormal Psychology, 101, 505±513. Davis, K., & Stolberg, A. L. (1988). Influences on professionals' child custody recommendations. Journal of Divorce, 11, 207±217. Deed, M. L. (1991). Court-ordered child custody evaluations: Helping or victimizing vulnerable families? Psychotherapy, 28, 76±84. Ellwood, M. S., & Stolberg, A. L. (1993). The effects of family composition, family health, parenting behavior and environmental stress on children's divorce adjustment. Journal of Child and Family Studies, 2, 23±36. Emery, R. (1982). Interparental conflict and the children of discord and divorce. Psychological Bulletin, 92, 310±330. Emery, R. E., & O'Leary, K. D. (1984). Marital discord and child behavior problems in a nonclinic sample. Journal of Abnormal Child Psychology, 12, 411±420. Emery, R. E., & Wyer, M. M. (1987). Divorce mediation. American Psychologist, 42, 472±480. Flavell, J. (1985). Cognitive development. (2nd ed.). Englewood Cliffs, NJ: Prentice-Hall. Forehand, R., Long, N., & Brody, G. (1988). Divorce and marital conflict: Relationship to early adolescent competence and adjustment in early adolescence. In E. M. Hetherington & J. D. Arasteh (Eds.), Impact of divorce, single parenting and step-parenting on children (pp. 155±196). Hillsdale, NJ: Erlbaum. Friedrich, W. N., & Einbender, A. J. (1983). The abused child: A psychological review. Journal of Clinical Child Psychology, 12, 244±256. Fry, P. S., & Addington, J. (1985). Perceptions of parent and child adjustment in divorced families. Clinical Psychology Review, 5, 141±157. Gilbert, R. K., & Christensen, A. (1988). The assessment of family alliances. Advances in Behavioral Assessment of Children and Families, 4, 219±252. Girdner, L. K. (1985). Adjudication and mediation: A comparison of custody decision making processes. Journal of Divorce, 8, 33±48. Grych, J. H., & Fincham, F. D. (1990). Marital conflict and children's adjustment: A cognitive-contextual framework. Psychology Bulletin, 102, 267±290. Grych, J. H., & Fincham, F. D. (1993). Children's appraisals of marital conflict: Initial investigation of the cognitive-contextual framework. Child Development, 64, 215±230. Hartup, W. W. (1989). Social relationships and their developmental significance. American Psychologist, 44, 120±126. Hendrix, H. (1989). Getting the love you want. New York: HarperCollins. Hetherington, E. M. (1979). Divorce: A child's perspective. American Psychologist, 34, 851±858. Hetherington, E. M. (1991). The role if individual differences and family relationships in children's coping with divorce and remarriage. In P. A. Cowan & E. M. Hetherington (Eds.), Family transitions (pp. 165±194). Hillsdale, NJ: Erlbaum. Hetherington, E. M., & Clingempeel, W. G. (1992). Coping with marital transitions: A systems perspective. Chicago: University of Chicago Press for the Society for Research in Adolescence. Hetherington, E. M., Cox, M., & Cox, R. (1982). Effect of divorce on parents and children. In M. E. Lamb (Ed.), Non-traditional families: Parenting and child development (pp. 233±288). Hillsdale, NJ: Erlbaum. Hinde, R. A., & Stevenson-Hinde, J. (1988). Relationships

References within families: Mutual influences. New York: Oxford University Press. Johnson, P. L., & O'Leary, K. D. (1987). Parental behavior patterns and conduct disorders in girls. Journal of Abnormal Child Psychology, 15, 573±581. Jouriles, E. N., Barling, J., & O'Leary, K. D. (1989). Interspousal aggression, marital discord, and child problems. Journal of Consulting and Clinical Psychology, 57, 453±455. Kalter, N. (1987). Long-term effects of divorce on children: A developmental vulnerability model. American Journal of Orthopsychiatry, 55, 587±600. Kalter, N. (1989). Growing up with divorce: Helping your child avoid immediate and later emotional problems. New York: Free Press. Kalter, N., Pickar, J., & Lesowitz, M. (1984) School-based developmental facilitation groups for children of divorce: A preventive intervention. American Journal of Orthopsychiatry, 54, 613±623. Katz, L. F., & Gottman, J. M. (1993). Patterns of marital conflict predict children's internalizing and externalizing behaviors. Developmental Psychology, 29, 940±950. Kerig, P. A., Cowan, P. A., & Cowan, C. P. (1993). Marital quality and gender differences in parent±child interactions. Developmental Psychology, 29, 931±939. Koestner, R., Franz, C., & Weinberger, J. (1990). The family origins of empathic concern: A 26-year longitudinal study. Journal of Personality and Social Psychology, 58, 709±717. Kerr R., & Bowen, R. A. (1988). Family evaluation. New York: W. W. Norton. Kressel, K., & Pruitt, D. G. (1985). Themes in the mediation of social conflict. Journal of Social Issues, 41, 179±198. Kressel, K., & Deutsch, M. (1977). Divorce therapy: An indepth survey of therapists' views. Family Processes, 16, 413±443. Kurdek, L. A. (1981) An integrative perspective on children's divorce adjustment. American Psychologist, 36, 856±866. Mann, B. J., Borduin, C. M., Henggeler, S. W., & Blaske, D. M. (1990). An investigation of systemic conceptualizations of parent±child coalitions and symptom change. Journal of Consulting and Clinical Psychology, 58, 336±344. McIsaac, H. (1982). Court connected mediation. Conciliation Courts Review, 21, 49±56. Miller, P. M., Danaher, D. L., & Forbes, D. (1986). Sexrelated strategies for coping with interpersonal conflict in children ages five to seven. Developmental Psychology, 22, 543±548. Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press. Neville, W. G. (1985). Reflections on the growth and significance of divorce mediation. Journal of Divorce, 8, 3±7. Patterson, G. R. (1977). Accelerating stimuli for two classes of coercive behaviors. Journal of Abnormal Child Psychology, 5, 335±350. Patterson, G. R. (1982). Coercive family processed: A social learning approach (Vol. 3). Eugene, OR: Castelia Publishing Company. Patterson, G. R. (1986). Performance models for antisocial boys. American Psychologist, 41, 432±444.

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Patterson, G. R., & Stouthamer-Loeber, M. (1984). The correlation of family management practices and deliquency. Child Development, 55, 1299±1307. Pearson, J., & Thoennes, N. (1984). Mitigating and litigating custody disputes: A longitudinal evaluation. Family Law Quarterly, 12, 497±454. Porter, B., & O'Leary, K. D. (1980). Marital discord and child behavior problems. Journal of Abnormal Child Psychology, 8, 287±295. Robinson, M., & Parkerson, L. (1985). A family systems approach to conciliation in separation and divorce. Journal of Family Therapy, 7, 357±377. Sarason, I. G., Sarason, B. R., & Pierce, G. R. (1990). Social support: An interactional view. New York: Wiley. Stinson, K. M. (1991). Adolescents, family and friends: Social support after parents' divorce or remarriage. New York: Wiley. Stolberg, A. L., & Bush, J. (1985). A path analysis of factors predicting children's divorce adjustment. Journal of Clinical Child Psychology, 14, 49±54. Stolberg, A. L., Camplair, C., Currier, K., & Wells, M. J. (1987). Individual, familial and environmental determinants of children's post-divorce adjustment and maladjustment. Journal of Divorce, 11, 51±70. Stoneman, Z., Brody, G. H., & Burke, M. (1989). Marital quality, depression, and inconsistent parenting: Relationship with observed mother±child conflict. American Journal of Orthopsychiatry, 59, 105±117. Thomas, A., & Chess, S. (1977). Temperament and development. New York: Brunner/Mazel. Trombatta, D. (1982). Custody evaluation and custody mediation: A comparison of two dispute interventions. Journal of Divorce, 6, 65±76. Turner, P. J., Gervai, J., & Hinde, R. A. (1993). Gender typing in young children: Preferences, behavioral and cultural differences. British Journal of Developmental Psychology, 11, 323±342. Vaux, A. (1988). Social support: Theory, research and intervention. New York: Prager. Vuchinich, S., Bank, L., Patterson, G. R. (1992). Parenting, peers, and stability of antisocial behavior in preadolescent boys. Developmental Psychology, 28, 510±554. Vuchinich, S., Emery, R. E., & Cassidy, J. (1988). Family members as third parties in dyadic family conflict: Strategies, alliances, and outcomes. Child Development, 59, 1293±1302. Vuchinich, S., Vuchinich, R., & Wood, B. (1993). The interparental relationship and family problem solving with preadolescent males. Child Development, 64, 389±400. Wallerstein, J. S., & Blakasee, S. (1989). Second chances: Men, women and children a decade after divorce. New York: Tichnor and Fields. Wallerstein, J. S., & Kelly, J. B. (1980). Surviving the breakup: How children and parents cope with divorce. New York: Basic Books. Wierson, M., Forehand, R., & McCombs, A. (1988). The relationship of early adolescent functioning to parentreported and adolescent-perceived interparental conflict. Journal of Abnormal Child Psychology, 16, 707±718. Weitzman, L. J. (1985). The divorce revolution: The unexpected consequences for women and children in America. New York: Free Press.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

9.18 Adult Victims of Child Sexual Abuse ROGER C. KATZ University of the Pacific, Stockton, CA, USA and PATTI LOU WATKINS Oregon State University, Corvallis, OR, USA 9.18.1 INTRODUCTION

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9.18.2 DEFINING CHILD SEXUAL ABUSE

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9.18.3 EXTENT OF THE PROBLEM

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9.18.3.1 Incidence and Prevalence 9.18.3.2 Victim and Perpetrator Characteristics 9.18.3.3 Risk Factors for Child Sexual Abuse 9.18.4 SEQUELAE OF CHILD SEXUAL ABUSE 9.18.4.1 9.18.4.2 9.18.4.3 9.18.4.4

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Post-traumatic Stress Disorder Problems of Male Survivors Medical Concomitants Positive Outcomes

9.18.5 TREATING ADULT VICTIMS

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9.18.5.1 Relationship Issues 9.18.5.1.1 Barriers to treatment 9.18.5.1.2 Iatrogenic complications 9.18.5.2 Treatment Models 9.18.5.2.1 Post-traumatic stress disorder model 9.18.5.2.2 Four traumagenic dynamics model 9.18.5.2.3 Eclectic models 9.18.5.2.4 Cognitive-behavioral treatments 9.18.5.3 Methodological Considerations 9.18.6 PREVENTION

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9.18.7 FUTURE DIRECTIONS

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children was regarded as a relatively rare event that was often neglected or trivialized by mental health professionals as a construction of the victim's Oedipal fantasies. It is now recognized as a real and all-too-frequent occurrenceÐone

9.18.1 INTRODUCTION Child sexual abuse (CSA) is one of the most common forms of child victimization in the USA. Until the 1980s, the sexual abuse of 291

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that researchers believe affects about one out of every four girls in the USA and one out of every ten boys (Walker, Bonner, & Kaufman, 1988). Although the exact number of victims will never be known, the consequences of CSA are far reaching, harmful, and long lasting. The focus of this chapter is on adult victims of child sexual abuse. By adult victims, we mean individuals over the age of 18 who, at a younger age, were forced to engage in sexual behavior by another person or engaged in sexual acts with someone much older than them even if force was not used (Browne & Finkelhor, 1986). The person or perpetrator could be a family member, relative, neighbor, or stranger. The act could be any type of sexual behavior ranging from relatively unobtrusive sexual touching and seductiveness to violent acts such as rape and ritualized sexual abuse (Lloyd, 1992). It is difficult to talk about the experience of adult victims of child sexual abuse without addressing the issue of sexual abuse at a more general level. Consequently, this chapter begins with a discussion of definitions of CSA because this has important implications for other aspects of the problem, including prevalence rates and the type of psychological sequelae that are observed in survivors. Following this, the issues of incidence and prevalence, victim and perpetrator characteristics are addressed, as well as contextual factors that researchers believe are associated with an increased risk of CSA. Next, the psychological sequelae of CSA are described. This includes a description of methods used to assess them and factors that seem to be associated with increased harm and resilience. The chapter concludes with a description of psychological interventions that have been developed to treat adult victims of CSA, their theoretical underpinnings, and accompanying empirical support. In this final section, attention is also directed to the need for increased methodological rigor in assessing therapy outcome, and to primary and secondary prevention.

9.18.2 DEFINING CHILD SEXUAL ABUSE One of the most basic yet controversial issues in the CSA literature is deciding what child sexual abuse is. There are many ways of defining the construct but none of them is universally accepted. This has profound implications for understanding the entire field of CSA because epidemiological and clinical research findings are only generalizable to the extent that researchers agree on the nature of their subject matter. Definitions of CSA are not the same as sexual abuse in adulthood (Wyatt, Guthrie, & Notgrass, 1992) and legal definitions of sexual

abuse are not the same as those used by researchers (Haugaard & Reppucci, 1988). Disagreement about what CSA is exists for many reasons. To begin with, sexual abuse can be subtle, sadistic, or overt and involve a myriad of behaviors (Lawson, 1993). It occurs between people of different ages (children and teenagers, teenagers and adults, adults and children) and in different relationships (family member, acquaintance, stranger). It can be a single incident or a repeated occurrence, and it may occur in conjunction with physical and emotional abuse. Moreover, its effects are varied and difficult to disentangle from the sequelae of other types of trauma or family dysfunction (Green, 1993; Polusny & Follette, 1995). Definitions of sexual abuse can be broad, such as forced sexual contact during the person's lifetime, or narrow, such as a particular type of molestation (e.g., father±daughter incest) (Burnam et al., 1988). Some definitions emphasize the exploitative intention of the perpetrator compared with other definitions which focus on the effects of the perpetrator's actions on the survivor. In their seminal review, Browne and Finkelhor (1986) point out that CSA involves two overlapping but distinct types of interaction: (i) coerced sexual activity that is forced on a child, and (ii) sexual activity between a child and a much older person, whether or not coercion is involved. While many researchers have adopted these guidelines in operationalizing CSA, differences of opinion exist about what constitutes a child (e.g., age 514, 16, or 18) and the age criterion for a person much older (Knutson, 1995). For many investigators, the criterion is at least five years older (Browne & Finkelhor, 1986). How CSA is defined has important consequences at different levels of analysis. To begin with, criteria used to define CSA affects how people perceive it, how they react to the individuals involved, and the type of sexual behaviors that are reported to the police and child welfare workers (Finkelhor, 1984). The latter bears directly on incidence and prevalence rates which provide an estimate of the severity of the problem at a societal level. Because these rates can vary tremendously depending on how CSA is defined, this impacts the decisions of policy makers who allocate resources for treatment, prevention, and research. At a less appreciated level, definitions of CSA have important implications for the identification and severity of abuse-related psychological problems (Briere, 1992). For example, researchers who restrict themselves to earlier and more intrusive forms of abuse might report more severe sequelae in survivors compared with researchers who rely on a broader definition.

Extent of the Problem One reason is that the effects of CSA may be mediated by developmental factors (Cole & Putnam, 1992; Downs, 1993). Haugaard and Reppucci (1988) recommended that terms like child sexual abuse are too broad to convey useful information and should be avoided in favor of more specific descriptions of the type of abuse being studied (e.g., children molested by their older siblings) or the type of victims being treated (e.g., adolescent boys molested by their mothers). Their point is that any effects of a specific type of abuse or of abuse on a specific type of individual might go undetected in studies using broad definitions of CSA that result in heterogeneous samples. It is helpful to distinguish between child molester, child rapist, and pedophile because these terms are sometimes used interchangeably when they have different meanings. A child molester is a person, usually an adult, who entices, entraps, or pressures a child into sexual activity (Walker et al., 1988). A child rapist, on the other hand, is a particular type of molester who uses force or assault in perpetrating their crime which, by definition, involves sexual intercourse. The term pedophile refers to an individual who suffers from pedophilia, a specific mental disorder defined in the DSMIV (American Psychiatric Association, 1994). 9.18.3 EXTENT OF THE PROBLEM 9.18.3.1 Incidence and Prevalence The 1980s and 1990s have ushered in a number of studies on the incidence and prevalence of CSA in the USA and abroad. As a rule, these studies have yielded discrepant findings (Wynkoop, Capps, & Priest, 1995). Some of the discrepancy is due to sampling error but differences in methodology are equally important. Relevant variables include (i) the group studied, (ii) the type of sampling procedures used, (iii) the rate of participation among possible subjects, (iv) the criteria used to define a sexual experience as abusive, (v) the upper age limit of the victim, and (vi) the methods used to collect the data (Anderson, Martin, Mullen, Romans, & Herbison, 1993; Cappelleri, Eckenrode, & Powers, 1993). Discrepancies in the data notwithstanding, statistics on CSA are widely assumed to underestimate the true extent of the problem for the simple reason that a significant percentage of cases go unreported (Urquiza & Keating, 1990). Prevalence rates determined by random samples of populations in the USA and abroad shed further light on the problem. For example, Russell (1983) found that 38% of 930 women, age 18 and older and living in the San Francisco

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area, had an unwanted sexual experience before they were 18. In 28% of the cases, the abuse occurred before the victim was 14. Wyatt (1985) estimated that 59% of her sample of AfricanAmerican and Caucasian women, age 18 to 36, reported some form of sexual abuse before they were 18. Rates were higher for whites than for African-Americans. Moreover, the prevalence increased to 62% when the definition of sexual abuse was broadened to include unwanted sexual experiences with peers. Somewhat lower rates of abuse (19±22%) were reported by Finkelhor (1979) and Fromouth (1986) in their work with female college students. On the other hand, in a study of women from New Zealand, Anderson et al. (1993) reported that 32% of their sample (N=3000) had one or more unwanted sexual experiences before they were 16, and 70% of the abuse involved genital contact or severe abuse, although only 7% of the cases were ever officially reported.

9.18.3.2 Victim and Perpetrator Characteristics The overwhelming majority of CSA victims are girls who are molested between the ages of 8 and 12 (Anderson et al., 1993; Finkelhor, 1984). The age of maximum risk is between 10 and 11; however, this does not mean that younger children and adolescents are immune to sexual mistreatment. While sexual abuse in boys is more likely to be under-reported (Urquiza & Keating, 1990), for every boy who is molested there are about 2.5 female victims (Finkelhor, 1986). Similar findings were reported by Cappelleri et al. (1993) from the Second National Incidence and Prevalence Study of Child Abuse and Neglect. They found a sexual abuse incidence rate (per 1000) of 3.28 for girls compared with 1.0 for boys. Epidemiological data from other countries show that women are abused 1.5 to 3 times more often than men and that prevalence rates are comparable to those in the USA and Canada (Finkelhor, 1994). The experiences of victims of CSA vary depending on the group being studied (Green, 1993; Knutson, 1995). For this reason, the origin of the sample needs to be considered when addressing issues like victim characteristics and short- and long-term effects of the abuse. While large-scale surveys have called attention to the prevalence of CSA, information derived from these surveys is not the same as results from clinical samples. Compared to large-scale surveys of college students, for example, groups of previously identified victims who are either in therapy or requesting it report more severe and protracted forms of sexual abuse and a higher incidence of actual or

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attempted intercourse (Haugaard & Reppucci, 1988). For both male and female victims, there is also a higher percentage of fathers as perpetrators. This has important implications because abuse by father figures or abuse involving force and penetration may be associated with increased psychological harm (Kendall-Tackett, Williams, & Finkelhor, 1993; Mennen, 1993). Perpetrators of sexual abuse against girls are almost always male. Most of them are in their mid-30s and acquainted with their victim (Anderson et al., 1993; Russell & Trainor, 1984). They include family members, neighbors, and people in positions of trust or authority, such as teachers and baby-sitters. With female perpetrators, the abuse tends to occur within a caretaker role; moreover, the victim is more likely to be younger and, often, a male (Rudin, Zalewski, & Boomer-Turner, 1995). Between 15% and 24% of female victims are molested by strangers (Anderson et al., 1993). Among males, the figure may be a little higher (Finkelhor, Hotaling, Lewis, & Smith, 1990) except when the abuser is a female (Rudin et al., 1995). The most common situation is one in which the child is molested only once, usually fondling by a family member. Sexual intercourse is more common in extrafamilial abuse (Russell, 1983). Finklehor (1979) found that having a stepfather more than doubled a young girl's vulnerability to molestation, and Anderson et al. (1993) reported that stepfathers were 10 times more likely to be abusers than biological fathers. Like victims of CSA, perpetrators are a heterogeneous group. They include men and women in different role relationships with the victim, young and old, and sometimes with a propensity for many types of deviant sexual behavior (Abel & Rouleau, 1990; Lawson, 1993). Margolin (1992) has noted that a vast majority of sexually abusive grandparents are grandfathers who were sexually abusive as fathers and chose their granddaughters as a victim. Stepgrandchildren tended to be at greater risk. In their study of adult male child molesters and other sex offenders, Abel and Rouleau (1990) found that most of the men had many different paraphilias. This was especially true of incest offenders who molested male children. Reviewing the literature on child and adolescent perpetrators, Vizard, Monck, and Misch (1995) pointed out that at least 20% of the sexual offenses in the USA are committed by young men under the age of 18, many of whom grow up to become adult offenders. A large number of these youthful perpetrators were physically or sexually abused themselves, and their victims are often younger siblings.

Although their offending behavior is sexual, the motivation behind it may have more in common with dominance or bullying behaviors. For example, Katz (1990) reported that social skills deficits and peer isolation predispose some adolescents to commit sexual crimes against younger children. 9.18.3.3 Risk Factors for Child Sexual Abuse Risk factors for CSA often say more about the victim's environment than the victim per se (Knutson, 1995). The most common victim characteristics are gender (female), age (older), and social isolation (Cappelleri et al., 1993). However, seven of the eight risk factors described by Finkelhor (1984) were familial (e.g., had a stepfather, separated from mother, sexually punitive mother, no physical affection from father), as were the major risk factors identified by Benedict and Zautra (1993) Ðparental absence and conflict. Low family income (Bergner, Delgado, & Graybill, 1994; Cappelleri et al., 1993), family history of alcoholism (Windle, Windle, Scheidt, & Miller, 1995), and having a disability that requires residential placement are also associated with an increased risk of abuse (Sullivan & Knutson, 1993). 9.18.4 SEQUELAE OF CHILD SEXUAL ABUSE A decade after Browne and Finkelhor (1986) first reviewed the long-term effects of CSA, research continues to show that its sequelae are highly diverse. While much of the research in this area has been atheoretical, several reviewers have attempted to place their findings within a theoretical framework. For instance, Cole and Putnam (1992) discussed the sequelae of father± daughter incest within a developmental framework. They contended that adults victimized as preschoolers may experience psychopathology involving denial and dissociation which are common coping strategies during this developmental phase. Indeed, dissociation in clinical or subclinical forms is among the established concomitants of CSA (Polusny & Follette, 1995). Focusing on abusive parent±child relationships, Alexander (1992) discussed CSA sequelae in the context of Bowlby's (1973) attachment theory. While these attempts are somewhat limited in that they focus primarily on incestuous father±daughter relationships, they are to be lauded for their efforts to explain CSA sequelae in theoretical terms. Perhaps because of such efforts, researchers have begun to test theoretical models linking CSA to

Sequelae of Child Sexual Abuse particular symptom presentations. For example, Mallinckrodt, McCreary, and Robertson (1995) provided empirical support for an association between CSA and eating disorders that may be mediated by impaired maternal attachment and lack of social competencies, such as interoceptive self-awareness and the ability to solicit social support. Polusny and Follette (1995) have suggested that many of the sequelae of CSA transcend traditional diagnostic categories. They conceptualized CSA-related problems as manifestations of emotional avoidance, a theory that is not incompatible with the developmental and attachment-based perspectives previously described. They suggested that CSA survivors use coping strategies, such as substance abuse and self-mutilation, that are negatively reinforced by the reduction of painful affect associated with the abuse experience and related stimuli. Although such strategies may enhance a child's ability to cope, excessive reliance on them in adulthood can compromise adjustment. Polusny and Follette's (1995) review also revealed that adult survivors exhibit higher levels of general psychological distress, as well as more specific problems including major depression, anxiety disorders, substance abuse, eating disorders, dissociative disorders, somatization, and personality disorders. A history of CSA was associated with increased dissatisfaction with partner and parenting roles, less sexual satisfaction, high-risk sexual practices, more sexual dysfunction, and an increased risk of sexual revictimization in adulthood. The remainder of this section discusses the current status of post-traumatic stress disorder (PTSD) (American Psychiatric Association, 1994) as a diagnosis for the problems experienced by CSA survivors, then focuses on the relationship of CSA to mental health problems experienced by male survivors because, compared to female survivors, this is a relatively neglected topic. Next, some of the medical concomitants of CSA are examined, and from there a brief discussion of resiliency factors and potential adaptive or beneficial effects of being a CSA survivor.

9.18.4.1 Post-traumatic Stress Disorder Rowan and Foy (1993) addressed the applicability of PTSD as a diagnosis for the constellation of symptoms displayed by CSA survivors. Historically, PTSD was first used to describe the psychological problems of Vietnam combat veterans. Later it was applied to victims of rape and domestic violence, as well as adult survivors of CSA who were experiencing

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psychological difficulties. Indeed, as Rowan and Foy contend, other DSM disorders ªfail to encompass the full range of primary symptoms frequently experienced by CSA survivorsº (p. 4). A PTSD diagnosis includes criteria which characterize impairments in both self (e.g., psychological distress) and social functioning (e.g., feelings of detachment or estrangement from others) that are commonly observed among CSA survivors. Rowan and Foy reviewed research studies which examined the prevalence of PTSD among CSA survivors as well as those which examined the relationship of assorted exposure variables to PTSD. While they concluded ªthat the PTSD model appears to describe the core features of the psychological difficulties of many survivorsº (p. 17), they tempered this statement with cautions concerning the methodologies employed. In particular, they noted a lack of clarity and/or variability in definitions of CSA, along with an absence of standardized measures of PTSD. Rowan, Foy, Rodriguez, and Ryan (1994) conducted a study in which they operationalized CSA exposure as well as employed standardized measures, both interview and questionnaire, of PTSD. Results revealed that between 64% and 69% of their clinical sample of CSA survivors met full criteria for PTSD, with another 19% meeting partial criteria. Furthermore, duration of abuse was significantly related to PTSD, as was frequency according to interview-based diagnoses. McNew and Abell (1995) compared CSA survivors and Vietnam veterans on self-report measures of PTSD symptomatology, anger, social intimacy, and anxiety. Both groups experienced moderately severe levels of the PTSD symptoms, intrusion and avoidance, along with high levels of anger and anxiety. Furthermore, both groups evidenced patterns of anger expression likely to interfere with optimal functioning and an impaired sense of self in relation to others. The veterans obtained significantly higher intrusion scores. Otherwise, the two groups did not differ in symptom severity which led the researchers to conclude that relational disturbances and anxiety may manifest themselves regardless of the type of trauma experienced. McNew and Abell concluded that CSA survivors are similar to Vietnam veterans in their experience of PTSD symptoms, emphasizing that anger might best be considered as a central, rather than an associated, feature of PTSD. Newman and Peterson (1996) investigated the relatively neglected experience of anger in CSA survivors. They found that female incest survivors were angrier (in general, and toward both parents in particular) than a control group

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of women without a history of CSA. Rather than view these findings in pathological terms, Newman and Peterson suggested that it may be ªlegitimate and perhaps beneficial for incest survivors to be angry about specific individuals and occurrencesº (p. 471). They cautioned, however, that anger experienced by CSA survivors might be counterproductive if it is expressed in ways that undermine current relationships.

9.18.4.2 Problems of Male Survivors Compared with female survivors of CSA, male survivors have been neglected in the research literature. This neglect has extended to opportunities for support and treatment (Lisak, 1994). Jumper (1995) conducted a metaanalysis examining the relationship of CSA to adult psychological adjustment based on research published between 1978 and 1991. While he concluded that male and female CSA survivors are similar in terms of psychological symptomatology, only four of the 23 studies analyzed included male samples. Further work has seen a much-needed increase in studies aimed at understanding the psychological sequelae of CSA for men. In Lisak's (1994) study, 26 adult male survivors completed a psychological symptom inventory which revealed elevated global severity scores and elevated PTSD-subscale scores relative to normative samples. Providing even more insight into the plight of men who were molested as children were the participants' responses to audio-taped autobiographical interviews. These were transcribed verbatim, then subjected to a content analysis which identified 15 different themes. Fear, commonly involving intrusions, was the one theme identified by all members of the sample. Lisak noted that ªoften the words and expressions used by these men to describe their feelings and experiences are identical to those used by women survivorsº (p. 546). Indeed, six of the themes (i.e., helplessness, isolation and alienation, legitimacy, loss, self-blame/guilt, and shame/humiliation) were originally derived from an interview-based study of women rape survivors. While men were similar to women in terms of quantitative and qualitative measures of anxiety, their distress was manifested in some gender-specific ways. Among them were struggles with masculinity and fear of homosexuality. Another way in which sexually abused men and women often differ concerns the expression of anger or efforts to regain a sense of control over their lives. We previously noted that female CSA survivors experience anger, as did 90% of

Lisak's male sample. While men often attempted to suppress angry feelings, many ultimately snapped which culminated in violent behavior. In fact, nearly one-third of Lisak's sample admitted victimizing others through physical assault of adult men as well as female partners, rape of adult women, and sexual abuse of children. This last form of victimization has been the primary focus of other studies investigating CSA sequelae in males. Freund and Kuban (1994) tested the abused-to-abuser theory that CSA predisposes men toward pedophilia. Their sample was somewhat restricted in that it included only heterosexual pedophiles and excluded cases of incest. Furthermore, the authors questioned the accuracy of participants' self-reports of CSA, given the criminal nature of their sample. Nevertheless, pedophilia was significantly associated with CSA, while sexoffender status, in general, was not. Bagley, Wood, and Young (1994) took a different approach to examining the abused-to-abuser theory. They conducted a community survey of male CSA survivors which paralleled an earlier study investigating the psychological sequelae of CSA among women (Bagley, 1991). Specifically, this study included 750 men between the ages of 18 and 27 years, 65 of whom reported a single instance of CSA and 52 who reported multiple or ongoing episodes. As in previous studies of women, male survivors of long-term CSA experienced more severe symptomatology than survivors of short-term CSA or nonabused controls. Moreover, men with long CSA histories, accompanied by histories of emotional abuse, were the most likely candidates to engage in pedophilic behavior. As in the case of female CSA survivors, Bagley et al. speculated that attachment problems may underlie the psychological sequelae of CSA.

9.18.4.3 Medical Concomitants Although researchers have focused on the psychological and interpersonal sequelae of CSA, they have also turned their attention to physical consequences of this experience. For example, Lechner, Vogel, Garcia-Shelton, Leichter, and Steibel (1993) assessed the selfperceived medical problems of over 500 women visiting a family practice clinic, 26% of whom reported a history of CSA. Apart from indicating they had experienced a significantly greater number of sexually-related medical problems (e.g., surgical evaluation of pelvic pain), the CSA survivors reported more medical complaints in general, including respiratory and gastrointestinal distress. Based on interviews of

Treating Adult Victims female college students with CSA histories, Hulme and Grove (1994) found that six physical symptoms, including insomnia, sexual dysfunction, overeating, drug abuse, severe headache, and two or more major surgeries, occurred in over half of their sample. In addition, over onethird of their sample reported undergoing a single hospitalization, and a similar proportion reported experiencing ulcers. Obviously, both of these studies can be criticized on the basis of failing to provide objective verification of medical complaints. Nevertheless, these data suggest that CSA survivors who experience physical symptoms, whether they represent a manifestation of a somataform disorder or an organically-based malady, may well present to medical, rather than mental health, facilities. Hulme and Grove (1994) contend that health professionals in all clinical areas must be alert to symptom presentations suggestive of CSA. Lechner et al. (1993) placed the burden for detecting such a history on the physician rather than the patient because only 5.1% of their sample of CSA survivors disclosed the experience to their doctors. They believe that physician identification of CSA sequelae might reduce unnecessary repeat visits to primary care settings and facilitate entry into appropriate mental health treatment. In their opinion, the high incidence of sexual abuse warrants this approach.

9.18.4.4 Positive Outcomes While most researchers have focused on the adverse effects of CSA, some have turned their attention to the positive attributes of survivors. These include resiliency factorsÐcoping styles that seem to contribute to healthy adult functioningÐas well as positive consequences of the abuse experience itself. For example, Valentine and Feinauer (1993) recruited 22 adult women who defined themselves as wellfunctioning, despite their CSA histories, to participate in an interview aimed at eliciting factors important to their survival. The authors substantiated participants' self-perceptions of adjustment, indicating that all were currently employed and/or living without benefit of government assistance and that none had been institutionalized in hospitals, prisons, or shelters for homeless or battered women. From these interviews, six resiliency themes emerged, including the ability to build supportive relationships outside of the abusive environment in settings such as school and church. Furthermore, these contacts helped to develop participants' self-regard, allowing them to embark on careers and other positive life paths.

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In addition to providing sources of social support, religious settings appeared to foster a sense of purpose in the participants' lives, while alleviating misplaced guilt surrounding their abuse. Valentine and Feinauer (1993) observed several cognitive coping strategies in their participants, including an internal locus of control and a philosophy of life in which the abuse was reframed as a learning experience. The participants were also able to externalize blame for the abuse, recognize that ªit won't always be this way,º and understand that the abuse ªdid not have to affect everything they didº (p. 221). In essence, these well-functioning survivors employed an optimistic explanatory style characterized by external, unstable, and specific causal beliefs about negative events. Peterson and Bossio (1991) have ascertained that such thinking is related to adaptive functioning among various populations other than CSA survivors. Similarly, Feinauer and Stuart (1996) found that blaming oneself for CSA was an impediment to recovery and associated with increased symptomatology. Morrow and Smith (1995) used a similar approach to gather qualitative information from a clinic sample of 11 women in order to learn how they coped with their abuse. Some common themes emerged. For instance, many participants reframed their abuse to minimize its emotional impact and create an illusion of control or power. They also developed other areas of their life and sought out the consolation of others. McMillen, Zuravin, and Rideout (1995) interviewed 222 low-income mothers who were CSA survivors and related their responses to self-report measures of adjustment. Nearly onehalf of the sample reported some benefits from their abuse which tended to fall into one of four categories: (i) increased ability to protect one's children, (ii) better protection of self, (iii) greater strength and self-sufficiency, and (iv) improved understanding of CSA, along with enhanced empathy for other survivors. Perceived benefit was positively related to self-esteem and comfort depending on others, while negatively related to interpersonal anxiety. The findings of McMillen and his coworkers have implications for treating adult survivors, especially in terms of how the abuse experience is processed intellectually and emotionally.

9.18.5 TREATING ADULT VICTIMS The long-term effects of CSA vary from person to person and are moderated by different factors. Some of these factors are abuse related,

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such as its frequency and duration (KendallTackett et al., 1993), and others involve the developmental stage when the abuse occurred (Cole & Putnam, 1992; Downs, 1993). Still others comprise a dynamic interaction between the person, the event, and the surrounding milieuÐthe ªecology of the individual's experienceº (Lebowitz, Harvey, & Herman, 1993, p.379). What adult victims of CSA share is a common event, not a specific syndrome. Many victims grow up relatively unscathed (Finkelhor, 1990), while some reported they even benefited from the experience (McMillen et al., 1995). Differential effects of CSA depend on many factors. Because the long-term effects of CSA are nonspecific and varied, it is not surprising that many different techniques have evolved to treat them. What remains to be determined is how well these treatments work because outcome studies with appropriate control groups and long-term follow-ups are nonexistent in this area (Beutler & Hill, 1992; Briere, 1992). Treatment is designed to help victims cope with the long-term effects of their abuse. Improved coping means lessening the destructive impact of the experience and any subsequent trauma that may have resulted from sexual revictimization (Wyatt et al., 1992). Beyond this, the specific goals of treatment depend on the theoretical orientation of the clinician and the identified needs of the patient. In planning treatment, one of the first tasks is to evaluate the severity of the individual's symptoms. Contextual variables and host characteristics (e.g., personality attributes, coping skills, co-morbid psychiatric conditions) often interact with the abuse experience to buffer or magnify its impact (Meiselman, 1994). From an ecological perspective, many variables affect the course of treatment which underscores the importance of a careful assessment and the realization that multiple treatment modalities may be needed. An important but neglected topic in this regard is treatment matchingÐthat is whether better outcomes are achieved when survivors are matched with an appropriate intervention based on their unique features and identified needs (Lebowitz et al., 1993). Logic says this would be true but the requisite studies have not been done.

9.18.5.1 Relationship Issues An important prelude to treatment is rapport building and developing a therapeutic relationship. This is especially important in treating survivors because, during the course of treatment, they can expect to partially reexperience

memories and affects that were too painful to be processed normally when their abuse occurred (Meiselman, 1994). In order for patients to confront their trauma, they must first develop trust in their therapist. 9.18.5.1.1 Barriers to treatment Before a therapeutic relationship is established, barriers may need to be overcome that prevent victims from seeking help. Walker (1994) has described four of these barriers: (i) denial, minimization or complete repression of the abuse; (ii) self-blame, where victims hold themselves responsible for their ordeal; (iii) shame or guilt which can be so powerful that victims are unable to discuss the event with anyone else, and (iv) fear of punishment or retaliation from the perpetrator. Walker also described some obstacles to effective treatment, including the patient's fear of the therapist's reaction and the possibility that his or her story will not be believed. Another barrier is the fear of opening up which results when victims try to cope with their abuse by avoiding the issue or keeping their feelings walled off and under tight control. A third barrier is excessive efforts to please the therapistÐa coping strategy some victims learned to reduce the amount of abuse they received. When this generalizes to the therapist's office, it generates the facade of being helped but in reality it only interferes with the real business of treatment. According to Walker, it is important for the therapist not to pressure the person seeking treatment or hold them responsible for their abuse. Either of these can discourage the victim from seeking further help. 9.18.5.1.2 Iatrogenic complications Adult survivors seeking treatment face the possibility of iatrogenic complications and unwanted effects. One possibility is that disclosing sexual abuse may trigger an outpouring of psychological distress brought on by painful memories of the ordeal. Directly or indirectly, this can disrupt relationships with significant others and increase vulnerability to psychiatric disorder (McNulty & Wardle, 1994). The controversy surrounding repressed memories of sexual abuse, recovered memory therapy, and the so-called false memory syndrome is another concern (Loftus, 1993). In a recent California court case, the plaintiff was the first accused parent to sue therapists for implanting false abuse memories in his teenage daughterÐa malpractice suit he won, along with half a million dollars (Ramona vs. Isabel, 1994). Without denying the reality of CSA,

Treating Adult Victims Loftus (1993) has questioned the reliability of a particular class of recovered memories that emerge in adulthood after extensive memory work with a therapist. In some cases, these memories may be subtly and unwittingly implanted by overzealous counselors who are convinced that if their patients cannot remember an abuse experience, they probably repressed it. This line of reasoning is not only destructive to the accused but potentially damaging to the patient. McCarthy (1992) raises an additional concern about treating abuse victims, especially in 12-step recovery groups. He believes some survivors get stuck in the role of the angry victim which then becomes the focal point of their existence. 9.18.5.2 Treatment Models

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Traumatic sexualization results from sexual stimulation and reinforcement of the child's sexual responses. One of the consequences of this is that the child learns to use sexual behavior to satisfy nonsexual needs. This can lead to deviant arousal patterns, confused sexual identity, and hypersexual behavior. Betrayal occurs when the child is sexually exploited by adults who are supposed to love and protect them. This can produce generalized feelings of distrust, anger, and hostility. Stigmatization refers to the child's sense of being damaged, defective, or blamed for the molestation. This often generates guilt, shame, and low selfesteem. Powerlessness stems from feelings of helplessness during the assault and leads to problems involving fear, anxiety, and depression. Difficulties in each of these areas may require different treatments modalities.

9.18.5.2.1 Post-traumatic stress disorder model According to this model, abuse-related symptoms of adult survivors result from an interplay of cognitive and learning variablesÐfaulty information processing and distorted assumptions about the abuse on the one hand, conditioned emotional reactions and learned avoidance behavior on the other (Resnick & Newton, 1992; Smucker, Dancu, Foa, & Niederee, 1995). While this model has led to important therapeutic advances, it does not apply to all victims nor does it explain the symptoms that result from many types of sexual abuse (Finkelhor, 1988). For Polusny and Follette (1995), different symptoms of CSA, like binge eating, hypersexuality, drug abuse, and dissociation, are functionally equivalent ways of avoiding emotional pain caused by the person's memories of their victimization. According to this view, gradual exposure to anxiety-eliciting stimuli is necessary for therapy to be effective. 9.18.5.2.2 Four traumagenic dynamics model Finkelhor (Finkelhor, 1988; Finkelhor & Browne, 1985) has described an alternative to the PTSD model which seems to explain a wider range of symptoms while also providing a useful guide for developing comprehensive intervention strategies. Called the four traumagenic (or trauma-causing) dynamics model, the basic idea is that CSA has different effects depending on its impact on four important areas of children's development: sexuality, the ability to trust, selfesteem, and beliefs about self-efficacy or personal mastery. The four traumagenic dynamics corresponding to these areas are traumatic sexualization, betrayal, stigmatization, and powerlessness.

9.18.5.2.3 Eclectic models Walker (1994) described an eclectic approach called survivor therapy which has its origins in feminist therapy theory and trauma theory. Her emphasis is on treating female victims. The primary goal of the approach is meeting the individual's safety needs. Once this is accomplished, the therapist moves on to other objectives, including reinstilling a sense of control, validating the person's feelings by supportive and empathic means, exploring options and their associated consequences, helping the person make decisions and exercise good judgment and, finally, healing the acute symptoms of abuse. The last often involves the use of cognitive-behavioral interventions such as cognitive restructuring, assertiveness training, and relaxation training. Meiselman (1994) described another eclectic approach for treating adult survivors called reintegration therapy. Her approach is similar to the stage-by-dimension model of Lebowitz et al. (1993). Both of these models put a premium on insuring the client's safety which is broadly defined as physical well-being, establishing a safe living environment, and the reduction of self-destructive behaviors and PTSD-like symptoms. Following this, the focus of therapy is on achieving a personal understanding of the effects of the abuse and working on a healthy realignment of important social relationships. Lebowitz et al. advocate an ecological orientation attuned to the totality and variability of the survivor's experience. In their view, a beneficial therapy outcome requires not only effective treatment methods but also a willingness on the part of the therapist to remain flexible so there can be a good fit between the type of treatment offered and the particular needs of the patient.

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9.18.5.2.4 Cognitive-behavioral treatments Several researchers have written about the use of cognitive-behavioral approaches for treating adult survivors. One such approach is called imagery rescripting (Smucker et al., 1995). Designed for patients with PTSD and utilizing imaginal exposure and cognitive restructuring, this approach replaces victimization imagery with mastery imagery. The goal is to help the survivor feel strong and empowered instead of trapped in a childlike state of helplessness. Treatment involves identifying and challenging maladaptive self-schemas and replacing them with more adaptive schemas as viewed through the eyes of an adult. This is a relatively brief structured therapy that can be carried out in as few as nine sessions. McCarthy (1986, 1990) has described a cognitive-behavioral intervention for treating victims of sexual trauma including CSA and incest. To his credit, he pays particular attention to the problems of male victims. The focus of his work is on the treatment of sexual dysfunctions that result from abuse as well as the maladaptive consequences of the victimization syndrome. The latter occurs when the person adopts a victim's role and acts it out sexually or otherwise until it becomes the defining event in their life. In the process, personal and sexual self-esteem plummet. For McCarthy, the goal of treatment is to teach the patient to be a survivor, not a victim, and to feel relaxed and in control in sexual situations. This often entails cognitive restructuring techniques. For example, instead of dwelling on their suffering and victim status, patients are encouraged to abide by the affirmation that ªLiving well is the best revenge.º Relaxation training, guided imagery, and systematic desensitization are also used, especially if sexual fears or desire problems are present. If the person has a sexual problem and is in a relationship, the problem is dealt with as a couple issue. In many cases, the person is encouraged to confront the perpetrator with the idea of improving self-esteem by not reverting to the role of a helpless victim. Resnick and Newton (1992) described a multifaceted treatment for survivors of sexual assault with PTSD. Their approach draws heavily on exposure techniques combined with stress-inoculation training. Patients are provided with a learning-based explanation of their fears and the treatment they receive. This includes a discussion of stimulus generalization, higher-order conditioning, avoidance and its role in maintaining anxiety, plus the different channels through which anxiety is expressed (i.e., physiological, cognitive, and behavioral). Among the skills taught are controlled breath-

ing, deep muscle relaxation, thought stopping, and guided self-dialogue or self-instructions. Role playing and covert modeling are used to address inappropriate avoidance behavior. Evidence for the usefulness of cognitive therapy is provided by Jehu (1989). Participants in his study were 34 women who were molested as children and suffered from mood-related problems. Jehu hypothesized that the mood problems resulted from self-blame and other distorted beliefs associated with their abuse. A treatment package consisting mainly of cognitive restructuring techniques was developed to modify the distortions in hopes of alleviating the associated mood disturbance. Results showed reductions in distorted beliefs that were accompanied by improvements in the patient's selfesteem and mood. This is one of the few treatment studies with a relatively large sample and objective data. While the results are encouraging, their importance is weakened by the absence of an appropriate control group. Gazan (1986) used relaxation training combined with a cognitive restructuring approach similar to Jehu's (1989) to improve the sexual satisfaction of five women who were sexually abused as children. Results showed that treatment improved the sexual functioning of the women and helped them modify erroneous beliefs about their victimization. Pearson (1994) conducted a thorough review of treatment techniques for adult female survivors of CSA. Focusing on techniques used in individual therapy, he divided them into 11 categories including cognitive and behavioral techniques. Some of the other categories were life skills training, role playing, gestalt work, and psychodrama; relationship building techniques, transactional analysis and inner child work, family of origin techniques, and hypnotherapy and guided imagery. Summing up his findings, Pearson points out that while most of these techniques seem to produce some success, there is virtually no data to suggest which techniques work best for treating which symptoms or underlying issues common to survivors.

9.18.5.3 Methodological Considerations The studies we reviewed were weakened by the absence of comparison groups. None of them were controlled studies that allowed for unambiguous interpretations about the effectiveness of treatment. In many cases, they were anecdotal accounts of global therapies that were used with vaguely described and heterogeneous groups of persons. At best, the outcome research in this area has been characterized by the use of single group designs with some

Prevention objective data in the form of scores on fairly generic psychological tests. Under these conditions, it is impossible to determine if the results attributed to treatment were any better than changes that could have resulted from the passage of time, therapist attention, or placebo effects. There is a clear need for controlled outcome studies in this area. In an era of managed care, with its emphasis on empirically validated therapies, this need will only increase. While ethical and practical considerations preclude the use of randomized group designs, this should not discourage individual practitioners from using systematic assessment and evaluation procedures in their clinical practice. For therapists who regularly treat CSA survivors, causal inferences about treatment effects can be made using case study methods as long as treatment procedures are clearly specified and objective measures of the problem are taken continuously, before and during the course of therapy. With systematic replications across patients who have somewhat different characteristics, a compelling case can be made that the patients' improvement was due to the treatment they received and not some extraneous variable. The work of Maletzky (1980) with exhibitionists, Blanchard et al. (1985) with headache sufferers, and Morin, Stone, McDonald, and Jones (1994) with insomniacs are examples of how clinical replication studies can be used to gain valuable knowledge about the effectiveness of particular treatments for particular problems and patients. Similar methodologies can be used with CSA survivors. In the absence of specific information about the type of subjects being treated, how they were recruited, attrition rates, and the way child sexual abuse was defined, it is impossible to know if, and to what extent, the results are generalizable to other populations, or if persons with certain characteristics benefit more than others. Briere (1992) raises an interesting question: do adult survivors require abuse-specific treatments that are based on precipitating events and a presumed common etiology (i.e., their abuse), or would they fare just as well with treatments that focus on presenting symptoms and cut across etiologic boundaries? Most of the symptoms seen in CSA survivors are common to other disorders. Consequently, they might be amenable to problem-specific therapies that are widely available and whose efficacy has been established (Task Force on Promotion and Dissemination of Psychological Procedures, 1995). The treatment studies we reviewed were also limited by the absence of follow-up data. Even if

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a treatment works in the short run, its long-term effects still need to be evaluated. In a similar vein, the specific methods of treatment in the studies discussed were often vaguely described which makes replication difficult, if not impossible. The availability of treatment manuals would be an important step for improving future studies and a benefit to clinicians as well (Beutler, 1993).

9.18.6 PREVENTION Efforts to prevent CSA go back to the women's movement of the 1960s and 1970s. Shortly thereafter, concerns about protecting adult women from sexual abuse were extended to child populations. Thus, the 1980s saw a proliferation of programs geared toward protecting children from molestation. Research suggests that primary prevention programs based on the acquisition of relevant safety skills hold the most promise (Wurtele & Miller-Perrin, 1992). One such program, Safety with strangers (Gipson et al., 1984), consists of a series of slides, with accompanying audio tape, that depicts 20 situations in which a stranger approaches a child. Scenes and verbal prompts were derived from interviews with incarcerated child molesters in an effort to present realistic stimuli to the target audience, primarily grade school children in a classroom setting. The perpetrators depicted reflect the demographic characteristics of convicted child molesters. As such, they feature primarily Caucasian men (although some women and minorities are included), ranging in age and style of dress, thus addressing Doyle's (1995) concern that ªChildren often think that a `stranger' is an ugly manº and are not taught to be ªon guard against woman or good looking, charming menº (p. 166). Scenes include playing alone in the yard, becoming separated from parents in a store, and visiting the local video parlor. Verbal inducements range from bribes (e.g., ªCome over to my house and I'll let you play with my kittens.º), to trickery (e.g., ªYour mother is in the hospitalÐhurry, come with me!º) and physical threats if the child does not comply. Children then actively role play their response to these situations, with feedback and prompting from the program administrator. Correct responses include ignoring or saying no to the stranger, exiting the situation, and reporting the incident to a trusted adult. Recognizing that CSA perpetrated by strangers constitutes the minority of cases relative to those perpetrated by family members, acquaintances, and caretakers, other programs address

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this possibility by teaching children to identify inappropriate advances regardless of their relationship to the perpetrator (e.g. Wurtele, Saslawsky, Miller, Marrs, & Brichter, 1986). In addition, these programs explicitly acknowledge the sexual nature of the situation. Rather than requiring children to discriminate good and bad touching based on emotional or physical pleasure, Wurtele (1987) suggested that children be taught not to let ªany one bigger or olderº (p. 12) than themselves look at or touch their private parts and vice versa. Wurtele's recommendation seems well grounded in that a study found that CSA survivors described some pleasurable aspects of the contact, at least in the early stages (Briggs & Hawkins, 1995). Once sexually-threatening situations have been identified, similar roleplay methodology is used to teach children to resist these attempted violations. Consumers must be aware that, unlike the CSA prevention programs reviewed above, many are available that have not been empirically tested. Furthermore, several criticisms have been made of those subjected to empirical scrutiny. For example, dependent measures have largely consisted of knowledge tests, rather than direct observation of behavioral skills, particularly in real-life situations. In addition, rates of CSA among treated versus nontreated children have yet to be ascertained. A second criticism is that programs are often not developmentally sensitive which may render them ineffective. In fact, some researchers contend that expecting preschool children to protect themselves from potential abuse is unreasonable (Peterson, 1993). However, Wurtele (1990) demonstrated improvements in knowledge and skills which lasted up to a month when she adapted her program to fouryear-old preschoolers. Wurtele also addressed another criticism that participation in such programs will produce deleterious side effects. On the contrary, she encountered no programrelated behavior problems according to either teachers or parents, and parents did not report increased fear in their children subsequent to participation in the program. While skills-based primary prevention programs hold promise, they are limited in their impact considering the broader context in which abuse occurs. Researchers warn about imparting a false sense of security to child participants and their parents, recognizing that successful prevention efforts must reach beyond intervention with the children themselves (Wurtele & Miller-Perrin, 1992). Winett, King, and Altman (1989) have suggested that problems in prevention be approached simultaneously on multiple levels of analysis. While individual interventions

may have merit, their effects might be enhanced by interventions targeting small groups such as the family, community systems, and sociocultural institutions. Wurtele and Miller-Perrin (1992) invoked a similar ecological model in their consideration of CSA, calling for a comprehensive prevention response which emphasizes person±environment interactions. Furthermore, they stressed the importance of secondary prevention which entails recognition of prodromal signs and symptoms that abuse has or is occurring, along with early intervention to terminate the trauma. Secondary prevention efforts seem crucial, considering that survivors who endured prolonged abuse suffer more serious consequences than those subjected to isolated instances of abuse or abuse of brief duration. Focusing on the family system, Wurtele and Miller-Perrin (1992) suggested that primary prevention programs be extended from the classroom to the home, with parents implementing strategies such as those presented in the school. Parents are also advised to discuss sexuality and the potential for abuse in a direct and open manner with their children, disarming the secrecy which many perpetrators use to their advantage. These authors stressed the importance of CSA prevention programs occurring in the context of sound and accurate sexual education. Taking a different tack to primary prevention, Peterson (1993) reviewed studies in which regular home visits by various health care personnel resulted in fewer instances of parental physical abuse among at-risk families. Perhaps a similar strategy, designed to increase parental accountability, might reduce the chances of sexual abuse occurring as well. With regard to secondary prevention, parents might become more vigilant for warning signs of sexual abuse. Wurtele and Miller-Perrin (1992) list behavioral, emotional, and physical indicators of sexual abuse by developmental level. Hernandez (1995) provided evidence that both male and female adolescents experiencing CSA manifest eating-disordered behavior. Wurtele and Miller-Perrin provide information concerning age-appropriate sexual knowledge as another means of detecting potential abuse. For example, preschool children who use correct terminology for genitalia or girls who are knowledgeable about penile erections prior to age 12 may have acquired this information through abuse experiences. Another way in which parents can minimize the impact of abuse, once it is detected, involves their subsequent reaction to the child. Wurtele and Miller-Perrin provide guidelines regarding appropriate and inappropriate verbal, emotional, and behavioral responses. Indeed, many children who bring

Future Directions their abuse to the attention of an adult are met with negative reactions (e.g., Briggs & Hawkins, 1995). Doyle (1995) warns that ªThe phrase `Children should be seen and not heard' is manna to perpetratorsº (p. 167), and stresses the importance of responding to children's reports of abuse in a nonpunitive manner. On a community level, primary prevention programs might continue to be sponsored through school settings as well as other community bodies such as churches and day care settings. In addition, well-publicized, organized community involvement might deter would-be perpetrators from acting on their intentions. Of course, community members who have contact with and authority over children must be carefully screened regarding their potential to perpetrate abuse. Wurtele and Miller-Perrin (1992) strongly suggest background checks for staff and volunteers in youth organizations as well as foster care and juvenile detention settings. Secondary prevention efforts in the community might parallel those described for parents. That is, various professionals throughout the community might be taught to better recognize the early signs of abuse and to communicate their concerns in ways that facilitate entry into appropriate treatment. Wurtele and MillerPerrin (1992) contend that such resources are underutilized, citing several barriers such as fears associated with reporting CSA and lack of support from professional supervisors and agencies.

9.18.7 FUTURE DIRECTIONS The past decade has seen a phenomenal increase in attention paid to CSA among health care professionals and the general public alike. While this focus has spurred the development of prevention and treatment programs, much work remains to be done. For example, many interventions which have not been subjected to empirical scrutiny are readily available for public consumption. These include preventive programs disseminated through schools as well as self-help groups and literature for CSA survivors. Given the highly sensitive nature of CSA, concerns abound that consumers may experience emotional and relationship distress without adequate support to cope with these potentially adverse reactions. Enns, McNeilly, Corkery, and Gilbert (1995) have encouraged researchers to work in conjunction with clinicians who treat CSA survivors, as well as selfhelp organizations comprised of survivors, in an effort to enhance the quality of existing interventions. With the continuing growth of

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managed care, self-help modalities may become important supplements to formal therapy because they have the potential to reinforce coping skills as well as a sense of empowerment. Qualitative research in which CSA survivors act as participants may also serve to empower survivors while generating hypotheses to be tested by quantitative methods. Certainly, a need exists for more quantitative research, including controlled treatment outcome studies that use objective measures of specific CSArelated problems. Assessment begins with ascertaining an individual's abuse status. No longer are gross determinations of abuse history accepted in light of research implicating variables such as duration, type of contact, and relationship to the perpetrator as important factors in symptom presentation. Continuing efforts to specify, if not to quantify, the abuse experience are essential. While researchers endeavor to operationally define CSA, many health care practitioners are reluctant to ask clients about their abuse histories. Enns et al. (1995) implicate the false-memory debate as a contributor to this reluctance. That is, clinicians may be wary of accusations that they have implanted inaccurate recollections of abuse in their clients. To counter this fear, they suggest that questions about abuse be integrated within a comprehensive assessment, perhaps using open-ended questions about negative childhood experiences and family member's roles. In this way, clinicians may be less likely to be perceived as leading their clients to describe nonexistent events. In this chapter, overview of the current literature on adult victims of CSA is provided. In doing so, problems defining CSA were discussed, and the impact they have on epidemiological and treatment-oriented research. It was noted that the sexual mistreatment of children is all too common, and that its long-term effects are varied and moderated by ecological variables such as the duration and type of abuse, the relationship between victim and perpetrator, and the way in which the abuse is processed by the victim, both intellectually and emotionally. It was pointed out that different theoretical models and techniques are available for treating adult victims of CSA, but all of them are based more on conjecture and anecdotal support than on empirical evidence. Controlled outcome studies in this area, with appropriate control groups and long-term follow-up, are nonexistent. Finally, ways to prevent CSA and minimize its deleterious effects by early detection and treatment were described. The study of adult victims of CSA is relatively new. While much has been learned since interest in this area

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developed in the 1980s, researchers are still in the early stages of understanding what can be done to prevent the problem and mitigate its damaging effects. ACKNOWLEDGMENTS Appreciation is extended to Mr. James Wilson for his generous support, and to Ms. Shannon Witcher for her clerical assistance. 9.18.8 REFERENCES Abel, G., & Rouleau, J. (1990). The nature and extent of sexual assault. In W. Marshall, D. Laws, & H. Barbaree (Eds), Handbook of sexual assault: Issues, theories, and treatment of the offender. New York: Plenum. Alexander, P. (1992). Application of attachment theory to the study of sexual abuse. Journal of Consulting and Clinical Psychology, 60, 185±195. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders. Washington, DC: Author. Anderson, J., Martin, J., Mullen, P. Romans, S., & Herbison, P. (1993). Prevalence of childhood sexual abuse experiences in a community sample of women. Journal of American Academy of Child and Adolescent Psychiatry, 32, 911±919. Bagley, C. (1991). The prevalence and mental health sequelae of child sexual abuse in a community sample of women aged 18 to 27. Canadian Journal of Community Mental Health, 10, 103±116. Bagley, C., Wood, M., & Young, L. (1994). Victim to abuser: Mental health and behavioral sequelae of child sexual abuse in a community survey of young adult males. Child Abuse and Neglect, 18, 683±697. Benedict, L., & Zautra, A. (1993). Family environment characteristics as risk factors for child sexual abuse. Journal of Consulting and Clinical Psychology, 22, 365±374. Bergner, R., Delgado, L., & Graybill, D. (1994). Finkelhor's risk factor checklist: A cross validation study. Child Abuse and Neglect, 18, 331±340. Beutler, L. (1993). Designing outcome studies: Treatment of adult victims of sexual abuse. Journal of Interpersonal Violence, 8, 402±414. Beutler, L., & Hill, C. (1992). Process and outcome research in the treatment of adult victims of childhood sexual abuse: Methodological issues. Journal of Consulting and Clinical Psychology, 60, 204±212. Blanchard, E., Andrasik, F., Evans, D., Neff, D., Appelbsum, K., & Rodichok, L. (1985). Behavioral treatment of 250 chronic headache patients: A clinical replication series. Behavior Therapy, 16, 308±327. Bowlby, J. (1973). Attachment and loss: Vol 1. Attachment. New York: Basic Books. Briere, J. (1992). Methodological issues in the study of sexual abuse effects. Journal of Consulting and Clinical Psychology, 60, 196±203. Briggs, F., & Hawkins, R. (1995). Protecting boys from the risk of sexual abuse. Early Child Development and Care, 110, 19±32. Browne, A., & Finkelhor, D. (1986). The impact of child sexual abuse: A review of the research. Psychological Bulletin, 99, 66±77. Burnam, M., Stein, J., Golding, J., Seigel, J., Sorenson, S., Forsythe, A., & Telles, C. (1988). Sexual assault and mental disorders in a community population. Journal of Consulting and Clinical Psychology, 56, 843±850. Cappelleri, J., Eckenrode, J., & Powers, J. (1993). The

epidemiology of child abuse: Findings from the Second National Incidence and Prevalence Study of Child Abuse and Neglect. American Journal of Public Health, 83, 1622±1624. Cole, P., & Putnam, F. (1992). Effect of incest on self and social functioning: A developmental psychopathology perspective. Journal of Consulting and Clinical Psychology, 60, 174±184. Downs, W. (1993). Developmental considerations for the effects of childhood sexual abuse. Journal of Interpersonal Violence, 8, 331±345. Doyle, C. (1995). Helping strategies for child sexual abuse. London: Whiting & Birch. Enns, C., McNeilly, C., Corkery, J., & Gilbert, M. (1995). The debate about delayed memories of child sexual abuse: A feminist perspective. Counseling Psychologist, 23, 181±279. Feinauer, L., & Stuart, D. (1996). Blame and resilience in women sexually abused as children. American Journal of Family Therapy, 24, 31±40. Finkelhor, D. (1979). Sexually victimized children. New York: Free Press. Finkelhor, D. (1984). Child sexual abuse: New theory and research. New York: Free Press. Finkelhor, D. (1986). A source book on child sexual abuse: New theory and research. Beverly Hills, CA: Sage. Finkelhor, D. (1988). The trauma of child sexual abuse: Two models. In G. Wyatt & G. Powell (Eds.), The lasting effects of child sexual abuse. Newbury Park, CA: Sage. Finkelhor, D. (1990). Early and long-term effects of child sexual abuse: An update. Professional Psychology: Research and Practice, 21, 325±330. Finkelhor, D. (1994). The international epidemiology of child sexual abuse. Child Abuse and Neglect, 18, 409±417. Finkelhor, D., & Browne, A. (1985). The traumatic impact of child sexual abuse: A conceptualization. American Journal of Orthopsychiatry, 55, 530±541. Finkelhor, D., Hotaling, G., Lewis, A., & Smith, C. (1990). Sexual abuse in a national survey of adult men and women: Prevalence, characteristics, and risk factors. Child Abuse and Neglect, 14, 19±28. Freund, K., & Kuban, M. (1994). The basis of the abused abuser theory of pedophilia: A further elaboration on an earlier study. Archives of Sexual Behavior, 23, 553±563. Fromouth, M. (1986). The relationship of childhood sexual abuse with later psychological and sexual adjustment in a sample of college women. Child Abuse and Neglect, 10, 5±15. Gazan, M. (1986). An evaluation of a treatment package designed for women with a history of sexual victimization in childhood and sexual dysfunctions in adulthood. Canadian Journal of Community Mental Health, 5, 85±102. Gipson, M., Green, J., Telch, M., Watkins, P., Griffith, L., Agras, A., & Ballard, B. (1984). Safety with strangers: A manual for teachers. Fort Lauderdale, FL: Adam Walsh Center. Green, A. (1993). Child sexual abuse: Immediate and longterm effects and intervention. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 890±902. Haugaard, J., & Reppucci, N. (1988). The sexual abuse of children. San Francisco: Jossey-Bass. Hernandez, J. (1995). The concurrence of eating disorders with histories of child abuse among adolescents. Journal of Child Sexual Abuse, 4, 73±85. Hulme, P., & Grove, S. (1994). Symptoms of female survivors of child sexual abuse. Issues in Mental Health Nursing, 15, 519±532. Jehu, D. (1989). Mood disturbances among women clients sexually abused in childhood. Journal of Interpersonal Violence, 4, 164±184. Jumper, S. A. (1995). A meta-analysis of the relationship of

References child sexual abuse to adult psychological adjustment. Child Abuse and Neglect, 19, 715±728. Katz, R. (1990). Psychological adjustment in adolescent child molesters. Child Abuse and Neglect, 14, 567±575. Kendall-Tackett, K., Williams, L., & Finkelhor, D. (1993). Impact of sexual abuse on children: A review and synthesis of recent empirical findings. Psychological Bulletin, 113, 164±180. Knutson, J. (1995). Psychological characteristics of maltreated children: Putative risk factors and consequences. Annual Review of Psychology, 46, 401±431. Lawson, C. (1993). Mother±son sexual abuse: Rare or underreported? A critique of the research. Child Abuse and Neglect, 17, 261±269. Lebowitz, L., Harvey, M., & Herman, J. (1993). A stage by dimension model of recovery from sexual trauma. Journal of Interpersonal Violence, 8, 378±391. Lechner, M., Vogel, M., Garcia-Shelton, L., Leichter, J., & Steibel, K. (1993). Journal of Family Practice, 36, 633±638. Lisak, D. (1994). The psychological impact of sexual abuse: Content analysis of interviews with male survivors. Journal of Traumatic Stress, 7, 525±547. Lloyd, D. (1992). Ritual child abuse: Definitions and assumptions. Journal of Child Sexual Abuse, 1, 1±14. Loftus, E. (1993). The reality of repressed memories. American Psychologist, 48, 518±537. Maletzky, B. (1980). Self-referred versus court-referred sexually deviant patients: Success with assisted covert sensitization. Behavior Therapy, 11, 306±314. Mallinckrodt, B., McCreary, B., & Robertson, A. (1995). Co-occurrence of eating disorders and incest: The role of attachment, family environment, and social competencies. Journal of Counseling Psychology, 42, 178±186. Margolin, L. (1992). Sexual abuse by grandparents. Child Abuse and Neglect, 16, 735±741. McCarthy, B. (1986). A cognitive-behavioral approach to understanding and treating sexual trauma. Journal of Sex & Marital Therapy, 12, 322±329. McCarthy, B. (1990). Treating sexual dysfunction associated with prior sexual trauma. Journal of Sex and Marital Therapy, 16, 143±146. McCarthy, B. (1992). Sexual trauma: the pendulum has swung too far. Journal of Sex Education and Therapy, 18, 1±10. McMillen, C., Zuravin, S., & Rideout, G. (1995). Perceived benefit from child sexual abuse. Journal of Consulting and Clinical Psychology, 63, 1037±1043. McNew, J., & Abell, N. (1995). Post-traumatic stress symptomatology: Similarities and differences between Vietnam veterans and adult survivors of childhood sexual abuse. Social Work, 40, 115±126. McNulty, C., & Wardle, J. (1994). Adult disclosure of sexual abuse: A primary cause of psychological distress? Child Abuse & Neglect, 18, 549±555. Meiselman, K. (1994). Treating survivors of child sexual abuse: A strategy for reintegration. In J. Briere (Ed.), New directions in mental health services: Assessing and treating victims of violence (pp. 91±100). San Francisco: Jossey-Bass. Mennen, F. (1993). Evaluation of risk factors in childhood sexual abuse. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 934±939. Morin, C., Stone, J., McDonald, K., & Jones, S. (1994). Psychological management of insomnia: A clinical replication series with 100 patients. Behavior Therapy, 25, 291±310. Morrow, S., & Smith, M. (1995). Constructions of survival and coping by women who have survived childhood sexual abuse. Journal of Counseling Psychology, 42, 24±33. Newman, A., & Peterson, C. (1996). Anger of women incest survivors. Sex Roles, 34, 463±473. Pearson, Q. (1994). Treatment techniques for adult female

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survivors of childhood sexual abuse. Journal of Counseling & Development, 73, 32±37. Peterson, C., & Bossio, L. (1991). Health and optimism. New York: Free Press. Peterson, M. P. (1993). Physical and sexual abuse among school children: Prevalence and prevention. Educational Psychology Review, 5, 63±86. Polusny, M., & Follette, V. (1995). Long-term correlates of child sexual abuse: Theory and review of the empirical literature. Applied and Preventive Psychology, 4, 143±166. Ramona vs. Isabel, No. C61898 (Superior Court, Napa County, CA, 1994). Resnick, H., & Newton, T. (1992). Assessment and treatment of post-traumatic stress disorder in adult survivors of sexual assault. In D. Fox (Ed.), Treating PTSD: Cognitive behavioral strategies. New York: Guilford. Rowan, A., & Foy, D. (1993). Post-traumatic stress disorder in child sexual abuse survivors: A literature review. Journal of Traumatic Stress, 6, 3±20. Rowan, A., Foy, D., Rodriguez, N., & Ryan, S. (1994). Post-traumatic stress disorder in a clinical sample of adults sexually abused as children. Child Abuse and Neglect, 18, 51±61. Rudin, M., Zalewski, C., & Boomer-Turner, J. (1995). Characteristics of child sexual abuse victims according to perpetrator gender. Child Abuse and Neglect, 19, 963±973. Russell, A., & Trainor, C. (1984). Trends in child abuse and neglect: A national perspective. Denver, CO: The American Association. Russell, D. (1983). The incidence and prevalence of intrafamilial and extrafamilial sexual abuse of female children. Child Abuse and Neglect, 7, 133±146. Smucker, M., Dancu, C., Foa, E., & Niederee, J. (1995). Imagery rescripting: A new treatment for survivors of childhood sexual abuse from post traumatic stress. Journal of Cognitive Psychotherapy 9, 3±17. Sullivan, P., & Knutson, J. (1993). The relationship between child abuse and neglect and disabilities: Implications for research and practice. Presented at the National Conference on Child Abuse and Neglect, Pittsburgh, PA. Task Force on Promotion and Dissemination of Psychological Procedures (1995). Training and dissemination of empirically-validated treatments. The Clinical Psychologist, 48, 3±23. Urquiza, A., & Keating, L. (1990). The prevalence of sexual victimization in males. In M. Hunter (Ed.), The sexually abused male: Prevalence, impact, and treatment (Vol. 1, pp. 89±103). New York: Lexington. Valentine, L., & Feinauer, L. (1993). Resilience factors associated with female survivors of childhood sexual abuse. American Journal of Family Therapy, 21, 216±224. Vizard, E., Monck, E., & Misch, P. (1995). Child and adolescent sex abuse perpetrators: A review of the research literature. Journal of Child Psychology and Psychiatry, 36, 731±756. Walker, C., Bonner, B., & Kaufman, K. (1988). The physically and sexually abused child: Evaluation and treatment. New York: Pergamon. Walker, L. (1994). Abused women and survivor therapy: A practical guide for the psychotherapist. Washington, DC: American Psychological Association Press. Windle, M., Windle, R., Scheidt, D., & Miller, G. (1995). Physical and sexual abuse and associated mental disorders among alcoholic inpatients. American Journal of Psychiatry, 152, 1322±1328. Winett, R., King, A., & Altman, D. (1989). Health psychology and public health: An integrative approach. Elmsford, NY: Pergamon. Wurtele, S. (1987). School-based sexual abuse prevention programs: A review. Child Abuse and Neglect, 10, 85±92.

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Wurtele, S. (1990). Teaching personal safety skills to fouryear old children: A behavioral approach. Behavior Therapy, 21, 25±32. Wurtele, S., & Miller-Perrin, C. (1992). Preventing child sexual abuse: Sharing the responsibility. Lincoln, NE: University of Nebraska Press. Wurtele, S., Saslawsky, D., Miller, C., Marrs, S., & Britcher, J. (1986). Teaching personal safety skills for potential prevention of sexual abuse: A comparison of treatments. Journal of Consulting and Clinical Psychology, 54, 688±692.

Wyatt, G. (1985). The sexual abuse of Afro-American and White-American women in childhood. Child Abuse and Neglect, 9, 507±519. Wyatt, G., Guthrie, D., & Notgrass, C. (1992). Differential effects of women's child sexual abuse and subsequent sexual revictimization. Journal of Consulting and Clinical Psychology, 60, 167±173. Wynkoop, T., Capps, S., & Priest, B. (1995). Incidence and prevalence of child sexual abuse: A critical review of data collection procedures. Journal of Child Sexual Abuse, 4, 49±66.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

9.19 Adult Victims of Physical Violence RON ACIERNO, CHRISTINA BYRNE, HEIDI S. RESNICK, and DEAN G. KILPATRICK Medical University of South Carolina, Charleston, SC, USA 9.19.1 INTRODUCTION

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9.19.2 PREVALENCE

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9.19.2.1 Measurement Problems 9.19.2.2 Prevalence Rates 9.19.3 NATURE 9.19.3.1 9.19.3.2 9.19.3.3 9.19.3.4 9.19.3.5 9.19.3.6

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Domestic Violence Etiological Theory Trauma Sequelae: PTSD Trauma Sequelae: Depression Trauma Sequelae: Substance Abuse Trauma Sequelae: Panic

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9.19.4.1 Trauma Assessment 9.19.4.1.1 Trauma assessment: interviews 9.19.4.2 Post-trauma Assessment of PTSD: Interviews 9.19.4.3 Post-trauma Assessment of PTSD: Questionnaires 9.19.4.4 Post-trauma Assessment of Related Symptomatology: Interviews 9.19.4.5 Post-trauma Assessment of Related Symptomatology: Questionnaires

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9.19.5 TREATMENT

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9.19.5.1 PTSD

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9.19.6 FUTURE DIRECTIONS

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9.19.7 SUMMARY

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violent crime results in at least 2.2 million known injuries, requiring over 700 000 hospitalization days, with medical and lost productivity expenses in excess of $6 000 000 000 (Harlow, 1989). It is, therefore, not surprising that violence is considered both a social and public health emergency in the USA and other countries (Koop, 1992; Novello, 1992). Importantly, the overt economic and medical impact of violence is complemented by less visible, albeit equally significant psychological and emotional difficulties endured by victims,

9.19.1 INTRODUCTION Violence is an unavoidable facet of human experience. Virtually no one escapes at least vicarious exposure to severe interpersonal conflict, and over 10% of the population endures direct aggression in the form of simple, aggravated, or domestic assault at some point in their lives (Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993). Tangible effects of physical assault are far-reaching and devastating. The US Department of Justice reported that annual 307

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including extreme levels of anxiety, depression, substance abuse, and impaired interpersonal and vocational functioning (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Kilpatrick, Saunders, Veronen, Best, & Von, 1987; Resnick et al., 1993). 9.19.2 PREVALENCE 9.19.2.1 Measurement Problems Initial estimates of physical assault prevalence were based on indirect indicators of violence, such as police reports or hospital records. However, because most crime is not reported, both the relevance and validity of these data were severely limited (Kilpatrick et al., 1987; Kilpatrick, Resnick, Saunders, & Best, in press). The ongoing National Crime Victimization Survey (NCVS) (Bachman, 1994), a primary source of assault and victimization data for the US Bureau of Justice Statistics, and the Epidemiologic Catchment Area Survey (Helzer, Robins, & McEvoy, 1987), were two initial attempts to address these early assessment problems through use of interview, rather than archival data. Weaknesses in NCVS assessment methodology continue to exist, however, and NCVS assault prevalence estimates are low compared to those reported by epidemiological researchers in the social sciences. Disparity between past survey findings and those of contemporary social scientists results from differences in assessment techniques. Specifically, initial surveys employed legalistic terminology to define assault variables to the exclusion of behavioral descriptions of assault events. Consequently, reporting rates were greatly affected by both idiotypic interpretation of that which defined assault and psychological factors that impinged upon reporting. In response to these short-comings, criminal justice researchers directing the NCVS altered their survey techniques in 1992 and incorporated the relatively more sensitive assessment methodology utilized by social scientists (e.g., Kilpatrick, Resnick, Saunders, & Best, 1989). Specifically, the redesigned survey included behavioral descriptions of assault variables in the form of closed-ended questions. Expectedly, estimates of assault prevalence increased dramatically. 9.19.2.2 Prevalence Rates Prevalence rates of physical assault appear to vary by gender, race, and age. Across studies, physical assault is either the most common, or among the most common, forms of experienced trauma in the general population (Breslau, Davis, Andreski, & Petersen, 1991; Kessler

et al., 1995; Resnick et al., 1993). Investigating a nationally representative sample of 4009 women, Resnick et al. estimated that 9.9 million female Americans (10.28%) had experienced severe physical assault at some point in their lives. Consistent with these findings, Kessler et al. (1995) reported that 6.9% of the women and 11.9% of the men in their stratified random sample of 5877 participants had been physically assaulted. These are rates directionally similar to those reported by Norris (1992) for women (11.7%) and men (18.7%). Comparable rates of assault were found by Kilpatrick et al. (1987), who studied a random sample of 391 women and by Breslau et al. (1991), who assessed 1007 randomly sampled members of a large Health Maintenance Organization (HMO), with overall prevalence ranging from 9.7% to 15% of participants. Not surprisingly, rates of assault were lower in the NCVS survey, in which Bachman (1994) noted that approximately 3.8 million American women and 4.7 million American men reported being physically attacked. The 1992±1993 NCVS annual data revealed that men reported suffering violent crime at the hands of strangers at a rate 11 times that of known perpetrators, whereas women experienced assault primarily by known assailants. In terms of lifetime prevalences, men were equally likely to be attacked by known or unknown perpetrators, while women were far more frequently attacked by known individuals such as husbands or ex-husbands (31%), boyfriends (16%), other relatives (27%), and acquaintances (9%) (Kilpatrick et al., in press). Direct sex-based comparisons revealed that men were about twice as likely to be assaulted by strangers as women, and were more likely to be assaulted by multiple assailants (Bachman, 1994). Further, Kessler et al. (1995) noted that while men were more likely to experience trauma in general, women were more likely to experience severe trauma (e.g., rape). In addition to gender differences, Norris (1992) found that a significantly greater proportion of Caucasians experienced physical assault (18.4%) than non-Caucasians (11.6%), although the latter group appeared relatively more susceptible to post-traumatic psychopathology. Kessler et al. (1995) also noted comparable racial differences, irrespective of income level. Although no race-based differences were discovered by Breslau et al. (1991), these investigators reported that assault was associated with being male, having less than a college education, or having a history of early misconduct. Age and income differences have also been identified, with youth and poverty associated with increased risk of being assaulted. Norris

Nature (1992) reported assault prevalence rates of 16.8% in younger adults vs. 8.6% in older adults. Similarly, Kilpatrick et al. (in press) noted that 23.7% of their sample of women reported being assaulted before age 17, 46.8% experienced assault between ages 17 and 29, and only 26.8% reported that their first attack occurred after age 30. These investigators also found that individuals with annual incomes below $10 000 were at increased risk of victimization. In addition to age and income, experience of past assault was associated with future assault. Of those with a positive assault history, 30±54% had been victimized at least twice (Kilpatrick et al., 1987; Resnick et al., 1993; Steketee & Foa, 1987).

9.19.3 NATURE Psychological sequelae of trauma are often severe and debilitating. ªImportantly, several relevant aspects of victimization are strongly related to subsequent development and/or exacerbation of psychopathology. In determining factors that increase risk of negative outcome, it is useful to define potentially traumatic events along objective and subjective lines (Weaver & Clum, 1995). Objective parameters of assault include whether a weapon was used, duration and location of the attack, level of force imposed, resultant physical injury, and relationship of perpetrator to the victim. By contrast, subjective aspects of physical assault include perceptions of life threat or potential for injury, appraisal of responsibility and self-blame or guilt, and perceptions of controllability and attacker intentionality (Kilpatrick, Resnick, et al., 1989). Subjective factors appear to be relatively more important in determining post-trauma psychological distress than objective factors (Weaver & Clum, 1995). For example, Kilpatrick, Resnick et al. (1989) noted that perceived threat accounted for 6.4% of the unique variance in prediction of post-traumatic stress disorder (PTSD), whereas actual injury accounted for 4.9%. Indeed, risk of post-traumatic psychopathology is greatest in individuals who report that during the trauma they feared they would be seriously injured or die, or actually were injured (Green, 1990; Kilpatrick, Resnick et al., 1989; Resnick et al., 1993; Wirtz & Harrell, 1987a). Specifically, 30.8% of those assault victims who reported both perceived life threat and actual physical injury developed PTSD, compared to 20.6% with only life threat, and 25% with only injury (Kilpatrick, Resnick et al., 1989). Because perceived threat of serious injury and actual injury are both risk factors for

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post-traumatic psychopathology, it is important to identify which forms of trauma are associated with these events. Along these lines, Resnick et al. (1993) demonstrated that threat of injury or actual injury were most often observed in physical assault victims (90.8%), followed by rape victims (67.9%). Further, both perceived threat of injury and actual injury were reported by 61.1% of physical assault victims, compared to 36.7% of rape victims. These findings are hardly surprising when considering that the intention of most assailants during physical assault is to inflict pain and injury. In addition, these results are all the more impressive when trauma characteristics and outcomes of physical assault are compared to those of severe sexual assault. Resnick et al. (1993) found that women with a history of physical trauma were more likely to meet criteria for both life (38.5%) and current (17.8%) PTSD, than victims of all other trauma, including rape (for which lifetime and current rates of PTSD were 32% and 12.4%, respectively). Similarly, in cases of domestic violence, relatively larger proportions of victims of physical assault feared that they would be killed (100%) than victims of spousal rape (82%) (Riggs, Kilpatrick, & Resnick, 1992). Finally, in their meta-analysis of studies measuring psychological distress associated with interpersonal violence, Weaver and Clum (1995) found no difference between physical and sexual assault. Other factors that may be positively related to development of post-trauma psychopathology include: intensity of anxiety and distress during an attack, past history of psychopathology, past history of trauma, familial psychopathology, presence and intensity of dissociation during trauma, and low age, education, and socioeconomic status (Breslau et al. 1991; Freedy, Resnick, Kilpatrick, Dansky, & Tidwell, 1994; Norris, 1992). By contrast, stable sources of social support appear to buffer against development of post-traumatic problems in psychological functioning (Burgess & Holstrom, 1974; Wilson & Kraus, 1985).

9.19.3.1 Domestic Violence Since the late 1970s, the problem of relationship violence has been formally acknowledged as a major social problem. Survey data indicate that violence occurs in 20±30% of marriages in the USA (Straus & Gelles, 1990; Straus, Gelles, & Steinmetz, 1980) and that approximately 1.8 million women are physically abused by their partners each year (Straus & Gelles, 1986). Furthermore, nearly 1700 women die each year as a direct result of their partner's abuse

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(Steinmetz, 1978), and women are more likely to be victimized by current or former male partners than by other perpetrators (Koss et al., 1994).

9.19.3.2 Etiological Theory Psychological models proposed to explain the process by which assault and other forms of traumatic stress potentiate psychopathology include conditioning, cognitive, and social learning theories. An integration of these models appears best to account for post-traumatic symptom outcome. In such a comprehensive etiological model, post-traumatic fear, anxiety, and avoidance behaviors are presumed to be conditioned responses that may be modulated by cognitive styles and social context, and further influenced by individual characteristics such as age or intelligence. Kilpatrick, Veronen, and Resick (1979), and Keane, Zimering, and Caddell (1985) adapted Mowrer's (1960) twofactor model of phobic avoidance to posttraumatic psychological reactions, particularly PTSD. In this conceptualization, assault is the unconditioned stimulus that leads to the unconditioned responses of avoidance, hyperarousal, and intrusive ideation (i.e., the symptom constellation of PTSD). Initial responses might also include symptoms of depression and panic. These responses become associated with salient stimuli present in the environment during the attack (e.g., perpetrator race and build, location, time of day) that then serve to elicit conditioned fear responses in the future. Thus, when a victim is exposed to an individual of the same sex or race as the perpetrator, or, for example, finds herself walking to her car in the darkness, a conditioned response identical or very similar to the unconditioned response will occur. In order to reduce or eliminate extreme aversiveness of this learned anxiety response, individuals will seek to escape from conditioned stimuli. Because escape results in diminution of the fear response, avoidance behavior is negatively reinforced and the probability of its future occurrence is increased. Moreover, because repeated, extended exposure to conditioned stimuli is avoided, extinction of fear responses does not occur. Thus, according to two-factor theory, conditioned post-traumatic anxiety responses are initially acquired through classical conditioning and maintained (in the form of avoidance) through operant conditioning. Some indirect support for conditioning theory, particularly as it relates to avoidance behavior, has been provided by Wirtz and Harrell (1987a, 1987b). They demonstrated that victims who avoided fear stimuli (i.e., engaged in behavior that would, predictably, maintain

conditioned fear responses) experienced more psychological distress than those who exposed themselves to relevant fear-producing stimuli, irrespective of initial distress level. Moreover, success of exposure-based treatments for PTSD (e.g., Fairbank & Keane, 1982; Foa, HearstIkeda, & Perry, 1995; Foa, Rothbaum, Riggs, & Murdock, 1991) provides additional indirect support for the model. Refinement of the conditioning theory of post-traumatic psychopathology has included relatively greater consideration of cognitive factors and individual characteristics. Foa, Steketee, and Rothbaum (1989) provided a thorough discussion of this point and illustrated the major role cognitive components, such as perceptions of controllability over past and future events, and estimates of the risk of danger associated with specific stimuli, appear to play in determining intensity and duration of anxiety responses. Moreover, Keane (1985) highlighted the need to consider individual characteristics, such as family history of psychopathology, level of social support, and age, when assessing and treating post-traumatic symptomatology.

9.19.3.3 Trauma Sequelae: PTSD According to the Diagnostic and statistical manual of mental disorders (4th ed.; DSM-IV) (American Psychiatric Association, 1994), a diagnosis of PTSD is assigned only when an individual is exposed to a traumatic event that both presents actual or threatened death or serious injury to oneself or others, and elicits intense fear, helplessness, or horror. Obviously, physical assault sufficiently meets this criterion. Additional parameters of the PTSD diagnosis include symptoms of re-experiencing, avoidance, and hyperarousal that persist for at least one month and cause functional impairment in interpersonal or vocational spheres. Re-experiencing may take the form of recurrent recollections of the event, nightmares, flashbacks, or reactivity upon exposure to traumatic cues. Avoidance is typically manifest as behavioral or cognitive escape from thoughts, feelings, individuals, or places associated with the trauma, as well as the experience of feelings of detachment, foreshortened future, and restricted affect. Finally, hyperarousal is indicated by elevated startle response, sleep disturbances, hypervigilance, and concentration difficulties. Overall, population prevalence estimates of lifetime PTSD range from 7.8% to 12.3%, and prevalence estimates of past-year PTSD range from 2.3% to 4.2% (Breslau et al., 1991; Kessler et al., 1995; Resnick et al., 1993). Groups at increased risk for developing PTSD resemble

Nature those at greater risk of assault, including individuals low in social and economic resources (Freedy, Shaw, Jarrell, & Masters, 1992; Hobfoll, 1989; Kilpatrick et al., in press). Also at increased risk are non-Caucasians (Kulka et al., 1990), and those with familial or personal histories of psychopathology (Davidson, Smith, & Kudler, 1989). Moreover, PTSD is significantly more prevalent in women, who are 2±15 times more likely to develop the disorder in response to physical attack than men (21.3% of women vs. 1.8% of men develop PTSD after physical assault) (Kessler et al., 1995; Norris, 1992). PTSD prevalence rates increase with age for men, but not for women, indicating that women generally experience trauma and suffer its psychological after-effects earlier. Kessler et al. (1995) reported that the most common precipitants of PTSD in men are combat and witnessed violence, whereas for women sexual and physical assault/abuse are primary index events. Rates of PTSD in women following physical assault and abuse are comparable to those observed with rape. Indeed, Kilpatrick et al. (1987) noted that lifetime rates of postrape and postassault PTSD in women were 57.1% and 36.8%, respectively, while Resnick et al. (1993) found rates of postrape and postassault PTSD of 32% and 38.5%, respectively. Finally, Kessler et al. observed rates of postsexual and physical assault PTSD of 48.0% and 39.1%, respectively. Data regarding the course of PTSD have been presented for rape victims but not for victims of physical assault. However, given the comparability of outcomes related to physical and sexual assault, it is reasonable to assume that similar proportions of seriously physically assaulted victims will suffer from the disorder over time. Rothbaum, Foa, Riggs, Murdock, and Walsh (1992) found that 90% of rape victims met symptom criteria for PTSD within two weeks of rape, and about 50% continued to meet criteria three months later. Moreover, Kilpatrick et al. (1987) showed that the disorder was present 17 years after assault in 16.5% of cases. Overall, about 50% of those who do meet criteria for PTSD recover within two years, while almost 33% do not experience full remission of symptoms, even after several years (Kessler et al., 1995).

9.19.3.4 Trauma Sequelae: Depression Although often considered secondary to PTSD, depression is frequently observed in crime victims (Breslau et al., 1991; Kilpatrick et al., 1985). The co-occurrence of depression and anxiety following trauma is well documen-

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ted, and significant overlap exists between PTSD and the diagnostic criteria for depression (Breslau et al., 1991; Davidson, Hughs, Blazer, & George, 1991; Helzer et al., 1987; Uddo, Allain, & Sutker, 1996). Breslau et al. found that 36.6% of those diagnosed with PTSD concurrently met criteria for major depression. Similarly, Kessler et al. (1995) reported that 47.9% of men and 48.5% of women with PTSD in their sample also suffered from major depression. These rates reflect estimates of comordity following any type of trauma, including, but not limited to physical assault. Relatively few studies have investigated the relationship between depression and physical assault in isolation. However, data indicate that severity of depression produced by physical assault approximates that produced by rape. Riggs et al. (1992) compared SCL-90-R depression subscale scores of victims of domestic violence and nondomestic violence with nonvictimized women. Women raped or assaulted by their husbands had SCL-90-R depression scores of 0.66 and 0.61, respectively, while women raped or assaulted by strangers had scores of 0.72 and 0.87, respectively. By contrast, nonvictimized women scored 0.47 on the depression subscale. The National Womens Study (NWS; Kilpatrick, Edmunds, & Seymoor, 1992) also examined effects of physical assault on affect. The NWS was a three-wave longitudinal research project in which a national household probability sample of adult women (N = 4009) was interviewed using random digit dialing methodology. Of these women, 3006 also completed Wave III interviews two years later. Interview content included queries about lifetime and recent victimization, post-traumatic stress disorder, depression, and substance use. Variables relevant to physical violence included lifetime and recent (past two years) physical assault, lifetime and recent (past month) depression, and lifetime and recent (past year) substance use/ abuse. The following analyses involving depression and assault were conducted: lifetime depression predicted by lifetime physical assault status, current depression predicted by lifetime physical assault status, and current depression predicted by recent assault status. Women with life histories of physical assault were 3.31 times as likely to demonstrate life histories of depression. Similarly, past occurrence of assault increased odds of current depression by a factor of 2.9. Most importantly, recently assaulted women were 5.5 times as likely to present with depression as women who were not recently assaulted, with 12.6% of assaulted vs. 2.6% of nonassaulted women meeting criteria for active depression.

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9.19.3.5 Trauma Sequelae: Substance Abuse Recent investigations also reveal high comorbidity between assault-related PTSD and substance use disorders. Breslau et al. (1991) demonstrated that approximately 45% of participants with PTSD also met criteria for substance use or abuse, with 31% meeting criteria for alcohol abuse or dependence. Kessler et al. (1995) found that 35% of men and 27% of women in their sample diagnosed with PTSD experienced drug abuse or dependence, and over 50% of men and 28% of women with PTSD reported concurrent alcohol abuse or dependence. Following a violent assault, victims may increase substance use to cope with resultant symptoms of PTSD and depression. According to this conceptualization, extremely high levels of negative affect produced by assault cause individuals to engage in behaviors that rapidly reduce negative emotions (Beckham et al., 1995), such as situational escape and ingestion of alcohol or drugs. Objective support for this model of postassault drug and alcohol use has been provided by Levenson, Oyama, and Meek (1987), who demonstrated that alcohol ingestion successfully reduced both psychophysiological and subjective indices of negative affect during stress tasks in individuals at particular dispositional and familial risk of alcoholism. Despite theory-based evidence that victimization facilitates substance abuse, directionality of the assault/substance abuse relationship remains unclear. Several investigators (Breslau et al., 1991; Cottler, Compton, Mager, Spitznagel, & Janca, 1992; Scribner, Mackinnon, & Dwyer, 1995) have reported an increased risk of trauma given a proximate association with substance abuse. Indeed, victims use substances at significantly elevated rates relative to nonvictims and this substance use appears to facilitate additional violence (Cottler et al., 1992; Kulka et al., 1990). For example, Buss et al. (1995) determined, on the basis of selfreport and toxicology screens, that 69.7% of seriously assaulted individuals seeking hospital treatment were under the influence of drugs or alcohol at the time of their attack, and 60% reported that their attackers were drinking or were on drugs. Data illustrating origins of the substance abuse/assault cycle remain sparse and are derived primarily from long-term retrospective reports. However, prospective data from the NWS demonstrated that rape and physical assault may lead to substance use and abuse in previously nonusing women (Kilpatrick, Acierno, Resnick, Saunders, & Best, 1997). That is, likelihood of progression to substance use/ abuse following assault in previously nonusing

women was double that of nonassaulted women. Thus, the position that substance use follows physical and sexual assault (in addition to preceding victimization) is strengthened. As is evident from the above reviewed studies, relatively more specific information is available on risk of substance use following sexual assault than physical assault. The NWS (Kilpatrick et al., 1992) data indicated that, compared to noncrime victims, victims of rape were 13.4 times as likely to have two or more major alcohol-related problems and 26 times more likely to have two or more serious problems related to drug abuse. In addition, rape victims were 3.4 times as likely to use marijuana, 6 times more likely to have used cocaine, and 10.1 times as likely to use hard drugs other than cocaine. Given similarities in outcome between sexual and physical victimization outlined above, analogous findings would be expected in victims of physical assault. Data from the NWS demonstrate that this is precisely the case. Specifically, logistic regression was employed to estimate associated risk of use and abuse of substances following lifetime and recent physical assault. Odds ratios and prevalence rates are given in Table 1. As was the case with rape, physical assault greatly increased the risk of using all substances. Specifically, likelihood of active cigarette use was doubled and risks of active alcohol abuse and drug use were more than tripled in women who had been assaulted in the previous two years. Increased risk was also observed when considering lifetime history of physical assault.

9.19.3.6 Trauma Sequelae: Panic In addition to PTSD, depression, and substance use, assault appears to facilitate panic in some women. This is not surprising when one considers that the symptom overlap between PTSD and panic is great, and includes palpitations, chest pain, dizziness, shortness of breath, nausea, derealization, sweating, trembling, and numbness (Falsetti, Resnick, Dansky, Lydiard, & Kilpatrick, 1995). The etiological role of stressful events (e.g., trauma) in the development of panic is consistent with the two-factor theory of PTSD and depression outlined above. As applied to panic, initial anxiety attacks are conceptualized as appropriate and logical responses to a life-threatening situation. These responses then become associated with salient stimuli that serve to trigger additional panic in the future (Barlow, 1988). Some empirical evidence for this relationship has been provided by Falsetti et al. who reported that 94.4% of 391 women meeting criteria for panic disorder had

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Assessment Table 1

Odds ratios and prevalence rates of lifetime and current substance abuse, predicted by lifetime and current assault status.a

Predicted variable Lifetime cigarette use Lifetime alcohol abuse Lifetime marijuana use Lifetime hard drug use Current cigarette use Current alcohol abuse Current marijuana use Current hard drug use Current cigarette use Current alcohol abuse Current marijuana use Current hard drug use a

Predictor variable

Rate if positive for Rate if negative for predictor variable predictor variable (%) (%) Odds ratios and CIs

Lifetime assault Lifetime assault Lifetime assault Lifetime assault Lifetime assault Lifetime assault Lifetime assault Lifetime assault Recent assault Recent assault Recent assault Recent assault

51.8 28.3 44.3 15.1 30.2 12.7 14.3 4.3 37.0 15.1 17.6 2.5

41.7 13.9 20.0 5.1 18.9 5.8 4.9 0.9 19.0 2.8 4.0 0.8

1.5 2.4 3.2 3.3 1.9 2.4 3.3 4.8 2.4 6.2 5.1 3.1

(1.2±1.8) (1.9±3.0) (2.6±3.9) (2.5±4.5) (1.5±2.3) (1.7±3.2) (2.4±4.4) (2.7±8.4) (1.6±3.5) (3.7±10.7) (3.1±8.4) (0.9±10.3)

Lower-limit confidence intervals greater than 1 indicate significance at p50.05.

positive victimization histories. In addition, Kessler et al. (1995) reported that odds of lifetime comorbid panic disorder in female respondents with PTSD were increased by a factor of three, with 12.6% of PTSD women also meeting criteria for panic, compared to 4.3% of non-PTSD women. Relatedly, Falsetti and Resnick (1997) noted that 68.9% of a clinical sample of 62 participants seeking treatment for trauma-related problems experienced four or more symptoms of panic attacks, and 67.6% of those diagnosed with PTSD reported suffering from panic. Breslau and Davis (1987) have also demonstrated associations between stressor events and panic. Stress-related panic is particularly prevalent in instances where trauma is life-threatening, extremely uncontrollable, and results in significant reductions in self-esteem (Roy-Byrne, Geraci, & Uhde, 1986). Although physical assault meets these criteria, no data are currently available describing the specific relationship between physical violence and panic.

terminology rather than behavioral description of events to determine assault status. In addition, these studies imposed unidimensional structure on inherently multidimensional constructs, with relatively little consideration given to interaction effects of multiple vs. isolated traumatic events, occurring across the lifespan vs. only in adulthood, and committed by known vs. unknown (or multiple vs. single, or peer vs. nonpeer) perpetrators (Kilpatrick et al., in press). Fortunately, advances in measurement of both trauma and post-traumatic psychopathology have been made. As Resnick, Falsetti, Kilpatrick, and Freedy (1996) noted, commonalities of sensitive, reliable, and valid trauma event assessment include: (i) appropriate prefacing statements, (ii) use of behaviorally specific queries, (iii) questions and analyses that consider multiple trauma parameters and relate multiple traumatic events to symptoms, and (iv) queries about qualitative/subjective aspects of trauma.

9.19.4 ASSESSMENT

9.19.4.1 Trauma Assessment

Two distinct areas of measurement are relevant to the study of interpersonal violence: first, assessment of the trauma itself, and second, assessment of post-traumatic psychological functioning. Of course, accurate assessment of the latter presupposes adequate assessment of the former. Examination of studies of interpersonal violence reveals, however, that such methodological adequacy is not always achieved. Early investigations employed flawed strategies to measure rates of physical and sexual assault, such as the use of legal

Traumatic events are, by definition, associated with extremely aversive cognitions and affective states. Therefore it is important, both experimentally and ethically, to create an environment in which self-disclosure is met with acceptance, empathy, knowledge, and encouragement. Clearly, victims must feel that their participation in assessment interviews for clinical or research purposes will be worth their effort and discomfort if they are to engage in frank and open discussion of exceedingly personal and often humiliating material. Simply

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asking an individual if he or she has ever been raped or physically assaulted in the absence of appropriate preface statements does little to convey concern for respondents' well-being, or remove psychological defenses employed to protectively minimize personal relevance or recall of the assault. Rather, a preface statement should provide a simple context within which interviewees can comfortably respond. Resnick et al. (1996) suggested brief prefacing statements that demonstrate concern on the part of interviewers and understanding of the nonrare nature of DSM-IV PTSD Criterion A traumatic events. The second aspect of sensitive and accurate trauma assessment is perhaps the most important. Use of behaviorally specific closed-ended questions increases likelihood that traumatic events will be both reported and operationally definable. This is because behavior-based queries are relatively less affected by cultural and individual differences of respondents. In addition, it may also be less aversive for some victims to answer yes or no to questions about particular behavioral events than to generate descriptive information about their assault. As such, sources of error produced by personal definitions of assault or rape or abuse, or respondent inability or hesitancy to disclose information relating to victimization, are minimized. The third factor in comprehensive trauma assessment involves measurement of multiple events in context, rather than single events in isolation. Psychological responses and treatment needs of individuals who have been previously assaulted may differ significantly from those who have not experienced such victimization. This point is particularly relevant when considering that approximately 50% of physically and sexually assaulted individuals have prior victimization histories (e.g., Kilpatrick, 1990). Therefore, behaviorally specific close ended questions and postassessment case conceptualization should address childhood physical and sexual assault status; adult physical and sexual assault status; relationship of victim to perpetrator during all assaults; and frequency, intensity, and type of assaults across the lifespan. In addition to assault parameters, it is also essential to assess other contextual factors that influence post-traumatic outcome, including familial and personal history of psychopathology, social and vocational adjustment, and level of social support. The powerful effects exerted by several qualitative aspects of trauma on post-assault psychological functioning also argue for their inclusion in any comprehensive trauma assessment. Subjective aspects of assault that have proven particularly predictive of post-traumatic

outcome include degree of perceived life threat, level of incurred injury, intensity of distress during attack, perceived level of force employed by perpetrator, and level of dissociation experienced. Inclusion of these factors in assessment reduces heterogeneity within broad assault typologies and increases the precision with which intervention techniques can be employed. For example, repeated assault with a handgun by a spouse (objective trauma characteristics) involving high perceived force, high perceived life threat, and intense distress (qualitative or subjective trauma characteristics) expectedly produces different results and requires different treatment components than (objectively) identical assault in which perceived force, life threat, and distress are relatively low. A final, controversial area of trauma assessment that may prove extremely informative to researchers, clinicians, and diagnosticians alike is victim behavior related to risk of assault. While no individual is responsible for being attacked by another person, several specific behaviors, such as substance use and abuse, have been shown to increase likelihood of victimization (e.g., Kessler et al., 1995; Kilpatrick et al, 1997). It is not clear whether victims' perceptions of responsibility are associated with relatively improved or impaired functioning; however, arguments can be made for both outcomes. That is, individuals who think that their behavior contributed to their victimization may feel empowered to change, or to exert relatively greater control over their environment. By contrast, victims might instead experience intense guilt and selfflagellation for allowing themselves to enter into risky situations. Assessment of assault-related traumatic events is currently achieved, with varying degrees of success, through standardized questionnaires and structured clinical interviews. As Resnick et al. (1996) noted, inquiries that produce dichotomous data regarding event occurrence/nonoccurrence should be complemented by questions that generate qualitative data regarding event characteristics. In this manner, multivariate relationships between trauma factors can be assessed and targeted by interventions. The next subsection of the chapter is devoted to brief description of some well-known trauma assessment measures that yield both dichotomous and qualitative information, and have at least limited empirical evaluation; later subsections are devoted to assessment of post-traumatic psychopathology. 9.19.4.1.1 Trauma assessment: interviews The PTSD module of the Structured Clinical Interview for DSM-III-R (SCID-R) and the

Assessment newer version for DSM-IV (SCID-IV) contains a very brief preface describing possible PTSD Criterion A events, followed by a short trauma priming list. No behavioral definitions of assault are provided, and respondents are required to generate descriptions of any experienced trauma that are not on the list. Although the interviewer documents all traumatic events, only the subjectively defined ªworstº trauma is considered in the diagnostic section. No attempt is made formally to identify or evaluate subjective aspects of trauma that relate to outcome, such as perceived risk of severe injury or death. Similarly, no specific prompts are provided to elicit relevant objective event characteristics, such as number of assailants, duration of assault, or presence of a weapon. Overall, lack of behaviorally defined closeended assault questions; weaknesses of the preface statement, event documentation, and prompting; and the extent to which objective and subjective parameters of assault are overlooked lessen the likelihood that SCID-based assessments of assault trauma will be of sufficient sensitivity to detect all instances of interpersonal aggression. The Diagnostic Interview Schedule-III-Revised (DIS-III-R, Robins, Helzer, Cottler, & Goldring, 1988) is a structured clinical interview similar in emphasis and format to the SCID. Specifically, a brief preface statement is followed by a listing of traumatic events intended to prime respondents to describe their own trauma history. As with the SCID, no behavioral descriptions of assault events are provided. In addition to the index question, respondents are prompted to report up to two additional ªterribleº or ªshockingº experiences they have had. In contrast to the SCID, the DISR qualitatively assesses whether injury resulted in response to the traumatic event, but does not specifically measure other objective or subjective aspects of assault. Both the SCID and the DIS-R emphasize assessment of PTSD symptomatology over that of trauma per se. While achieving acceptable diagnostic reliability, both interviews fail to employ sufficiently sensitive or valid techniques to measure trauma. This is somewhat ironic and distressing in that no diagnosis of PTSD is possible without preliminary positive identification of a traumatic event. Hence, in a diagnostic sense, these interviews put the cart before the horse. This is particularly problematic when considering that the overwhelming majority of treatment outcome and epidemiological studies, in addition to hundreds of clinic practices, employ these structured interviews to assess psychopathology. An effective solution to this sensitivity problem involves pairing these

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symptom-focused interviews with a traumafocused assessment instrument. Such a hybrid has been developed by Kilpatrick et al. (1989) for the NWS. The NWS Event History-PTSD Module represents the synthesis of several trauma assessment devices refined through years of epidemiological research on physical and sexual assault by the National Crime Victims Research and Treatment Center at the Medical University of South Carolina. This interview comprehensively assesses lifetime occurrence of civilian crime, and includes a preface statement that provides contextual orientation to the trauma victim, along with accurate information regarding criterion A event prevalence. Moreover, the preface statement details the interviewer's interest in any assault event, not just those perpetrated by strangers or reported to police or individuals in a position of authority. In addition to physical assault, the NWS Event History PTSD Module assesses other typically stressful life events (e.g., automobile accidents, natural disasters). Past-year occurrence of common life stressors (e.g., marital discord, financial difficulty) are addressed in another section of the interview. Sensitivity is further enhanced and popular stereotypical definitions of trauma terminology avoided through use of behaviorally specific closedended questions about physical and sexual assault. Both objective and subjective traumarelated data are obtained, including number of lifetime interpersonal violence episodes, age at first incident of each trauma type, relationship to perpetrator, personal and perpetrator use of substances preceding attack, most serious incident of each trauma type, and perceptions of imminent injury or death from the attack. Although all victimization events are addressed, qualitative information about physical assault history is gathered for only one event (as opposed to rape, for which information is gathered in response to the first, most recent, and ªworstº victimization). Further, the measure is geared toward severe assault and may produce overly conservative estimates of some forms of domestic violence. Convergent validity of the instrument has been established, with estimated rates of sexual and physical assault approximating those of other studies (e.g., Norris, 1992).

9.19.4.2 Post-trauma Assessment of PTSD: Interviews The intended focus of the SCID and the DISR is on symptom rather than trauma assessment. Not surprisingly, therefore, stability of

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diagnostic conclusions based on these instruments is quite high. The SCID-IV PTSD module provides specific prompts and follow-up inquiries, intended to be read verbatim to respondents, to assess presence or absence of each DSM-IV PTSD symptom. Symptom presence is rated on a three-point confidence scale based on the interviewer's interpretation of the victim's responses to prompts. Respondents are asked to frame symptoms in terms of their ªworstº trauma experience. As with other modules of the SCID, diagnostic cutoff criteria are readily available on scoring forms, along with decision trees and skip-out instructions. Although specific instructions for probe questions and guidelines for response interpretation are provided, the instrument is intended for use by clinicians and highly trained interviewers. While psychometric qualities of the SCID PTSD diagnosis following physical assault have not been investigated, reliability and validity of the PTSD diagnosis in general has been established. Kappas for SCID PTSD range from 0.68 to 0.93 (Kulka et al., 1990; Skre, Onstad, Torgersen, & Kringlen, 1991). In addition, Kulka et al. demonstrated convergent validity with the IES (Horowitz, Wilner, & Alvarez, 1979) and the Mississippi Scale (Keane, Caddell, & Taylor, 1988). In contrast to the SCID-IV, the DIS-R was specifically designed for use by nonprofessional interviewers. The DIS-R also differs from the SCID in that it allows the PTSD diagnosis to be made with reference to three specific Criterion A events, whereas the SCID considers only the ªworstº event. Diagnosis is assigned on the basis of responses to specific questions relating to each DSM-III-R defined PTSD symptom. No behavioral anchors are provided to establish interrespondent consistency of symptom severity. Psychometric properties of the DIS PTSD diagnosis are mixed. Initial sensitivity and specificity ratings were quite good (0.87 and 0.73, respectively), as was overall kappa agreement with criterion diagnosis (0.64). However, with a large-scale community sample, sensitivity of the instrument was unacceptably low (0.22) as was diagnostic agreement (kappa = 0.26) (Kulka et al., 1990). Low DIS sensitivity may be a function of its weak trauma screen. For this reason, Resnick et al. (1996) recommended that both the SCID and the DIS PTSD modules be preceded by a sensitive, behaviorally specific trauma screen. In contrast to the broad-band focuses of the SCID and the DIS, the Clinician Administered PTSD Scale-1 (CAPS-1, Blake et al., 1990) was specifically designed to yield both continuous (i.e., severity) and dichotomous (i.e., diagnostic) information exclusively for PTSD. The CAPS-1

is intended for use by professionals and trained paraprofessionals, and addresses the 17 symptoms of PTSD that comprise the DSM-IV diagnosis. Thirteen additional questions target associated symptoms not part of the formal PTSD diagnosis, as well as functional impact of symptoms on social and vocational spheres. Separate ratings of frequency and intensity of each symptom are made on five-point (0 to 4) scales that employ specific behavioral reference anchors to maximize standardization and consistency of interviews. Both past-month and lifetime presence of the disorder are measured. The CAPS-1 has excellent psychometric properties. Blake et al. (1990) reported that test±retest diagnostic reliability ranged from 0.90 to 0.98, and internal consistency was 0.94. Using the SCID as criterion reference, the CAPS-1 achieved acceptable sensitivity (0.84), high specificity (0.95), and good agreement (kappa = 0.78) (Blake et al., 1990). Convergent validity was also demonstrated by a strong correlation between the CAPS-1 total severity score and scores on the Mississippi Scale for combat related PTSD (r = 0.91), and the MMPI PK scale (r = 0.77). Importantly, the CAPS-1 does not address Criterion A trauma events, and must be accompanied by a trauma screen.

9.19.4.3 Post-trauma Assessment of PTSD: Questionnaires In addition to structured clinical interviews, several PTSD rating scales enjoy widespread use. Among the most frequently employed are the PTSD Symptom Scale Self-report version (PSS-SR, Foa, Riggs, Dancu, & Rothbaum, 1993), the Impact of Event Scale (IES, Horowitz et al., 1979), and the Trauma Symptom Inventory (TSI, Briere, 1995). The PSS-SR is the self-report version of Foa's structured interview for PTSD by the same name. The 17 items on this scale are identical in content to the interview, but contain simplified wording, and directly correspond to DSM-IV symptoms. As such, this self-report scale permits diagnosis of the disorder. Diagnoses based on the PSS-SR are slightly more conservative than those based on its interview counterpart, the PSS-I. In contrast to the SCID and the DIS, the PSSSR is intended for use with individuals who have a known assault history, and should thus be accompanied by a trauma screen when assessing individuals for whom basic background information is lacking. For all items, symptom frequency over the preceding two weeks is reported on a four-point scale. A total score is obtained by summing each symptom rating. Subscale scores are calculated by summing

Assessment symptoms in the re-experiencing (four items), avoidance (seven items), and arousal (six items) clusters. Foa et al. (1993) evaluated the psychometric properties of the PSS-SR with subsets of 46 female recent rape victims and 72 female recent nonsexual assault victims. They obtained a total score alpha of 0.91 and subscale alphas (for re-experiencing, avoidance, and arousal) ranging from 0.78 to 0.82. In addition, one-month test±retest reliability for the total score was 0.74, while test±retest reliability for subscales ranged from 0.56 to 0.71. Convergent validity of the PSS-SR, with the IES and StateTrait Anxiety Inventory (Spielberger, Gorsuch, & Lusbene, 1970) was also demonstrated, with correlations ranging from 0.52 to 0.81. Moreover, using the SCID as the criterion reference, PSS-SR diagnostic sensitivity was 62%, specificity was 100%, positive predictive power equaled 100%, negative predictive power was 82%, and the total hit rate was 86%. Overall, the PSS-SR is an easily administered, psychometrically sound measure of PTSD symptom severity and diagnostic status, and is thus an appropriate tool for both clinical and empirical endeavors. The IES (Horowitz et al., 1979) has a longer history of use than the PSS-SR, but provides relatively less diagnostic specification. The IES is a 15 item self-report measure constructed to assesses intrusion and avoidance symptoms of PTSD experienced over the past week. Symptoms are phrased in the first person and respondents rate their frequency on a fourpoint scale. The scale focuses on cognitive PTSD symptomatology (as opposed to somatic arousal), and is an excellent indicator of subjective distress. Moreover, the IES is sensitive to effects of treatment (Kilpatrick & Amick, 1985). Although the IES does not permit diagnosis of PTSD along DMS-IV-defined criteria, severity cutoff scores have been used to predict diagnostic status. Psychometric evaluation of the scale's reliability by Horowitz et al. produced alphas of 0.78 for the intrusion subscale and 0.80 for the avoidance subscale. Split-half reliability of the total scale was 0.86, and one-week test±retest reliability equaled 0.87. A somewhat more comprehensive scale than the IES, the TSI (Briere, 1995) is an expanded version of the Trauma Symptom Checklist (Briere & Runtz, 1989). In addition to core symptoms of PTSD, this 100-item questionnaire taps areas of impaired functioning that are not subsumed under the DSM-IV definition of PTSD, but are nonetheless related to victimization. Specifically, the TSI is divided into 10 subscales assessing anxious arousal, depression, anger/irritability, intrusive experience, defensive avoidance, dissociation, sexual concerns, dys-

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functional sexual behavior, impaired self-reference, tension-reduction behavior. Symptoms are listed in brief descriptive phrases. Respondents rate the level at which they experienced each symptom over the previous six months on a fourpoint scale. The TSI total score can be used as an index of overall PTSD severity, and total scores in each subscale can be employed to illustrate focal severity of symptoms. The scale also contains 12 ªcritical itemsº that serve as flags for particularly severe psychopathology. Psychometric properties of the TSI have been determined with both clinical and general community samples. In nonclinical samples, reliability for the 10 clinical scales was quite high (average alpha = 0.85) and the hit rate for PTSD diagnostic status was 91% (Briere, 1995). Similar levels of reliability among the 10 scales were observed in clinical samples (alpha range across scales: 0.74 to 0.90) (Briere, Elliott, Harris, & Cotman, 1995). Construct validity of the TSI was evident from higher scores for individuals with positive victimization histories, even when controlling for demographic factors. The instrument also includes three validity scales (atypical response, response level, and inconsistent response), for which clinical psychometric data are not currently available. In light of its ease of administration and completion, and its excellent psychometric properties, the TSI is an appropriate tool for clinical and empirical realms.

9.19.4.4 Post-trauma Assessment of Related Symptomatology: Interviews Depression, substance abuse, and panic should also be assessed in crime victims. However, these diagnoses are typically considered secondary to PTSD in traumatized individuals, and relatively less coverage of measurement indices is offered here. It is useful, in both an assessment and treatment sense, to frame additional psychopathology in recipients of assault in the context of the traumatic event. For example, if assessment reveals that a victim abuses alcohol in order to reduce intrusive ideation, then standard substance abuse treatment must be complemented by strategies to develop alternative coping techniques. In this example, a diagnosis of alcohol abuse provides only limited information for treatment planning. By contrast, placing substance use in context greatly increases the treatment utility (McKnight, Nelson, Hayes, & Jarrett, 1984) of assessment. Similarly, if a woman's depression is related to cessation of all interpersonal activity after dusk because darkness has been associated with strong negative affect, strategies to increase

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evening activity should be accompanied by techniques to extinguish the anxiety response. In addition to PTSD, the SCID-IV contains modules to assess major depressive disorder, dysthymia, substance use disorders, and panic disorder. The structure of SCID modules for these diagnoses is identical to that for PTSD. As with PTSD, diagnostic questions parallel DSMIV classification criteria, and each criterion set of symptoms for each disorder is rated on a threepoint confidence scale from ªabsentº to ªpresent.º Both recent and lifetime occurrence of disorders are assessed; however, data are exclusively dichotomous. Although psychometric properties of the SCID-IV will be forthcoming, reliability and validity ratings of the previous version (SCID-III-R) have been reported by several investigators. For major depression, reliability kappas range from 0.69 to 0.93 (Riskind, Beck, Berchick, Brown, & Steer, 1987; Skre et al, 1991; Williams et al., 1992). For alcohol abuse or dependence, reliability ratings ranged from 0.75 to 0.96, and for substances other than alcohol, reliability ratings ranged from 0.73 to 0.89 (Malow, West, Williams, & Sutker, 1989; Skre et al., 1991; Williams et al., 1992). Finally, for panic disorder, reliability ratings ranged from 0.58 to 0.88 (Skre et al., 1991; Williams et al., 1992). Validity of SCID-III-R diagnoses is evident from their frequent role as criterion reference in demonstrations of convergent validity with newly developed instruments. The Addiction Severity Index (ASI, McLellan, Parikh, & Bragg, 1990) is a standardized clinical interview with an embedded rating scale that provides a continuous measure of the functional impact of substance use. In addition to providing data regarding substance use in the previous 30 days, the ASI illustrates functional impact and use severity in seven specific areas, comprising drug use, alcohol use, family-social functioning, medical functioning, psychological functioning, employment, and legal involvement. Concurrent and interrater reliabilities are impressive (0.74±0.93) and validity is acceptable (Kosten, Rounsaville, & Kleber, 1983; McLellan, Luborsky, & Woody, 1983).

Mock, & Erbaugh, 1961). Each of the 21 items on this scale contains four statements reflecting current manifestations of depression in increasing intensity, from neutral to severe. Scoring of items is on a 0±3 scale and total scores range from 0 to 63, with higher scores indicating greater depressive severity. Of the 21 items on the scale, 13 assess depressive symptoms that are primarily psychological in nature, while eight measure symptoms that are somatically oriented. Beck and Steer (1984) and Gallagher, Nies, and Thompson (1982) demonstrated that the BDI has high internal consistency (a = 0.86 and a = 0.91, respectively). Moreover, Olin, Schneider, Eaton, Zemansky, and Pollack (1992) found excellent concurrent validity between the BDI and the GDS (r=91). There are no standardized measures to assess panic. However, panic diaries, in which ratings of symptom type, frequency, and intensity are recorded daily and summed weekly or biweekly, are standard dependent measures in panic disorder research. These may be effectively complemented by the Beck Anxiety Inventory (BAI; Beck & Steer, 1991) to provide both standardized and descriptive information about somatic responses in crime victims. The BAI is a 21-item self-rating scale of anxiety symptomatology. Patients are asked to rate on a four-point scale the degree to which specific symptoms. Specific symptom clusters have been identified by Beck and Steer (1991) reflecting neurophysiological, subjective (cognitive), panic, and autonomic dimensions. Beck and Steer (1991), Fydrich, Dowdall, and Chambless (1992) and Steer, Ranieri, Beck, and Clark (1993) demonstrated the instrument's concurrent validity with the Hamilton Anxiety Rating Scale. Internal consistency of the BAI has been illustrated by Steer et al. (1993) and Fydrich et al. (1992).

9.19.4.5 Post-trauma Assessment of Related Symptomatology: Questionnaires

9.19.5.1 PTSD

Dichotomous measurements of post-traumatic psychological sequelae should be complemented by continuous data to determine symptom severity and describe diagnostic subtypes. The most widely used measure of depressive severity is the Beck Depression Inventory (BDI). (Beck, Ward, Mendelson,

9.19.5 TREATMENT Comprehensive description of treatments available for all postassault psychopathology is beyond the scope of this chapter. However, existing empirically validated treatments for PTSD will be reviewed below.

Exposure to fear-producing cues in a relatively safe environment is a central component of all effective treatments for PTSD (Keane, Gerardi, Quinn, & Litz, 1992). Techniques used in addition to exposure, such as muscle relaxation, serve a primarily palliative function in that they prevent anxiety from exceeding tolerable levels during exposure exercises.

Treatment Veronen and Kilpatrick (1983) and Foa et al. (1991) evaluated one of the earliest successful psychological treatments for PTSD in assault victims. This treatment is well tolerated and has received strong empirical support. The overall technique is in large part an adaption of Meichenbaum's Stress Inoculation Training (Meichenbaum & Jaremko, 1983) in which several behavioral and cognitive-behavioral procedures are combined to reduce or eliminate PTSD symptomatology. Primary components include: applied relaxation training, breathing retraining, thought stopping, stress inoculation training through imaginal exposure and guided self-dialogue, in vivo exposure assignments, and cognitive restructuring. These strategies are preceded by an education module, in which patients are familiarized with the conditioning model of fear acquisition and its appropriate treatment. Progressive Muscle Relaxation (PMR, Jacobson, 1938), is most frequently taught to patients according to the standard procedure outlined by Bernstein and Borkovec (1973) and Wolpe (1990). In this procedure, patients are trained to detect and replace muscle tension with relaxation. This is accomplished through systematic constriction and release of several specific sets of muscles throughout the body. Typically, therapists will first model the procedure, tensing an isolated group of muscles for about seven seconds, then relaxing that group of muscles for 15 to 20 seconds. Patients are then instructed to tense their muscles in a manner similar to that demonstrated by the therapist, followed by complete relaxation of those muscles. During tension and release cycles, the patient's attention is repeatedly directed toward the qualitatively distinct muscular sensation associated with each phase of the procedure. Once patients achieve proficiency in relaxing specific sets of muscles, more diffuse groupings are used, until finally patients are able to relax their entire body at will. In this manner, patients learn to recognize and eliminate somatic correlates of anxiety. Diaphragmatic breathing and guided positive imagery are often employed to augment relaxation. In younger adults, relaxation training routinely involves four or five weekly therapist-directed sessions complemented by 30 minutes of daily self-directed practice. Importantly, lower ªdosesº of training appear to be ineffective (e.g., Borkovec & Sides, 1979). In the treatment of PTSD and other disorders characterized by anxiety upon exposure to specific fear-stimuli, simple relaxation exercises should be augmented by Applied Relaxation Training (OÈst, 1988; OÈst, Sternes, & Lindahl 1984), in which patients are taught not only to

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relax their muscles, but actively to apply this state of relaxation to those circumscribed situations and stimuli known to produce anxiety and fear. In order to accomplish this, patients first practice inducing a state of relaxation under a variety of conditions, such as waiting in a line, walking, sitting in an uncomfortable chair, talking to others, or any other situation in which they might experience the fear response. This active form of relaxation is then gradually applied, imaginally or in role-play format, to specific fear-producing situations associated with the traumatic event. Finally, applied relaxation during exposure to actual anxietyproducing stimuli is encouraged and practiced. As mentioned, diaphragmatic breathing (Clark, Salkovskis, & Chalkley, 1985) frequently complements relaxation during exposure-based treatments and is employed to reduce respiration rate. It is particularly useful when treating victims of interpersonal violence, who are at greater risk of experiencing panic and its associated hyperventilatory symptoms. The procedure is relatively simple and involves replacement of shallow or ªupper chestº breathing with deep diaphragmatic inhalation and exhalation. In addition to altering ªlocationº of their breathing, patients are taught to monitor and pace the rate at which they inhale and exhale, so that exhalations last approximately five seconds and inhalations last about four seconds. This has the effect of minimizing hyperventilation, and, if the procedure has been extensively paired with progressive muscle relaxation, inducing a relaxed state. In SIT treatment of PTSD, the procedure is employed during exposure trials to limit exacerbation of somatic arousal. Thought stopping ªis a method of changing cognitive behavior that . . . does not depend on changing the meaning of words or interpretation of situationsº (Wolpe, 1990, p. 129). This procedure may aid in efforts to reduce intrusive ideation characteristic of PTSD by breaking cognitive chains of aversive thought through abrupt, patient-initiated incompatible behaviors. Interestingly, the technique is somewhat analogous to the behavioral procedure of response prevention/interruption used to eliminate compulsive behavior. In thought stopping, patients are trained to interrupt incipient thoughts as soon as they occur by exclaiming aloud ªStop!º or some other similar vocal command, followed immediately by the substitution of a competing benign thought for the intrusive cognition. As the occurrence of intrusive thoughts is diminished, self-commands are faded to the subvocal level. Thought stopping can be effective in reducing distress following exposure trials, but should not be

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used as a cognitive avoidance strategy to reduce stimulus salience during exposure. The relatively nonaversive nature of this technique, and the ease with which it is applied to repetitive anxiety-producing thoughts, justifies its inclusion in treatments for PTSD. The primary component of stress inoculation treatment for PTSD is exposure. Exposure treatments have as their theoretical basis the process of extinction, or the diminution of the probability of occurrence of a conditioned response following repeated nonreinforced exposure to a conditioned stimulus. Exposure typically varies in terms of the following parameters: (i) medium of stimulus presentation (i.e., imaginal vs. in vivo), (ii) intensity of stimulus presentation (graded vs. full), (iii) purity of stimulus presentation (pure extinction vs. addition of coping strategies). In stress inoculation treatment for PTSD, steps are taken to maximize exposure while minimizing aversive arousal. Thus, exposure is imaginal, graded, and accompanied by the coping techniques outlined above. The initial step in a graduated exposure treatment is construction of anxiety hierarchies. Anxiety hierarchies (Wolpe, 1990, p. 160) may involve internal (e.g., feelings of panic) or external (e.g., men who resemble the perpetrator) stimulus situations, or combinations of the two. Detailed and specific hierarchy items are preferable to general items (e.g., ªbeing with unknown menº) and facilitate relatively more powerful extinction effects by increasing the salience of anxiety-producing stimuli. Since this specificity may restrict therapeutic generalization, multiple hierarchies are regularly required to overcome all conditioned fear-producing stimuli in a particular patient. Spacing between successive hierarchy items should be even, and progression through the hierarchy tolerable. This spacing is accomplished by assigning a relative value of anxiety to each item via the Subjective Units of Discomfort Scale (SUDS; Wolpe, 1990), or some similar ªanxiety thermometer.º During hierarchy construction, patients are asked to generate the most anxiety-producing stimulus possible and assign it a SUDS value of 100. Complete relaxation is given a SUDS value of 0. As patient and therapist generate new hierarchy items, a relative SUDS value is assigned to each. Following construction and rank ordering of hierarchies, patients engage in imaginal exposure to the least aversive item. Exposure trials may include audiotaped descriptions of the trauma event. In order to maximize the opportunity for extinction of conditioned fear (i.e., maximize duration of exposure trials), exposure is accompanied by cognitive and

muscular (relaxation) coping techniques. While these coping responses may ªdiluteº extinction during the session by lessening stimulus salience, they increase the likelihood that patients will continue to engage in exposure within and across sessions by increasing perceptions of selfefficacy and control. Once imaginal exposure to anxiety hierarchy items can be endured with only minimal distress, in vivo exposure should be initiated when possible and safe. In vivo exposure is used in addition to imaginal exposure because the level of stimulus salience achieved by the former typically exceeds that of the latter. Hence in vivo exposure results in more ªefficientº extinction of conditioned anxiety responses. As with imaginal exposure, in vivo exposure is performed in a graded format, with introduction to mildly anxiety-producing stimuli on the hierarchy preceding exposure to stimuli that elicit great fear. The degree to which stimulus intensity is varied (i.e., highly graded to full exposure) is determined, in large part, by individual characteristics of each patient. Although high ªdosesº of stimulus exposure (and hence anxiety) typically produce relatively more rapid treatment response than lower doses, high-intensity exposure is also associated with greater attrition (Barlow, 1988). Thus, exposure should be graded so as to produce significant, but not overwhelming levels of anxiety. As with imaginal exposure, applied relaxation, and diaphragmatic breathing are employed during in vivo trials to reduce levels of experienced anxiety during progression through the hierarchy. Anxiety during exposure may also be graded by the proximity of a significant other or therapist. This form of graduation routinely incorporates positive reinforcement (provided by significant other or therapist) into the extinction process and increases the likelihood that exposure exercises will be practiced between sessions. Additional modulation of exposure is achieved simply by altering the duration and frequency of extinction trials. Complementing both imaginal and in vivo exposure is guided self-dialogue (Meichenbaum & Jaremko, 1983) in which each step in the behavioral chain of exposure is broken down and verbally rehearsed to successful completion immediately prior to the actual act. This cognitive rehearsal ªsets the stageº for successful completion of the exposure trial. Selfdialogue is first modeled aloud by the therapist during simulated exposure to anxiety hierarchy items. In addition to analysis of required behaviors and rehearsal of successful completion of these acts, positive self-statements are made. Overtly verbal self-dialogue is practiced prior to exposure to hierarchy items. Once

Summary proficiency is achieved, patients, aided by therapist prompts, engage in exposure exercises, utilizing similar overtly verbal coping selfstatements. After patients begin to demonstrate competency using self-statements, clinician prompts are faded. Finally, patients fade their verbal ªself-promptsº as well, first to whispers, and then to completely covert self-talk. In this manner, patients adopt a coping style that enables them to endure relatively greater lengths of exposure with gradually increasing independence. Finally, cognitive interventions are employed to eliminate or alter cognitions that impede treatment progress. Alternative treatments for PTSD exist, and have been subject, in varying degrees, to empirical evaluation. For example, Keane, Fairbank, Caddell, and Zimering (1989) developed and assessed a flooding intervention that employs highly intense imaginal exposure to reduce symptoms of PTSD in combat veterans. In contrast to the technique outlined above, little or no effort is made to reduce anxiety during extinction trials, and the overall intervention is quite aversive, albeit effective. In flooding, patients are instructed to imagine, in extremely vivid detail, the most aversive aspects of their anxiety-producing stimuli. Often, patient-narrated audiotapes depicting traumatic stimuli are employed to enhance visual imagery. Exposure trials typically last from 30 minutes to several hours. Although exceptionally high levels of anxiety are produced during these trials, repeated exposure results in a diminution or extinction of fear responses. This treatment may not be appropriate for all assault victims (e.g., children, older adults) and therapists and their patients should be cognizant of the fact that participants typically experience initial exacerbations, rather than reductions in anxiety. Obviously, high potential for attrition exists with this procedure, and treatment retention may be lower than that of the multicomponent treatment described above.

9.19.6 FUTURE DIRECTIONS Progress has been made to develop and refine procedures used to identify and delineate trauma and its sequelae. Similarly, effective treatments have been generated to reduce the wide variety of symptomatology produced by victimization. However, relatively little is known about the effects of physical assault per se, particularly when considered in terms of possible permutations of trauma context. That is, we are unaware of the relative effects of assault on adults who were victims of repeated childhood physical assault, compared to adults

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with no childhood trauma history. Likewise, we have no data regarding differential response of assault victims who have or have not previously experienced nonassault-related trauma, or responses of physical assault victims who have or have not previously been sexually assaulted. Each of these combinations of variables also must be considered in terms of demographic factors (e.g., age, education, ethnicity) and perpetrator status (e.g., known or unknown). Although we have identified risk factors for psychopathology and variables that appear to buffer against it, we cannot predict, with any significant degree of accuracy, who will or will not experience significant post-traumatic emotional difficulties. Therefore, future research should address the complexity of trauma history across the lifespan and in a variety of interpersonal contexts. Effects of physical assault must be examined in terms of childhood trauma history, adult trauma history, sexual trauma history, relation of perpetrator to victim, and victim age, education, gender, and ethnicity. Next, risk factors for development of postviolence psychopathology must be delineated for each of these possible assault permutations. Finally, research to facilitate effective prescriptive matching of intervention or interventions to trauma subtype must be conducted and disseminated.

9.19.7 SUMMARY Interpersonal violence is considered a major public health problem in most countries of the world. Assessment of postassault psychopathology is clearly a complex, but not necessarily overwhelming task for the clinician or empirical investigator. Importantly, several core components should be part of any postassault assessment. These include a behaviorally based, sensitive trauma screen with appropriate and accurate preface statements, a psychometrically validated structured clinical interview, and standardized self-report measures. The preface statement should provide contextual reference to the respondent and maximize the likelihood that traumatic events will be reported; the trauma screen should produce consistent and operationally defined information regarding event type and its subjective and objective characteristics, the structured interview should produce reliable and valid diagnoses across a variety of diagnostic classes associated with victimization; finally, standardized questionnaires should yield descriptive information about the intensity, frequency, and quality of postassault psychopathology.

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Adequate treatment of postassault psychopathology is contingent upon accurate, multidimensional assessment of symptomatology. Such assessment must address the broad scope of victims' emotional responses to trauma, including PTSD, depression, substance abuse, and panic. Likewise, individual interventions should be selected and implemented within the context of the traumatic event (e.g., if substances are used to cope with anxiety, removal of substance abuse should be accompanied by alternative, more adaptive stress-reduction strategies) in order to maximize treatment relevance. 9.19.8 REFERENCES American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington DC: Author. Bachman, R. (1994). Violence against women. A national crime victimization survey report. Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics. Barlow, D. H. (1988). Anxiety and its disorders: The nature and treatment of anxiety and panic. New York: Guilford. Beck, A. T., & Steer, R. A. (1984). Internal consistencies of the original and revised Beck Depression Inventories. Journal of Clinical Psychology, 40, 1365±1367. Beck, A. T., & Steer, R. A. (1991). Relationship between the Beck Anxiety Inventory and the Hamilton Anxiety Rating Scale with anxious outpatients. Journal of Anxiety Disorders, 5, 213±223. Beck, A. T., Ward, C. H., Mendelsohn, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561±571. Beckham, J. C., Rodman, A. A., Shipley, R. H., Hertzberg, M. A., Cunha, G. H., Kudler, H. S., Levin, E. D., Rose, J. E., & Fairbank, J. A. (1995). Smoking in Vietnam combat veterans with post-traumatic stress disorder. Journal of Traumatic Stress, 8, 461±472. Bernstein, D. A., & Borkovec, T. D. (1973). Progressive relaxation training. Champaign, IL: Research Press. Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., Klauminzer, G., Charney, D. S., & Keane, T. M. (1990). A clinician rating scale for assessing current and lifetime PTSD: The CAPS-1. The Behavior Therapist, 13, 187±188. Borkovec, T. D., & Sides, J. K. (1979). Critical procedural variables related to the physiological effects of progressive relaxation: A review. Behaviour Research and Therapy, 17, 119±125. Breslau, N., & Davis, G. C. (1987). Posttraumatic stress disorder: The etiological specificity of wartime stressors. American Journal of Psychiatry, 144, 578±583. Breslau, N., Davis, G. C., Andreski, P., & Petersen, E. (1991). Traumatic events and posttraumatic stress disorder in an urban population of young adults. Archives of General Psychiatry, 48, 216±222. Briere, J. (1995). Trauma Symptom Inventory professional manual. Odessa, FL: Psychological Assessment Resources. Briere, J., Elliott, D. M., Harris, K., & Cotman, A. (1995). Trauma symptom inventory: Psychometrics and association with childhood and adult victimization in clinical samples. Journal of Interpersonal Violence, 10, 387±401. Briere, J., & Runtz, M. (1989). The Trauma Symptom Checklist (TSC-33): Early data on a new scale. Journal of Interpersonal Violence, 4, 151±163.

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Copyright © 1998 Elsevier Science Ltd. All rights reserved.

9.20 Victims of Domestic Violence AMY HOLTZWORTH-MUNROE and NATALIE SMUTZLER Indiana University, Bloomington, IN, USA and ERNEST N. JOURILES and WILLIAM D. NORWOOD University of Houston, TX, USA 9.20.1 INTRODUCTION

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9.20.2 IMPACT OF MALE VIOLENCE ON INTIMATE FEMALE PARTNERS

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9.20.2.1 Psychological Problems Among Battered Women 9.20.2.1.1 Post-traumatic stress disorder 9.20.2.2 Depression 9.20.2.3 Self-esteem 9.20.2.4 Factors that Mediate a Woman's Reactions to Husband Violence 9.20.2.4.1 Coping skills 9.20.2.4.2 Cognitions 9.20.2.4.3 Dependency 9.20.2.4.4 Family of origin 9.20.3 WHY BATTERED WOMEN STAY

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9.20.3.1 Do Battered Women Stay in Abusive Relationships? 9.20.3.2 Is Leaving an Abusive Relationship Safe? 9.20.3.3 Factors Contributing to a Woman's Decision to Leave or Stay

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9.20.4 PSYCHOLOGICAL ABUSE

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9.20.5 PSYCHOLOGICAL INTERVENTIONS WITH BATTERED WOMEN

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9.20.6 FUTURE DIRECTIONS AND METHODOLOGICAL CONSIDERATIONS

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9.20.7 MARITAL VIOLENCE AND CHILDREN

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9.20.8 PREVALENCE

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9.20.9 CHILD ADJUSTMENT PROBLEMS

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9.20.9.1 Concurrent Problems 9.20.9.2 Long-term Problems 9.20.10 FACTORS ASSOCIATED WITH DETRIMENTAL IMPACT

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9.20.10.1 Parameters of Violence 9.20.10.2 Family Variables 9.20.10.3 Child Variables 9.20.11 INTERVENTIONS

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9.20.12 CONCLUSIONS

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9.20.13 REFERENCES

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9.20.2 IMPACT OF MALE VIOLENCE ON INTIMATE FEMALE PARTNERS

comingsº of these women, implying that they were responsible for their own victimization. For example, early accounts described the masochistic tendencies of abused women (e.g., Reynolds & Siegle, 1959) and, more recently, Walker (1991) noted that the DSM-III-R diagnosis of self-defeating personality disorder reifies the notion that battered women are somehow responsible for their partners' aggression. In addition, feminists ªargue that diagnosing victims deflects energy from alleviating societal deficitsº (Sato & Heiby, 1991, p. 151). According to feminist theory, husband violence is the result of a patriarchal society in which violence is simply one of many means used by men to ensure that women remain subordinate to them. Thus, to stop wife abuse, emphasis must be placed on building a more egalitarian society and holding men accountable for male violence. Given this view, focusing on the psychological characteristics of the victim is not only irrelevant but also counterproductive, as it may allow men to continue to ignore their role in the problem. In contrast, clinicians often value diagnostic labeling as it can facilitate treatment planning. For example, therapists who are aware of the symptoms suffered by battered women will consider the possibility of marital violence in their female clients' lives, rather than assuming that the psychological symptoms alone should be the focus of treatment (Browne, 1993). In addition, understanding the negative impact of physical aggression on women can help demonstrate that marital violence is a serious problem, deserving of attention and scarce resources. Despite disagreements about the potential usefulness of studying the psychological symptoms of battered women, researchers from divergent backgrounds have begun to agree that the symptoms of battered women should be viewed as the result or consequence of abuse rather than as stable characteristics predating abuse or as causes of abuse. Indeed, Browne (1993, p. 1077) warns that ªpsychologists continue to risk pathologizing women victims and [fail] to identify potential danger by not integrating what is known about assaults by relational partners with the rich literature on human responses to trauma.º Thus, a focus on the traumatic impact of husband violence may help bridge the gap between feminists and clinicians because it allows for psychological diagnoses that do not blame the victim.

9.20.2.1 Psychological Problems Among Battered Women

9.20.2.1.1 Post-traumatic stress disorder

The study of battered women's psychological symptoms and diagnoses is controversial. Historically, the application of diagnostic labels to battered women often focused on the ªshort-

For battered women, post-traumatic stress disorder (PTSD) involves symptom development following exposure to an extreme traumatic stressor (i.e., battering) that includes

9.20.1 INTRODUCTION Male violence against intimate female partners, whether it occurs in dating, cohabitating, or marital relationships (and which we will refer to as ªhusband violenceº), is a serious problem. Data from nationally representative surveys in the USA suggest that each year one out of every eight women will experience physical aggression and nearly two million women will be severely assaulted by their male partners (Straus & Gelles, 1986). But women are not the only victims; each year, over three million children are exposed to interparental violence (Carlson, 1984). This chapter reviews the negative consequences of husband violence on women and children. The first half of the chapter addresses the impact of male violence on intimate female partners. Although both men and women engage in physical aggression against partners, an accumulating body of evidence demonstrates that male violence has more detrimental effects than female violence. Male violence is more likely to result in physical injury and psychological problems (Holtzworth-Munroe, Smutzler, & Bates, 1997). Thus, the focus is on the problem of husband violence. The prevalence and correlates of the most common psychological problems among battered women and factors that may mediate a woman's responses to husband violence are reviewed. Also addressed is the issue of whether battered women stay in abusive relationships, and the problem of psychological abuse is introduced. Interventions with battered women are briefly discussed and some methodological considerations in this research area are mentioned. The second half of the chapter addresses the impact of male violence against female partners on children living in such homes. First, the prevalence of the problem is discussed. Then, the problems experienced by children in these homes are reviewed, including externalizing problems, internalizing problems, and social competence/ skills. Also reviewed are the factors associated with the detrimental impact of marital violence on children, including parameters of the violence, family variables, and child variables. Finally, the clinical implications of the available data are briefly discussed.

Impact of Male Violence on Intimate Female Partners actual or threatened death or serious injury. PTSD symptoms can include increased arousal, avoidance responses, numbing of general responsiveness, re-experiencing of the trauma as well as ªperception of life threat . . . extreme fear or terror, and a sense of helplessness at the time of the incidentº (Browne, 1993, p. 1081). Researchers have examined the prevalence rates of PTSD symptoms among samples of battered women. Across different samples and using different measures of PTSD, the reported rates of PTSD among battered women range from 30% to 80%, with most researchers reporting a prevalence rate of 40±60% (e.g., Astin, Lawrence, & Foy; 1993; Gleason, 1993; Houskamp & Foy, 1991; Saunders, 1994). As would be expected, rates of PTSD are higher among battered than among nonbattered women (e.g., Kemp, Green, Hovanitz, & Rawlings, 1995). However, Riggs, Kilpatrick, and Resnick (1992) found no differences in PTSD across four groups of women who were victims of violent crime. Thus, their results demonstrate that violence towards a woman that is perpetrated by her husband is no less traumatizing than violence from others. Consistent with the notion that PTSD is a consequence of the abuse experienced by women, recent studies have demonstrated a relationship between the severity and recency of the abuse experienced and risk for PTSD. When Houskamp and Foy (1991) categorized battered women as having been exposed to either high or low degrees of perceived life threat, 60% of the women in the high exposure group met criteria for PTSD compared with 14% in the low exposure group; in addition, the extent and severity of the abuse and length of relationship were positively related to the severity of PTSD symptoms. Similarly, Astin et al. (1993) found that severity of exposure to violence, as well as the recency of the abuse, were positively related to PTSD symptomatology. Kemp et al. (1995) compared battered women who met PTSD criteria to those who did not, finding that the PTSD group scored higher on measures of extent of physical and verbal abuse, number of injuries, forced sex, and greater sense of threat; they had also been out of the abusive relationship a shorter time. These researchers also examined the relationship between PTSD symptoms and other correlates. Astin et al. (1993) found that social support and positive life events occurring since the battering were negatively correlated with PTSD symptoms, whereas negative life events and developmental family stressors were positively related to PTSD severity. Kemp et al. (1995) found that negative life events and a history of child abuse predicted PTSD; per-

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ceived social support was related to lower levels of PTSD, while disengaged coping was one of the strongest predictors of PTSD symptoms.

9.20.2.2 Depression Researchers have also reported that a high percentage of battered women, usually about 50%, experience high levels of depression (e.g., Cascardi & O'Leary, 1992; Christian, O'Leary, & Vivian, 1994; Sato & Heiby, 1991). Researchers generally find a higher prevalence of depression among battered women than among nonbattered women (Andrews, 1995; Stets & Straus, 1990), including women experiencing nonviolent serious relationship problems (Campbell, 1989; Cascardi & O'Leary, 1992). Examining the correlates of depression among battered women, Sato and Heiby (1991) found that battered women who realistically assessed their battering relationship and who reported poor self-reinforcement skills, personal or economic losses, and past histories of depression appeared to be at particular risk for depression. Mitchell and Hodson (1983) found that the severity and frequency of the aggression was related to increases in depression. In addition, less active cognitive coping and more avoidance coping were related to more severe depression, minimal personal resources, less help from institutional sources, and higher levels of avoidance responses from friends were also related to depression. Campbell (1989) was able to account for about 57% of the variance in depression scores among battered women, using a combination of low self-esteem, low perceived ability to care for oneself, and feelings of less control in the relationship predicting depressive symptoms.

9.20.2.3 Self-esteem The majority of studies conducted suggest that battered women have lower self-esteem than nonbattered women (e.g., Aguilar & Nightingale, 1994; Cascardi & O'Leary, 1992; Perilla, Bakeman, & Norris, 1994). Mitchell and Hodson (1983) found that severity and frequency of husband violence was strongly related to lowered self-esteem. Frisch and MacKenzie (1991) found that chronically abused women scored significantly lower on measures of selfesteem than formally abused women. Similarly, Aguilar and Nightingale (1994) found that battered women who were currently involved with an abusive partner had lower self-esteem than women who had not been involved with their abusive partner for at least one year.

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9.20.2.4 Factors that Mediate a Woman's Reactions to Husband Violence 9.20.2.4.1 Coping skills How a woman copes with the abuse she is suffering may be related to her reactions to the abuse. For example, Mitchell and Hodson (1983) found that less active cognitive coping and more avoidance coping were related to more severe depression, as were minimal personal resources, less help from institutional sources, and higher levels of avoidance from friends. 9.20.2.4.2 Cognitions Cognitions of a battered woman may influence the steps she takes to deal with the violence in her life. Although a series of studies describe the attributions battered women offer for husband violence (Holtzworth-Munroe, 1988), only a few researchers have related these attributions to womens' responses to husband violence. Andrews and Brewin (1990) found that women who made internal and stable attributions of blame for abuse were more likely, than women who did not, to have suffered persistent depression after the violent relationship ended. In contrast, Campbell (1989) found that womens' attributions of blame for relationship problems did not add significantly to the prediction of depression among the women, once self-esteem, self-care agency, and feelings of control in the relationship were used as predictors. Thus, it is unclear how a woman's attributions for husband violence relate to her reactions to this violence. Researchers have also investigated the relationship between traditional sex role beliefs of women and husband violence, because a battered woman who holds traditional sex role beliefs may be less able to protect and care for herself (Warren & Lanning, 1992). Hotaling and Sugarman (1986) found that only 50% of studies reported a positive relationship between traditional sex role beliefs of women and marital violence. Subsequently, researchers have generally found that battered women are less masculine or androgynous and more feminine than nonbattered women (Apt & Hurlbert, 1993; Schwartz & Mattley, 1993; Warren & Lanning, 1992). However, whether such beliefs are related to women's reactions to the violence is still a matter of speculation. 9.20.2.4.3 Dependency Some theorists have hypothesized that wives with high marital dependency may be more tolerant of marital abuse. For example, Kalmuss and Straus (1990) found that women

experiencing objective (i.e., economic) or subjective (i.e., fear of negative effects resulting from loss of the marriage) dependency experienced more abuse than nondependent women. 9.20.2.4.4 Family of origin It has been proposed that women who grew up in violent homes are at risk of becoming adult victims of spouse abuse. For example, girls growing up in violent homes may come to believe that marital violence is normal and acceptable, thus tolerating such abuse when it occurs in their own marriages. Thus, a large number of researchers have asked battered and nonbattered women to retrospectively recall whether or not they experienced violence in their childhood family of origin (e.g., Doumas, Margolin, & John, 1994; Langhinrichsen-Rohling, Neidig, & Thorn, 1995; Simons, Johnson, Beaman, & Conger, 1993). However, these studies have produced mixed findings, so that, at this time, it cannot be definitively concluded that having grown up in a violent home is a risk factor for becoming a victim of husband violence. 9.20.3 WHY BATTERED WOMEN STAY 9.20.3.1 Do Battered Women Stay in Abusive Relationships? One of the most commonly asked questions in this area is why battered women stay with abusive partners. Schwartz (1988, p. 241) suggests that a more appropriate question may be ªwhy do we assume that abused women stay in their marriages?º Based on interviews with women in the National Crime Survey (NCS), Schwartz (1988) found that 32% of victims of spousal assault were divorced and 47% were separated at the time of the interview. These rates were significantly higher than those found among women who had been victims of a stranger assault (19.1% divorced, 11.2% separated) and women who were not victimized (8.5% divorced, 3.6% separated). These data suggest that the majority of physically abused women do not stay in an abusive relationship, and that our research focus might productively switch to an examination of the ways in which abused women take steps to improve their lives (Schwartz, 1988). A number of researchers have reported similar data, finding that 50% or more of battered women leave their partner within two years (Okun, 1986; Strube & Barbour, 1984). However, Okun (1986) also found that women may leave many times before finally ending the relationship, suggesting that the decision to leave an abusive relationship is an ongoing

Why Battered Women Stay process requiring multiple attempts. Okun (1986, p. 118) summarizes this idea: ªthe process of separating and recohabitating by battered women is not an endless back-and-forth shuttle in static equilibrium, but a progressive process toward change in the violent relationship, including the termination of that relationship.º 9.20.3.2 Is Leaving an Abusive Relationship Safe? Asking why women stay implies that leaving is a safe option for battered women. However, this may not be the case. Comparing rates of spousal homicide among cohabitating and separated couples, Wilson and Daly (1993) found that wives were at higher (i.e., 2±4 times) risk of being killed by their husbands following separation than when living with their partner. Saltzman and Mercy (1993) found that over one-fifth of the fatal incidents occurred between people whose relationships had terminated. These data raise the possibility that an individual cannot always stop the violence by terminating an abusive relationship. 9.20.3.3 Factors Contributing to a Woman's Decision to Leave or Stay Given the comprehensive Strube (1988) review addressing the question of why women stay in abusive relationships, here we only briefly note a few of the major factors believed to influence a woman's decision to stay in or leave an abusive relationship. Strube and Barbour (1983, 1984) found that economic dependence was related to a woman's decision to stay in an abusive relationship. Women who were employed were more likely to leave, and women who remained attributed economic hardship as at least one factor for staying. Similarly, Aguirre (1985) found that if the husband was the sole source of income, a woman was more likely to return to him after seeking help from a shelter. Okun (1986) also found that 55% of women who had a higher income than their husbands immediately terminated the relationship, compared to 28% of the women whose husbands earned equal or greater pay. In addition, if the husband was not gainfully employed, 48% of the wives immediately terminated the relationship, whereas 27% of women whose husbands were full-time or self-employed terminated cohabitation. Thus, it appears that financial status influences a woman's decision to remain in an abusive relationship. However, these results must be interpreted with caution because the majority of the women in these studies were in battered

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women shelters which often provide services to lower income women. There is little information as to how women from higher income brackets cope with wife abuse. Studies have provided mixed and contradictory evidence for the notion that the more severe the marital violence, the more likely the woman is to leave. Ferraro and Johnson(1983, pp. 331±332) speculated that it may not be the frequency or severity of violence that serves as an impetus for a woman's decision to leave a relationship but rather ªa sudden change in the relative level of violence. Women who suddenly realize that battering may be fatal may reject rationalizations in order to save their lives.º In addition, ªas battering progresses, periods of remorse may shorten, or disappear, eliminating the basis for maintaining a positive outlook on marriage.º Thus, focusing exclusively on the severity and frequency of violent episodes may be too simplistic. Rather, it may be a significant variation in the pattern of abuse that instigates a separation. Loseke and Cahill (1984, p. 304) challenged the notion that staying in an abusive relationship is a deviant response. They argued that terminating any type of intimate relationship is difficult, noting that ªeven a cursory review of the sociological literature on marital stability and instability suggests that, at least in regard to their reluctance to leave their mates, battered women are quite similar to both other women and to men.º Interestingly, researchers often approach the question of why battered women stay as if the woman was the only person participating in the process. Only recently have investigators begun to consider how the help obtained by women may impact the choice of remaining in or leaving a relationship. Similarly, researchers rarely consider the batterer's influence over his partner's decision to return to the relationship. However, this may be an important factor to examine. For example, Schutte, Malouff, and Doyle (1988) found that all the women in their shelter sample reported that their partner had attempted to persuade them to return to the relationship. Similarly, Gondolf (1988) found that the best predictor of returning to an abusive husband was the husband's having sought help or entering counseling, suggesting that battered women place their hope in the notion that their husbands will change, although not all batterers are helped by therapy (Rosenfeld, 1992). In summary, battered women appear to have many reasons for remaining with an abusive partner. However, such findings must be placed in the context that many battered women do eventually leave their abusers. Rather than continuing to narrowly examine why battered

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women stay, future research should consider broader issues, including what factors help women to end the abuse in their lives.

9.20.4 PSYCHOLOGICAL ABUSE Although the primary focus of this chapter is husband physical aggression, researchers have recently begun to recognize the importance of psychological abuse, which co-occurs with physical abuse. Researchers have delineated different types of psychological abuse. For example, Rodenburg and Fantuzzo (1993) assessed sexual, psychological, and verbal abuse, and Shepard and Campbell (1992) assessed social isolation, threats, use of male privilege, and economic control. Tolman (1989) found that the items on his measure of psychological abuse loaded on to two factorsÐemotional±verbal abuse and dominance±isolation. A consistent theme emerges across these studies, suggesting that psychological abuse involves an attempt to control or dominate one's partner (Murphy & Cascardi, 1993). Psychological abuse is prevalent among couples experiencing physical aggression. For example, Follingstad, Rutledge, Berg, Hause, and Polek (1990) found that 99% of the battered women they studied had experienced some type of emotional abuse and 72% experienced four or more types. Hudson and McIntosh (1981), examining a sample from a battered women's shelter, found a correlation of 0.86 between the physical abuse and psychological abuse. Using national survey data, Stets (1990) found that less than 1% of respondents indicated that physical aggression had occurred without verbal aggression. Psychological aggression is damaging to battered women. In their study of women who had been victims of physical abuse, Follingstad et al. (1990) found that 72% of the women believed that emotional abuse had a more severe negative impact on them than physical aggression. This is not surprising given the frequent occurrence of various forms of emotional abuseÐover 60% of the women reported that multiple forms of psychological abuse occurred weekly. It is thus possible that many of the effects of marital violence observed in battered women are actually due to psychological abuse or to the combination of psychological and physical abuse (Murphy & Cascardi, 1993). Recent research suggests that psychological aggression precedes, and is a risk factor for, physical aggression. For example, using national survey data, Stets (1990) found that in over 50% of the cases, verbal aggression occurred without physical aggression. However, less than 1% of

respondents indicated that physical aggression occurred without verbal aggression. Prospective studies have led to similar conclusions. For example, Malamuth, Linz, Heavey, Barnes, and Acker (1995) demonstrated that men's use of verbal aggression was the only direct predictor of men's use of physical nonsexual aggression toward women, with verbal aggression accounting for over 30% of the variance in physical aggression. In a study of newly married couples, Murphy and O'Leary (1989) found that husbands' use of psychological aggression at 18 months after marriage significantly predicted husband physical aggression at 30 months after marriage. In summary, only recently have researchers begun to study husbands' psychological abuse of women. These initial studies indicate that psychological abuse is a major problem. It is highly prevalent among violent couples and has a negative impact on battered women. In addition, psychological abuse may precede or predict husband physical violence.

9.20.5 PSYCHOLOGICAL INTERVENTIONS WITH BATTERED WOMEN There is insufficient empirical data to make recommendations about what type of psychotherapy is beneficial to battered women; indeed, little research has addressed this issue. This lack of research may reflect the fact that most marital violence experts do not believe that traditional psychotherapy, at least alone, is the most appropriate intervention for battered women (Dutton, 1996). Due to a lack of awareness of the problem of husband violence, psychologists have often mistreated battered women, focusing on their symptoms without fully understanding how the abuse in their lives causes such symptoms. However, focusing solely on psychological symptoms is unlikely to benefit a woman who leaves each therapy session to go home to an abusive partner. In addition, recent research on the correlates of psychological symptoms among battered women suggests that psychotherapy may not be necessary to help many battered women overcome their psychological symptoms; more simply, length of time out of an abusive relationship can lead to a decrease in symptoms. Furthermore, battered women often require help that is not part of a traditional psychotherapy approach and which most psychologists have not been trained to provide. For example, careful safety planning, to protect the woman from further abuse, is often the most important first intervention. Battered women

Futute Directions and Methodological Considerations often also require economic and legal assistance to deal with questions of restraining or protective orders, divorce and custody, prosecution of the batterer, how to obtain housing, and financial support. Often, these other needs must be addressed before a battered woman is able to deal with more traditional, psychological issues. Given these concerns, most experts on battered women recommend therapeutic interventions that address the multiple and individual needs of women who are living in, or have left, an abusive relationship. For example, Dutton (1996, p. 2) proposed that ªthe task for the therapist is to address the configuration of the client's needs derived from the battering experience, in the context of other life issues or problems that she may also face, and for which she may or may not be seeking help.º In addition, psychologists should coordinate their efforts with local womens' shelters and other community agencies. Indeed, Pence (1989) has argued that comprehensive community involvement is required; therapists should collaborate with law enforcement officials, the judicial system, and women advocacy services. Only through such coordinated efforts will therapists be able to adequately address the issues facing a battered woman. Given such emphases, recent developments in intervention efforts reflect the complexity of problems faced by battered women. For example, Dutton (1996) has presented an integrated intervention model based on social learning, cognitive-behavioral, and feminist theories. The model includes crisis intervention (e.g., safety planning), choicemaking (e.g., increasing awareness of options and skill building), and healing (e.g., assessing how a particular woman has reacted to the violence and implementing an appropriate treatment plan). In summary, traditional psychotherapies may be inadequate to address the immediate needs of a woman living with her batterer or having recently left him. Safety, economic, and legal needs are likely to take precedence. However, as a battered woman obtains an abuse-free life, she may wish to focus on the psychological sequelae of the trauma she has endured. Unfortunately, little is known about the best way to help such women, although supportive therapies and therapy focusing on PTSD are promising places to start.

9.20.6 FUTURE DIRECTIONS AND METHODOLOGICAL CONSIDERATIONS In early studies in this area, many researchers did not include comparison groups; instead,

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they simply tallied the percentage of battered women in a sample who showed psychological symptoms. Although more recent studies have included nonabused comparison samples, they rarely include women in nonviolent but maritally distressed relationships. Thus, it is difficult to establish which of the demonstrated effects are unique to violence vs. which are more generally related to living in an unhappy marriage. Another sampling problem involves the large number of studies examining only battered women in shelters or therapy. Such women are seeking help and/or have left their partner. Whether such findings will generalize to battered women in the community has not been extensively examined. In addition, most researchers assign all battered women to one subject group, comparing them with nonbattered women; however, two typology studies make it clear that battered women are a heterogeneous group. Snyder and Fruchtman (1981) and Follingstad, Laughlin, Polek, Rutledge, and Hause (1991) identified five clusters of battered women. In both studies, women varied along such dimensions as the severity, frequency, and chronicity of the violence they experienced, how stable and satisfactory their relationships were, whether or not they returned to the batterer, to whom or what they attributed the violence, whether they accepted violence in their relationship, and whether their children were also the victims of violence. These typologies demonstrate that it is important for researchers to begin considering such differences in the experiences of battered women. Studies examining how battered and nonbattered women differ have been controversial because the findings can easily be used to point to the deficits of battered women, implying that they are to blame for their abuse. However, researchers in this area are increasingly sensitive to such issues. For example, studies of PTSD clearly link the psychological distress found among battered women to theories of trauma, and findings relating degree of symptomatology to the amount of abuse experienced support the notion that the problems of battered women are the consequence of violence. These data support Hotaling and Sugarman's (1986, p. 118) conclusion: ªThe review of victim characteristics makes it clear that the most influential victim precipitant is being female . . . These findings do not augur well for theoretical models of victimization that focus upon characteristics of victims.º However, in reality, the correlational nature of the current research leaves questions about temporal sequence and causality unanswered and will continue to lead to theoretical debates about these issues. For

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example, it can be asked why virtually all of the correlates of violence found among husbands are assumed to be causes of violence, while many of the same correlates of violence found among battered women are assumed to be the consequences of violence. Future researchers need to address such questions. Recent work has begun to examine the correlates of these psychological problems. Unfortunately, however, there are few, if any, standardized measures of these correlates and mediators of the relationship between husband violence and its psychological impact on women; this makes it difficult to draw conclusions across studies. In addition, many potentially important correlates have received little attention. For example, there is a need to understand resiliency among battered women and to study the strengths of battered women who do not experience problems. Also, researchers have only begun to examine how leaving an abusive relationship affects a woman's psychological reactions to the abuse. Future longitudinal research should examine the longer term consequences for husband violence. 9.20.7 MARITAL VIOLENCE AND CHILDREN Women are not the only victims of marital violence; many children of battered women suffer devastating consequences as well. Although the empirical investigation of the effects of spousal violence on children is still in its infancy, one conclusion has received almost universal support: compared to children of nonviolent community families, the children of battered women are at substantially increased risk for behavior problems.

indeed, only fair agreement between parents about whether their children have seen or heard interparent aggression (O'Brien, John, Margolin, & Erel, 1994). Clinical investigators typically report that the children in these families witness more marital violence than their parents realize (Hughes, 1988; Rosenberg, 1987). The most widely cited prevalence estimates of children living in households in which marital violence has occurred are based on US demographic data and the Straus, Gelles, and Steinmetz (1980) national survey of community households. Carlson (1984) estimated that at least 3.3 million US children (aged 3±17 years) are exposed directly or indirectly to interparent violence each year. Pagelow (1982) estimated that more than 25 million children in the US are exposed to interparent violence at some point during their childhood. It is also important to note that both Carlson and Pagelow stated that their estimates are most likely lower boundaries, with the true number of children exposed to marital violence being much higher. Data on children's exposure to marital violence within clinical samples are limited, but the few existing studies suggest substantial rates of exposure. For example, over 40% of boys admitted to a child psychiatric clinic lived in families characterized by wife abuse (Stewart & deBlois, 1981). In a study of couples seeking marital therapy with children between 5 and 12 years, over 50% of the families reported recent spouse abuse (Jouriles, Murphy, & O'Leary, 1989). In sum, it appears that a large percentage of the children who eventually come into contact with mental health professionals live in maritally violent homes. 9.20.9 CHILD ADJUSTMENT PROBLEMS

9.20.8 PREVALENCE

9.20.9.1 Concurrent Problems

Prevalence estimates of children's exposure to marital violence are frequently based on estimates of the presence or absence of such violence in homes which include children. Exposure may thus refer to direct exposure (i.e., hearing or seeing the violence first hand), or to indirect exposure (i.e., living in a household characterized by violence but not directly witnessing it). This distinction is important for a number of reasons but, perhaps most importantly, because direct exposure is likely to have different effects on children than indirect exposure. Unfortunately, distinguishing empirically between direct and indirect exposure has been very difficult. There is little consistency between what parents believe their children have witnessed and what their children report having observed (Jaffe, Wolfe, & Wilson, 1990) and,

Most controlled investigations of the adjustment problems suffered by children of battered women have assessed the level of child problems that are evident after a recent exposure to marital violence, often during a child's stay at a battered women's shelter. In addition, most of these controlled investigations have assessed two broad-band dimensions of child problems: (i) externalizing problems, such as aggressive and oppositional behavior; and (ii) internalizing problems, such as anxiety and depression. Although there have been some inconsistencies in the specific results across studies, children of battered women have repeatedly been found to exhibit higher levels of problems when compared to children in community comparison families (Christopoulos et al., 1987; Holden & Ritchie, 1991; Wolfe, Jaffe, Wilson, & Zak,

Child Adjustment Problems 1985). Moreover, the available evidence generally indicates that marital violence is a more potent risk factor for both externalizing and internalizing problems than are verbal conflict or general marital discord (Fantuzzo et al., 1991; Jouriles et al., 1989; Rossman & Rosenberg, 1992), although there are at least two exceptions to this finding (Hershorn & Rosenbaum, 1985; Rosenbaum & O'Leary, 1981). Certainly an important and consistent finding is that a substantial proportion of the children of battered women score in the ªclinicalº range on standard measures of child problems, that is, at a level considered to warrant clinical intervention. Estimates of the percentage of children of battered women at such levels range from 25% to 70%, compared to 10±20% for children in community comparison groups (McDonald & Jouriles, 1991). Differences on externalizing and internalizing problems between children exposed to marital violence and community children have been documented with a variety of samples of children. Most commonly, differences have been documented in samples of wide age ranges with boys and girls grouped together (Hughes, 1988; Hughes, Parkinson, & Vargo, 1989), but they have also been found in more homogeneous samples of preschoolers (Fantuzzo et al., 1991), young school-aged children (Rossman & Rosenberg, 1992; Sternberg et al., 1993), and adolescents (Carlson, 1990). There is also some evidence that differences may be larger for younger as opposed to older children (Hughes, 1988), but this is not yet a firmly established finding. When results are reported separately by child gender, differences have emerged for both boys and girls (Christopoulos et al., 1987; Jaffe, Wolfe, Wilson, & Zak, 1986), but the types of problems experienced by boys and girls has not been consistent across studies. For example, some data indicate that boys exposed to marital violence exhibit more externalizing problems than community boys (Jaffe et al., 1986), whereas other data do not (Christopoulos et al., 1987; Rosenbaum & O'Leary, 1981). Similarly, some studies indicate that boys exposed to marital violence exhibit greater internalizing problems than community boys (Jaffe et al., 1986), whereas other studies indicate no such differences (Christopoulos et al., 1987; Rosenbaum & O'Leary, 1981). Similar inconsistent findings have emerged for girls on internalizing and externalizing problems. Nevertheless, at a more general level, the available data suggest that children exposed to marital violence are at increased risk for behavior problems, and the levels of these problems for many of these children are such that they warrant immediate attention.

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Other areas of functioning that have received some attention in the empirical literature include social competence, cognitive functioning, and physical health, but existing data on these problems remains preliminary. Several controlled studies indicate that children of battered women exhibit lower levels of social competence than children in community comparison families (Rossman & Rosenberg, 1992; Wolfe et al., 1985; Jaffe et al., 1986). Controlled research also suggests that the children of battered women do not differ on measured intelligence when compared to community children (Christopoulos et al., 1987; Rossman & Rosenberg, 1992). However, most studies of children's social competence, cognitive functioning, and physical health have not included a comparison group, and many have collected these data unsystematically and with instruments of uncertain reliability and validity. Although the findings from such studies often suggest that many children of battered women display problems in the domains of social competence, cognitive functioning, and physical health (Davis & Carlson, 1987; Stagg, Wills, & Howell, 1989). The methodological problems with these studies and conflicting results with some of the better controlled studies suggest that these be interpreted very tentatively. Clinical reports also suggest a number of additional problems suffered by children of battered women (Jaffe et al., 1990). These include symptoms associated with the diagnosis PTSD, the development of attitudes which support violence as an appropriate and effective means of obtaining power and control, and the development of beliefs that children are themselves responsible for their parents' marital violence. Also, clinical reports suggest that male children of battered women tend to be aggressive toward female targets in particular (Jaffe et al., 1990). Obviously, this is not an exhaustive list of problems derived from clinical data on the children of battered women, but it does help illustrate further the breadth of problems experienced by these children and the subtlety of some of the effects of violence exposure.

9.20.9.2 Long-term Problems Most investigations of child behavior problems among children of battered women have focused on the level of problems evident during an assessment at one point in time. At present little is known about the duration or developmental course of these problems. However, what little evidence there is indicates that the problems exhibited by children of battered women remain stable over time without specific

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intervention. In a cross-sectional study comparing a group of children who had recently been exposed to marital violence to a group of children who had not been exposed to violence for at least six months, the mean levels of externalizing and internalizing problems were very similar across the two groups (Wolfe, Zak, Wilson, & Jaffe, 1986). One long-term follow-up study indicates that boys' exposure to wife abuse is one of the few childhood factors which predict adult criminal activity (McCord, 1979), but this has yet to be tested by subsequent research. Retrospective data consistently indicate that boys' exposure to fathers' marital violence relates to spouse abuse in adult intimate relationships (Hotaling & Sugarman, 1986), and adolescents who report a history of parents' marital violence have been found to have higher ªchild abuse potentialº scores than those who do not report a background of domestic violence (Miller, Handal, Gilner, & Cross, 1991). Retrospective data also suggest that childhood exposure to marital violence relates to adult levels of internalizing problems, such as depression, low self-esteem, and trauma (Forsstrom-Cohen & Rosenbaum, 1985; Henning, Leitenberg, Coffey, Turner, & Bennett, 1996; Silvern et al., 1995). Thus, evidence from several sources converges to suggest that childrens' exposure to violence has potential long-term negative consequences.

9.20.10 FACTORS ASSOCIATED WITH DETRIMENTAL IMPACT Despite convincing evidence of increased risk, there is also evidence of substantial variability in the level of behavioral and emotional adjustment displayed by the children of battered women. Although a large percentage of these children are reported to be exhibiting problems at clinical levels, a subgroup of these children, even in families characterized by extreme marital violence, have been described as welladjusted (Hughes & Luke, 1998). The empirical literature on children's response to stress suggests that a number of factors may alter or deflect the impact of marital violence on children. These include parameters of the violence (e.g., frequency, severity), family variables (e.g., presence of child abuse, family socioeconomic status, quality of the parent± child relationship, family social support, psychological health of parents), and child variables (e.g., intelligence, problem-solving skills), among others. Although few of these variables have been investigated systematically among the children of battered women, several studies in the area provide important leads.

9.20.10.1 Parameters of Violence The empirical literature on marital conflict (as distinguished from marital violence per se) and child adjustment has uncovered several dimensions of conflict which appear useful in the prediction of child behavior problems. These include the frequency, intensity, resolution, and content of the conflict. In general, the more frequent and intense the marital conflict, the greater the likelihood of child difficulties; witnessing poorly resolved or unresolved marital conflicts are more detrimental to children than witnessing resolved conflicts; and overt marital conflicts about children or childrearing issues appear more detrimental than overt marital conflicts about other issues (Davies & Cummings, 1994; Grych & Fincham, 1990). The empirical literature on parameters of marital violence and child adjustment has focused primarily upon the frequency and intensity of violence. In most of this research, the frequency and intensity of the marital violence is confounded, perhaps inextricably (e.g., children exposed to frequent violence are also exposed to more severe violence). Similar to the results of research on marital conflict and child adjustment, the frequency and intensity of marital violence relates positively to both externalizing and internalizing child behavior problems (Fantuzzo et al., 1991; Jouriles & Norwood, 1995; Jouriles, Norwood, McDonald, Vincent, & Mahoney, 1996; O'Keefe, 1994; Spaccarelli, Coatsworth, & Bowden, 1995). Although the impact of content of conflicts which lead to marital violence on child adjustment has not yet been investigated, it has been found that arguments about children and childrearing are more likely to precede marital violence than conflicts about other topics (Straus et al., 1980). Such findings are noteworthy given that marital conflicts over childrearing are more often observed by children than other conflicts, and frequency measures of discord over childrearing relate more consistently to child problems than frequency measures of global marital discord or marital conflicts about other topics (Jouriles et al., 1991). 9.20.10.2 Family Variables Marital violence typically occurs in the context of other family risk factors for child problems. Marital discord, child abuse, poor parent±child relations, family economic disadvantage, and parent distress/psychopathology are examples. Some of these risk factors are probably a result of marital violence, whereas others are hypothesized to play key roles in the development of violence. It is also likely that

Factors Associated with Detrimental Impact some risk factors are neither a direct cause nor a consequence of violence, but simply coexist with it. Researchers are just beginning to investigate how marital violence interacts with other family variables in the development of child problems among these families. As indicated above, children are at greater risk for problematic adjustment when living in a family marked by recent marital violence than when living in a maritally discordant, nonviolent family (Fantuzzo et al., 1991; Jouriles et al., 1989; Rossman & Rosenberg, 1992). However, the frequency of some behaviors, such as insults or the kicking of objects, which often occur in the context of marital conflict but that do not involve direct physical assaults upon a spouse, still appear to be important in the prediction of concurrent child adjustment problems within maritally violent families. For example, in two separate studies, the frequency of spousal aggression other than physical marital violence has been found to contribute uniquely to the prediction of child problems after controlling statistically for physical marital violence (Jouriles et al., 1996). Consistent with this finding, laboratory data indicate that children with a history of exposure to physical marital violence respond more deviantly to simulated, nonviolent conflicts than children without such a history (Cummings, Pellegrini, Notarius, & Cummings, 1989; O'Brien, Margolin, John, & Krueger, 1991). Thus, children's exposure to physical marital violence does not appear to vitiate the impact of exposure to nonviolent marital conflict; in fact, exposure to physical violence may actually exacerbate the negative effects of exposure to nonviolent conflict. Physical marital violence is a very strong correlate of parental physical aggression towards children (Straus et al., 1980; Straus & Gelles, 1990), especially aggression towards male children (Jouriles & LeCompte, 1991; Jouriles & Norwood, 1995). There is also some indication that rates of child sexual abuse are extremely high in families characterized by physical marital violence (McCloskey, Figueredo, & Koss, 1995). As one might expect, children who are both victims of parental physical abuse and witnesses of interparent violence are at greater risk for problems than those who only witness interparent violence (Davis & Carlson, 1987; Hughes et al., 1989; O'Keefe, 1995; Silvern et al., 1995). Some research suggests that the effects of these two forms of family violence are additive (i.e., both the witnessing of interparent violence and the experiencing of parental aggression contribute unique variance in the prediction of child adjustment problems (O'Keefe, 1995). Other

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studies, however, emphasize the greater risk associated with the experience of physical parent±child aggression (Jouriles, Barling, & O'Leary, 1987; McCloskey et al., 1995). It is also possible that the experience of child abuse potentiates the effects of exposure to marital violence. Marital violence appears to be associated with poor mother±child relationships (McCloskey et al., 1995; O'Keefe, 1995). In fact, O'Keefe reported that within maritally violent homes, the mother±child relationship is more problematic than the father±child relationship. This finding is not only important in its own right, but it is also potentially important to our understanding of how violence affects children. Reviews of childhood stressors and protective factors (e.g., Garmezy, 1983; Luthar & Zigler, 1991; Rutter, 1987) suggest that a good parent±child relationship can buffer children from the negative consequences of stressful events. Thus, a child who has a poor relationship with his or her mother is perhaps more vulnerable to the negative effects of marital violence. It might be hypothesized that one of the pathways linking marital violence to child problems is its alteration of the quality of the mother±child relationship. Many other family variables have also been linked to marital violence, with varying support for marital violence's unique contribution to child behavior in the context of these other difficulties. Spaccarelli, Sandler, and Roosa (1994) found in a sample of inner city families that children's witnessing of marital violence correlated with parental divorce and singleparent status, lower family income, lower maternal education, frequent family moves, parental drinking, and father's incarceration. After statistically controlling for these variables, the witnessing of parental violence still contributed unique variance to the prediction of girls' conduct problems, and both boys' and girls' depression. In contrast, Wolfe et al. (1985) found marital violence to be correlated with maternal distress and the frequency of family moves, but exposure to marital violence did not contribute uniquely to the prediction of child problems after controlling for these variables.

9.20.10.3 Child Variables In the above review of the relationship between marital violence and child adjustment, research was discussed that has considered certain child variables such as age and gender. Very few studies have investigated other child variables. There are some data on child ethnicity which suggest that Caucasian boys may exhibit

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higher levels of externalizing problems in response to interparent violence than AfricanAmerican boys (O'Keefe, 1994; Stagg et al., 1989). There is also some evidence that children's cognitions about their parents' violence influences the effects of that violence. Specifically, children's ability to distract themselves and their ability to comfort themselves both appear to mitigate to some extent the negative impact of exposure to marital violence (Rossman & Rosenberg, 1992). However, methodological limitations make the reported data difficult to interpret precisely.

9.20.11 INTERVENTIONS The professional literature on children of battered women offers a number of suggestions for intervention and includes descriptions of several specific intervention programs. It is important to note, however, that many of these suggestions and programs are directed toward children of battered women as a group. That is, a child is targeted for intervention on the basis of the behavior of his or her mother's batterer rather than on the specific needs of the child. Moreover, with a few notable exceptions, systematic evaluation of the efficacy of these suggestions and programs has not been undertaken. With these problems in mind, we recommend the careful and thorough assessment of child and family functioning and then the customization of services to meet the specific needs of each family. Children respond in a variety of ways to their parents' marital violence, and this variability must be considered during assessment and intervention. For many of these children, the stress caused by factors associated with the sequelae of marital violence (e.g., changes in residence and schools) may be as or more important to the child's current level of functioning than their having witnessed martial violence (Jaffe, Wilson, & Wolfe, 1989). One area in need of assessment and potential intervention particularly worthy of note is children's safety. Children in maritally violent homes are at risk for child abuse, and its presence or potential must be considered. Children's knowledge of relevant safety steps has been identified as a potentially important area to address among children of battered women in that these children often require a greater repertoire of skills (e.g., finding a safe place for themselves during a violent incident, the ability to summon help or police without endangering themselves) than that required of most other children their age (Jaffe, Sudermann, & Reitzel, 1992). Other potentially important areas for assessment or intervention include

identifying and using social supports, coping with feelings of responsibility for family violence, coping with uncertainty about their own and their family's future, childrens' management of their own anger and other emotions, and the potential development of gender stereotypes based on their experience of violently coercive family interactions. These and other potential targets of intervention clearly warrant further research attention. 9.20.12 CONCLUSIONS Millions of women and children are exposed to husband violence each year in the USA, and the negative consequences of husband violence are many and varied. Not all women and children exposed to male violence suffer negative consequences or psychological problems; rather, the severity of consequences experienced is affected by a variety of factors, most importantly the level of violence experienced. Unfortunately, social scientists have only recently begun to study the problem of domestic violence. Thus, many therapists have received little formal training on this topic, and they may not be adequately prepared to deal with the problem of domestic violence as it affects the lives of their adult and child clients. For example, Hansen, Harway, and Cervantes (1991) mailed several hundred marital and family therapists case descriptions of couples seeking therapy and asked therapists to write a case conceptualization of the couple. The cases mentioned incidents of husband violence. However, very few of the therapists explicitly identified violence or battering as a problem, and therapists did not indicate that lethality was a possible concern, despite the fact that one of the cases actually ended in the husband's murder of the wife. These findings suggest that many therapists could benefit from learning more about the problem of domestic violence, the impact that aggression has on women and children, and the relationship between psychological symptoms and abuse experienced by women and children. Therapists owe it to the women and children who are the survivors of male violence to learn about this problem, respect their experiences, and do their best to help them end the violence in their lives. 9.20.13 REFERENCES Aguilar, R. J., & Nightingale, N. N. (1994). The impact of specific battering experiences on the self esteem of abused women. Journal of Family Violence, 9, 81±95. Aguirre, B. E. (1985). Why do they return? Abused women in shelters. Social Work, 30, 350±354.

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sion and abuse in marriage. In R. L. Hampton, T. P. Gollotta, G. R. Adams, E. H. Potter, & R. P. Weissberg (Eds.), Family violence: Prevention and treatment (pp. 86±112). Newbury Park, CA: Sage. Murphy, C. M., & O'Leary, K. D. (1989). Psychological aggression predicts physical aggression in early marriage. Journal of Consulting and Clinical Psychology, 57, 579±582. O'Brien, M., John, R. S., Margolin, G., & Erel, O. (1994). Reliability and diagnostic efficacy of parents' reports regarding children's exposure to marital aggression. Violence and Victims, 9, 45±62. O'Brien, M., Margolin, G., John, R. S., & Krueger, L. (1991). Mothers' and sons' cognitive and emotional reactions to simulated marital and family conflict. Journal of Consulting and Clinical Psychology, 59, 692±703. O'Keefe, M. (1994). Linking marital violence, motherchild/father-child aggression, and child behavior problems. Journal of Family Violence, 9, 63±78. O'Keefe, M. (1995). Predictors of child abuse in maritally violent families. Journal of Interpersonal Violence, 10, 3±25. Okun, L. E. (1986). Woman abuse: Facts replacing myths. Albany, NY: State University of New York Press. Pagelow, M. D. (1982). Children in violent families: Direct and indirect victims. In S. Hill & B. J. Barnes (Eds.), Young children and their families (pp. 47±72). Lexington, MA: D. C. Health. Pence, E. (1989). Batterer programs: Shifting from community collusion to community confrontation. In P. L. Caesar & L. K. Hamberger (Eds.), Treating men who batter (pp. 24±50). New York: Springer. Perilla, J. L., Bakeman, R., & Norris, F. H. (1994). Culture and domestic violence: The ecology of abused Latinas. Violence and Victims, 9, 325±339. Reynolds, R., & Siegle, E. (1959). A study of casework with sado-masochistic marriage partners. Social Casework, 40, 545±551. Riggs, D. S., Kilpatrick, D. G., & Resnick, H. S. (1992). Long-term psychological distress associated with marital rape and aggravated assault: A comparison to other crime victims. Journal of Family Violence, 7, 283±296. Rodenburg, F., & Fantuzzo, J. (1993). The measure of wife abuse: Steps toward the development of a comprehensive assessment technique. Journal of Family Violence, 8, 203±228. Rosenfeld, B. D. (1992). Court-ordered treatment of spouse abuse. Clinical Psychology Review, 12, 205±226. Rosenbaum, A., & O'Leary, K. D. (1981). Children: The unintended victims of marital violence. American Journal of Orthopsychiatry, 51, 692±699. Rosenberg, M. (1987). Children of battered women: The effects of witnessing violence on their social problemsolving abilities. The Behavior Therapist, 4, 85±89. Rossman, B. B. R., & Rosenberg, M. (1992). Family stress and functioning in children: The moderating effects of children's beliefs about their control over parental conflict. Journal of Child Psychology and Psychiatry, 33, 699±715. Rutter, M. (1987). Psychosocial resilience and protective mechanisms. American Journal of Orthopsychiatry, 57, 316±331. Saltzman, L. E., & Mercy, J. A. (1993). Assaults between intimates: The range of relationships involved. In A. V. Wilson (Ed.), Homicide: The victim/offender connection (pp. 65±74). Eastern Kentucky U, OH: Anderson Publishing. Sato, R. A. & Heiby, E. M. (1991). Correlates of depressive symptoms among battered women. Journal of Family Violence, 7, 229±245. Saunders, D. G. (1994). Posttraumatic stress symptom profiles of battered women: A comparison of survivors in

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Copyright © 1998 Elsevier Science Ltd. All rights reserved.

9.21 Victims of Child Maltreatment SANDY K. WURTELE University of Colorado, Colorado Springs, CO, USA 9.21.1 INTRODUCTION

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9.21.1.1 Defining Child Maltreatment 9.21.1.2 Nature of the Problem 9.21.1.3 Incidence and Consequences 9.21.2 ASSESSMENT

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9.21.2.1 Purpose and Process 9.21.2.2 Assessing Developmental Domains 9.21.2.2.1 Physical domain 9.21.2.2.2 Cognitive domain 9.21.2.2.3 Socioemotional domain 9.21.2.2.4 Behavioral domain 9.21.2.2.5 Psychosexual domain 9.21.3 TREATMENT

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9.21.3.1 Purpose and Process 9.21.3.1.1 Physical domain 9.21.3.1.2 Cognitive domain 9.21.3.1.3 Socioemotional domain 9.21.3.1.4 Behavioral domain 9.21.3.1.5 Psychosexual domain 9.21.4 PREVENTION

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9.21.5 FUTURE DIRECTIONS

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9.21.6 SUMMARY

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9.21.7 REFERENCES

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The purpose of this chapter is to provide an overview of the nature and prevalence of the three major types of child maltreatment: physical abuse, sexual abuse, and neglect. The chapter summarizes child-focused assessment strategies and psychosocial interventions with victims of child maltreatment. Finally, the chapter concludes by offering suggestions for moving research and practice forward.

9.21.1 INTRODUCTION Child maltreatment is a complex, tragic, and common social problem. Shamefully, ours is a society where children are hit, strangled, shaken, abandoned, starved, and raped. Every day, at least three children die from abuse and neglect in the USA. Numerous studies have implicated child maltreatment in the etiology of a broad range of physical, psychological, and social problems for children that can follow them into adulthood. Clearly, child maltreatment represents a significant physical and mental health concern for researchers and practitioners.

9.21.1.1 Defining Child Maltreatment It is important to distinguish between types of child maltreatment because the definition of 341

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child maltreatment will affect how cases are classified, how eligibility for social services is determined, and how treatment decisions are made. Definitions will also impact research findings. There is great variability among definitions of physical abuse, sexual abuse, and neglect, and the task of determining when adult actions are ultimately abusive remains complex. In this chapter, physical abuse involves acts of commission, which usually involve inflicting bodily injury on the child. Physical abuse can include scalding, shaking, beating the child with an object, severe physical punishment, and a rare form called Munchausen by proxy syndrome, where an adult feigns or induces illness in a child. Sexual abuse has been defined as contacts or interactions between a child and an adult when the child is used for the sexual stimulation of the perpetrator or another person (National Center on Child Abuse and Neglect, 1978). Offenders may include older children (usually five years age difference) and adults other than parents (e.g., teachers, coaches, strangers). Acts defining sexual abuse include penile penetration (oral, anal, or genital), fondling of genital areas, exposure to indecent acts, or involvement in child pornography. Neglect relates to acts of omission by the caregiver, and is evidenced by failing to meet the child's needs for adequate food, clothing, shelter, hygiene, supervision, education, and/or medical care. The most extreme form of neglect is failure to thrive or growth deficiency, where the infant fails to gain weight due to malnutrition. It has become clear that maltreatment subtypes overlap and that pure subtypes are rare. In this chapter, the term child maltreatment is used to reflect the variability of this phenomenon.

9.21.1.2 Nature of the Problem Who are the victims of these forms of maltreatment? Victims of child maltreatment can be of any age from zero to 18 years. According to the US Department of Health and Human Services (1996), in 1994 about 27% of victims were three years old or younger. Children aged four to six years represented about 20% of the victims, children aged seven to nine years represented 17%, children aged 10 to 12 years represented 15%, and teenagers (13±18 years old) made up about 21% of the victims. The highest risk for death from physical abuse and neglect is among children less than two years old; 41% of child abuse fatality victims are under the age of one (US Advisory Board on Child Abuse and Neglect, 1995). The number of victims of neglect rapidly decreases with

increasing age for both male and female cases, whereas sexual abuse cases increase with age. Victims of maltreatment include both boys and girls of different races. According to the US Department of Health and Human Services (1996), in 1994, 52% of the victims of maltreatment were female, and 47% were male (with 1% unknown). Victims of sexual abuse are predominantly female. Maltreated children are primarily white (56%), with African-American children representing 26%, Hispanic 9%, and native American victims making up about 2%. African-American children are relatively more likely to be fatally injured or neglected, and less likely to be sexually abused. Caucasian families are more likely to engage in physical abuse, sexual abuse, or a combination of physical abuse and neglect. 9.21.1.3 Incidence and Consequences In 1994, an estimated 2.9 million children were reported to public child protective service agencies as alleged victims of child maltreatment (US Department of Health and Human Services, 1996). Neglect was the most common form of reported child maltreatment, accounting for 53% of cases, followed by physical abuse (26%), and sexual abuse (14%). The incidence and tragic consequences of child maltreatment prompted the US Advisory Board on Child Abuse and Neglect (1990) to claim that the problem of child abuse and neglect has reached epidemic proportions in the USA and that it constitutes a national emergency. Child maltreatment is all too common, and much too tragic. Each day in the USA, three to five children die as a result of either physical abuse, neglect, or both (Daro; 1995; US Advisory Board on Child Abuse and Neglect, 1995). Child maltreatment is now the leading cause of death for children under the age of four (US Advisory Board on Child Abuse and Neglect, 1995). Each year, 150 000 children are seriously injured and 18 000 are permanently disabled by abuse or neglect. According to estimates provided by the General Accounting Office, the services required for children who have been abused or neglected cost more than $500 million annually. In addition to the economic costs, the human costs are also distressing. 9.21.2 ASSESSMENT 9.21.2.1 Purpose and Process Conducting a thorough assessment of victims of child maltreatment is important for both researchers and practitioners. Researchers need to obtain a reliable and valid assessment of

Assessment children's experiences and their current level of functioning to better understand the psychological sequelae of child maltreatment. Practitioners likewise need to understand children's experiences and reactions, but additional objectives for assessment are to devise appropriate treatment interventions and monitor treatment progress. Assessment is also important for forensic purposes, but this type of evaluation is complex and beyond the scope of this chapter. There are several measurement issues that need to be considered throughout the assessment process. The assessment process should be grounded in the field of developmental psychopathology, which is a perspective that examines the evolution of psychological disturbances in the context of development. This approach studies the developmental tasks that are compromised by stressful events, and utilizes measures that are linked to developmental tasks. Given that child maltreatment is associated with a variety of psychological sequelae, assessment in each developmental domain (i.e., physical, cognitive, socioemotional, behavioral) is recommended. What one chooses to measure is also determined by one's theoretical framework. For example, an ecological/transactional model of child maltreatment (Cicchetti & Lynch, 1993) suggests that assessment needs to occur at all levels of children's ecologies (i.e., the macrosystem, exosystem, microsystem, and ontogenic level). In addition to assessing areas of deficits, the assessment should also elucidate areas of strength. Understanding the child's and family's strengths should inform one's choice of effective treatment interventions. Another general measurement issue is from whom information about the case is obtained. Although many researchers and clinicians rely exclusively on reports provided by child protective service workers, there is much to be gained by using multiple sources of data, including parents, teachers, and children. The assessment process begins with the clinical interview, during which the clinician makes informal observations of the child. The purpose of assessment should be explained to the family, and the clinician must discuss the limits of confidentiality. Both parents and children should be asked questions about the circumstances surrounding the maltreatment. Behaviorally oriented clinicians often use a functional analysis model; asking about the antecedents to the abuse, the abusive behavior itself, and the consequences for the abusive behavior. Gathering information about the nature and extent of the abuse or neglect is important in order to gain insight into the clinical issues most salient to the case and to prescribe the most appropriate therapeutic intervention.

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Risk assessment should occur throughout this initial assessment process and on an ongoing basis. Children cannot benefit from therapy when they continue to be victimized outside the clinic setting. The family's willingness to discuss the maltreatment is important to monitor. With defensive parents, more time needs to be spent developing rapport before trying to conduct assessments. The clinician should relate to the parents and their children in a warm and supportive manner, but not condone the abusive or neglectful behavior. In addition to the identified abuse, it is critically important to determine whether other types of maltreatment or family violence are occurring. 9.21.2.2 Assessing Developmental Domains A number of assessment devices have been utilized with victims of child maltreatment. A list of measures used to assess the effects of child maltreatment for each developmental domain is contained in Table 1. Professionals will not need to use all of these measures. Hopefully, this list will serve to supplement one's current assessment battery, and to encourage assessment of each developmental domain. Readers are urged to select those measures that best fit the characteristics of their clients, time constraints, and their own expertise. 9.21.2.2.1 Physical domain Children's medical records should be reviewed to obtain health history data and results of medical or forensic evaluations. Physical or neurological damage may relate to academic and social functioning and may affect treatment outcome. Given the frequent finding of developmental delays, a developmental assessment may be necessary, and several instruments are available to measure motor, communication, self-care, and physical development (see Table 1). Somatic complaints have been mentioned frequently among sexually abused children, which may be related to a heightened focus on the physical self (Friedrich & Schafer, 1995). Somatic complaints have usually been assessed by using a checklist of symptoms or by employing the Child Behavior Checklist (CBCL; Achenbach & Edelbrock, 1983) which has a somatic complaints subscale. Very little is known about the psychophysiological consequences of child maltreatment. Researchers in the physical abuse area have sampled maltreated childrens' saliva to measure cortisol secretion (e.g., Hart, Gunnar, & Cicchetti, 1995), and have monitored childrens' heart rates in response to affect-ladened stimuli

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Victims of Child Maltreatment Table 1 Measures used to assess effects of child maltreatment. Developmental domain/tests

Physical Bayley Scales of Infant Development Denver Developmental Screening Test Learning Accomplishment Profile McCarthy Scales of Children's Abilities Minnesota Child Development Inventory Vineland Adaptive Behavior Scales-Revised Child Behavior Checklist Cognitive Intelligence WPSSI-R WISC-III Stanford±Binet K-ABC Language Peabody Picture Vocabulary Test-Revised (Dunn & Dunn; 1981) Test of Auditory Comprehension of Language-Revised (Carrow-Woolfolk, 1985) Expressive One-word Picture Vocabulary (Gardner, 1979) Academic Achievement WRAT-R Woodcock Mastery Tests Iowa Test of Basic Skills Child Behavior Checklist (Achenbach & Edelbrock, 1983) Self-esteem Piers±Harris Children's Self-concept Scale (Piers & Harris, 1984) Pictorial Scale of Perceived Competence and Social Acceptance for Young Children (Harter & Pike, 1984) Self-perception Profile for Children (Harter, 1985) Coopersmith Self-esteem Inventory (Coopersmith, 1986) Tennessee Self-concept Scale (Fitts, 1965) Rosenberg Self-esteem Scale (Rosenberg, 1979) Self-perception Profile for Adolescents (Harter, 1988) Attributions Children's Attributional Style Questionnaire (Kaslow, Tannenbaum, & Seligman, 1978) Hopelessness Scale for Children (Kazdin et al., 1983) Locus of Control Scale for Children (Nowicki & Strickland, 1973) Stanford Internal±External Locus of Control Scale (Mischel, Zeiss, & Zeiss, 1974) Children's Impact of Traumatic Events Scales (Wolfe et al., 1991) Children's Attributions and Perceptions Scale (Mannarino et al., 1994) Coping Styles Ways of Coping Checklist-Revised (Folkman & Lazarus, 1980) Child Dissociative Checklist (Putnam et al., 1993) Socioemotional Social Behavior/Skills Child Behavior Checklist Preschool Behavior Questionnaire (Behar & Stringfield, 1974) Teacher±Child Rating Scale (Hightower, Spinell, & Lotyczewski, 1985) Behavior Problem Checklist (Quay & Peterson, 1987) Matson Evaluation of Social Skills with Youngsters (Matson, Esveldt-Dawson, & Kazdin, 1983) Self-perception Profile for Children (Harter, 1985) Friendship Questionnaire (Bierman & McCauley, 1987) Social Problem-solving Measure (Pettit et al., 1988) Depression Children's Assessment Schedule (Hodges, Kline, McKnew, & Cytryn, 1992) Diagnostic Interview for Children and Adolescents (Welner, Reich, Herjanic, Jung, & Amado, 1987) Diagnostic Interview Schedule for Children-Revised (Shaffer et al., 1993) Interview Schedule for Children (Kovacs, 1983) Schedule of Affective Disorders and Schizophrenia-Child Version (Chambers et al., 1985) Children's Depression Inventory (Kovacs, 1981, 1992) Beck Depression Inventory (Beck, 1976) Reynolds' Adolescent Depression Scale (Reynolds, 1987)

Assessment

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Table 1 (continued) Developmental domain/tests Anxiety Fear Survey Schedule for Children-Revised (Ollendick, 1983) Revised Children's Manifest Anxiety Scale (Reynolds & Richmond, 1985) State±Trait Anxiety Inventory for Children (Spielberger, 1973) Children's Impact of Traumatic Events Scale-Revised (Wolfe et al., 1991) Children's Post-traumatic Stress Disorder Inventory (Saigh, 1989) Behavioral Child Behavior Checklist (Achenbach & Edelbrock, 1983) Louisville Behavior Checklist (Miller, 1979) Eyberg Child Behavior Inventory (Eyberg & Ross, 1978) Revised Behavior Problem Checklist (Quay & Peterson, 1987) Preschool Behavior Questionnaire (Behar & Stringfield, 1974) Psychosexual Child Sexual Behavior Inventory (Friedrich et al., 1992) Children's Impact of Traumatic Events Scale-Revised (Wolfe et al., 1991) Trauma Symptom Checklist for Children (Briere, 1996)

(Hill, Bleichfield, Brunstetter, Hebert, & Steckler, 1989). There is some evidence that sexual abuse may elevate cortisol levels and advance the onset of puberty among girls (Putnam & Trickett, 1993), and disrupt the hypothalamic± pituitary±adrenal axis (De Bellis et al., 1994). The lack of sensory experience (as during neglect), or excess exposure to traumatic experiences (as during physical or sexual abuse), can alter neuronal neurochemistry, cytoarchitecture, and, ultimately, brain structure and function in severely traumatized children (Perry, Pollard, Blakley, Baker, & Vigilante, 1995). Although continued research in this area will undoubtedly shed light on abuse-related symptomatology and help us to understand how children adapt to various traumatic experiences, the methodological limitations associated with biological measures will most likely limit their use among practicing clinicians. 9.21.2.2.2 Cognitive domain Physically abused and neglected children often demonstrate deficits on measures of intelligence (Crouch & Milner, 1993). Intellectual impairments may be due to direct insult, poor nutrition, or insufficient stimulation. General intellectual functioning can be assessed by an individually administered psychometric test of intelligence (see Table 1). A language assessment is often important to conduct, given that maltreated children have been found to exhibit delays in both expressive and receptive language (Vondra, Barnett, & Cicchetti, 1990), as well as deficits in their abilities to maintain dialogues and discuss or identify their own feelings (Coster, Gersten, Beeghly, & Cicchetti, 1989).

Maltreated children perform poorly on academic achievement tests, receive low grades, and exhibit problematic classroom conduct (Eckenrode, Laird, & Doris, 1993; KendallTackett & Eckenrode, 1996; Leiter & Johnsen, 1994). A standard achievement test, along with teacher reports and school records, can provide information on academic functioning of schoolaged children. Teachers themselves can provide a wealth of information about the child's academic functioning in the classroom and his/her social competence with peers. Children's perceptions of their academic competence can be assessed using the cognitive competence subscale of the Pictorial Scale of Perceived Competence and Social Acceptance for Young Children (Harter & Pike, 1984). Research has shown that maltreated children evidence deficits in self-concept and self-esteem (Kaufman & Cicchetti, 1989; Toth, Manly, & Cicchetti, 1992), although the findings with sexually abused children have been mixed, with some researchers finding lower self-esteem among incest victims (Hotte & Rafman, 1992) and others finding no evidence for lower selfesteem (Mannarino, Cohen, Smith, & MooreMotily, 1991). These conflicting results may be due to differences in the ages of the victims and/ or the types of abuse experienced. Another concern is whether victims overestimate the amount of danger in the world and underestimate their self-efficacy or self-worth. Some researchers have assessed the ways in which children attribute causality for good and bad events using the Children's Attributional Style Questionnaire (CASQ; Kaslow, Tannenbaum, & Seligman, 1978). Negative expectations about the future can be assessed by using

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the Hopelessness Scale for Children (HPLS; Kazdin, French, Unis, Esveldt-Dawson, & Sherrick, 1983). Table 1 also contains measures of generalized locus of control used with maltreated children. Attributions that victims make about themselves and the abuse are also important for understanding children's reactions and for guiding treatment interventions. Sexual abuse victims frequently have distorted cognitions about themselves and the abuse. The Children's Impact of Traumatic Events Scale (CITES; Wolfe, Gentile, Michienzi, Sas, & Wolfe, 1991) contains subscales designed to measure children's perceptions and attributions concerning their sexual abuse. The Children's Attributions and Perceptions Scale (CAPS; Mannarino, Cohen, & Berman, 1994) was also designed to measure abuse-related perceptions and attributions among sexually victimized children, although it has also been used with physically abused children (Kolko, 1996). Other ways to explore a child's attributions of responsibility include direct questioning, asking children what they would do differently if they were molested again, and using projective techniques to help children talk about their attributions indirectly (Celano, 1992). Several researchers have suggested that the coping styles victims use play important roles as mediators of sexual abuse sequelae (e.g., Spaccarelli, 1994). For example, Johnson and Kenkel (1991) assessed coping strategies of sexually abused adolescent females by using a modified version of the Ways of Coping Checklist-Revised (WCCL-R; Folkman & Lazarus, 1980). Teenagers were asked to rate their use of such strategies as problem-focused coping, wishful thinking, distancing/detachment, emphasizing the positive, tension-reduction, self-isolation, and support seeking. Dissociation as a coping strategy has also been assessed. Putnam, Helmers, and Trickett (1993) developed the Child Dissociative Checklist (CDC) which measures several domains of dissociative behaviors (e.g., amnesias, trance states, hallucinations). Research into the coping processes of children exposed to traumatic experiences has only begun (e.g., Compas, 1987; Wertlieb, Weigel, & Feldstein, 1987) and will hopefully inform the child maltreatment field as to the impact coping behaviors might have on the development and course of abuse-related symptomatology. 9.21.2.2.3 Socioemotional domain According to Cicchetti (1987), childhood maltreatment should be conceived of as relational psychopathology, arising from a dysfunction in the parent±child±environment

transactional system. This type of relational disorder can be seen during the first year of life, when the development of a secure attachment relationship with the primary caregiver occurs. Several investigators have found that maltreated infants and toddlers are significantly more likely to form insecure attachment relationships (e.g., Carlson, Cicchetti, Barnett, & Braunwald, 1989). There have been no studies to date looking at attachment in a sexually abused population, although Alexander (1992) has argued that sexual abuse often develops out of the context of an insecure parent±child attachment. In addition to negative relationships, it is also important to determine if the child has any positive relationships (e.g., with a grandparent, teacher, or sibling). If positive relationships exist, this suggests that the child may be more open to forming a therapeutic alliance, a positive outcome may be optimized, and it also suggests the possibility that this significant other might provide assistance during the therapeutic process. Kaufman (1991) used a modified form of the Arizona Social Support Interview Schedule (ASSIS; Barrera, 1980) to assess the extent and quality of the child's social supports. These early attachment difficulties are likely to be carried forward through development, affecting the subsequent developmental task of forming effective peer relations. Maltreated children, especially physically abused children, are at risk for poor peer relations (Conaway & Hansen, 1989). Compared with nonmaltreated children, physically abused or neglected preschool-aged children tend to be more aggressive, less prosocial, have fewer positive interactions, and are more likely to respond to distressed peers with aggressive behaviors instead of concern, empathy, or sadness. Maltreated preschoolers also show developmental delays in their play behavior (Alessandri, 1991). School-aged maltreated children have been shown to have lower peer status, are viewed by their peers as aggressive and uncooperative, and evidence less reciprocity in friendship relations (Dodge, Pettit, & Bates, 1994; Rogosch & Cicchetti, 1994; Salzinger, Feldman, Hammer, & Rosario, 1993). With peers, physically abused children also show a negative attributional bias toward inferring negative and hostile intent, which increases the likelihood of aggressive responding (Weiss, Dodge, Bates, & Pettit, 1992), but evidence is mixed regarding whether they lack effective social problem-solving skills (Levendosky, Okun, & Parker, 1995). Neglected children tend to withdraw from interaction with peers (Crittenden, 1992), making them at risk for increasing isolation and rejection.

Assessment Problems relating to peers have been assessed using a variety of measures. For example, children have been asked to nominate peers who are cooperative, disruptive, and aggressive, nominate classmates to portray specified roles in a class play, such as ªpicks on other kids,º or ªmakes new friends easilyº (Rogosch & Cicchetti, 1994), or to rate on five-point scale how much they like and dislike their classmates (Dodge et al., 1994). Play and social behavior in maltreated children have also been observed and then coded into types of play (Alessandri, 1991) or scored according to how much aggressive or prosocial behavior is exhibited during structured or unstructured play (Howes & Eldredge, 1985). Teachers can also provide valuable information about children's behaviors in the classroom and when interacting with peers. Teacher-completed and self-report measures of social behaviors and social skills are included in Table 1. In addition, maltreated children's social problem-solving skills have been assessed using the Social Problem-Solving measure (SPS; Pettit, Dodge, & Brown, 1988) which presents hypothetical peer scenarios and asks children to generate solutions to each scenario. A related impairment within this domain is that maltreated children often have affectregulation deficits. They have difficulty understanding or accepting emotions in themselves and others. Physically abused (and neglected) children perform more poorly than controls on measures of affective and cognitive role-taking, social sensitivity, the ability to discriminate emotions in others, and in their ability to respond empathically to others in distress (Howes & Eldredge, 1985; Main & George, 1985). The problem with assessing this developmental impairment is the absence of standardized measures. Instead, researchers have used audiotaped skits, puppet play procedures, and direct observation of children; procedures which most clinicians will find too time intensive for routine use. The development of a comprehensive assessment battery of emotional regulation problems of maltreated children is most needed. Research evidence also supports a relationship between maltreatment in childhood and such internalizing psychological problems as depression and anxiety. Physically abused children evidence higher levels of depressive symptomatology compared with nonmaltreated children (Toth et al., 1992), although the findings with sexually abused children are less consistent, with some researchers finding sexually abused children to be more depressed (e.g., Wozencraft, Wagner, & Pellegrin, 1991), and others finding no support for elevated levels of depression (Mannarino, Cohen, & Gregor, 1989). To elicit information about the child's

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depressive symptoms, along with other aspects of the child's behavior, thinking, and mood, various structured interviews have been developed. The most common structured interviews used with maltreated children are contained in Table 1, which also includes instruments for measuring self-reported depression. Depressive symptomatology can also be revealed in children's Rorschach responses (Shapiro, Leifer, Martone, & Kassem, 1990). Maltreated (especially sexually abused) children also evidence heightened levels of anxiety. General anxiety problems can be assessed using the instruments listed in Table 1. Given that sexually abused children often exhibit symptoms of re-experiencing the trauma, avoidance of abuse-related stimuli, diminished responsiveness to the environment, and increased arousal/anxiety, many researchers have conceptualized sexual abuse as possibly leading to post-traumatic stress disorder (PTSD; Miller-Perrin & Wurtele, 1990). Indeed, significant percentages of sexually abused children have met the diagnostic criteria for PTSD. For example, in their extensive literature review of the impact of sexual abuse on children, Kendall-Tackett, Williams, and Finkelhor (1993) found that 53% of sexually abused children exhibited PTSD symptomatology. To assess PTSD symptoms via parent report, Wolfe, Gentile, and Wolfe (1989) selected 20 PTSD-like behaviors from the CBCL to comprise a CBCL-PTSD scale. These items measure such problems as difficulty concentrating, difficulty sleeping, somatic complaints, and obsessive thoughts. The Children's Impact of Traumatic Events Scale-Revised (CITES-R; Wolfe et al., 1991) assesses children's perceptions and attributions concerning their own sexual abuse. It includes a subscale which measures such PTSD symptoms as intrusive thoughts, avoidance, hyperarousal, and sexual anxiety. A checklist of PTSD symptoms was used by McLeer, Deblinger, Atkins, Foa, and Ralphe (1988). Raters indicate whether the child exhibits any behaviors listed in the three subcategories: (i) re-experiencing behaviors (e.g., flashbacks, nightmares); (ii) avoidant behaviors (e.g., avoidance of people or places associated with the abuse); and (iii) autonomic hyperarousal (e.g., irritability, difficulty falling asleep). Finally, the Children's PTSD Inventory has been developed by Saigh (1989) to be used in a structured interview format. Existing measures rely heavily upon verbal and reading skills. With younger children, evidence of PTSD symptoms can be gleaned from children's drawings or observation of the child's play (Pynoos & Eth, 1986). Given that assessing stress-related reactions in victimized children is an important step

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in the assessment process, it is hoped that researchers will continue their efforts to validate these measures and observational approaches. 9.21.2.2.4 Behavioral domain Behavior problems appear to be very common among maltreated (especially physically abused) children, including heightened aggressive behavior, noncompliance, impulsivity, and conduct problems. The aggressiveness of physically abused children often extends into delinquency during adolescence and also violent criminal acts during adulthood (Widom, 1989a, 1989b). Physical aggression and antisocial behavior have been assessed using observational methods, or more frequently by having parents or staff complete instruments measuring behavior problems. Several well-validated instruments are available to identify problem areas within the behavioral domain; five of them are listed in Table 1. 9.21.2.2.5 Psychosexual domain Effects of maltreatment on this domain have only been examined with respect to sexually victimized children. Over the course of abuse, a child's sexuality becomes distorted; a process Finkelhor and Browne (1985) refer to as traumatic sexualization. Sexually abused children are much more likely to display behaviors indicative of abnormal or precocious sexual development. There is also a strong relationship between child sexual abuse and adolescent pregnancy (Boyer & Fine, 1992; Rainey, Stevens-Simon, & Kaplan, 1995). In their review of the literature, Kendall-Tackett et al. (1993) noted that sexuality problems, in addition to PTSD symptomatology, were the only sets of symptoms that consistently discriminated sexually abused children from nonabused, clinicreferred children. These researchers estimated that 38% of sexually abused children exhibited sexuality problems. In order to assess sexuality problems, researchers have most often used either the sexual behavior subscales of the CBCL, or the Child Sexual Behavior Inventory (CSBI), a parentreport measure for children aged two to 12 (Friedrich et al., 1992). Other researchers have created lists of sexual symptoms, and then asked parents to indicate if the behaviors have occurred (e.g., White, Halpin, Strom, & Santilli, 1988). In addition to questionnaires, sexuality problems have also been assessed using drawings, doll play, and self-report. Human figure drawings of sexually abused children have been characterized by either exaggerated or mini-

mized genitalia (e.g., Burgess, 1988; Hibbard, Roghmann, & Hoekelman, 1987). Regarding play behaviors, sexually abused children are more likely to demonstrate sexual behaviors with anatomically detailed dolls (Jampole & Weber, 1987), although nonabused children have also been observed to show some sexual play with these dolls (Everson & Boat, 1990). Finally, two self-report instruments tap sexual issues: CITES-R (Wolfe et al., 1991) and the Trauma Symptom Checklist for Children (TSCC; Briere, 1996). 9.21.3 TREATMENT 9.21.3.1 Purpose and Process Treating victimized and neglected children presents several unique challenges. Given the often abhorrent acts done to children, the first challenge is being able to form a therapeutic alliance with the parent who has abused or neglected the child. Then the characteristics of many abusive and neglecting families can make this work difficult, as they may be poorly educated, deny that they need help or be mandated to participate in treatment, or have chaotic lifestyles that can disrupt the treatment process. Traditional models of therapy often fail to meet their needs. Maltreated children present unique challenges, as they may be anxious, withdrawn, aggressive, inattentive, overly dependent, or sexually provocative. Given the likelihood of attachment problems and their previous experiences of being abused or manipulated, it often takes several sessions for maltreated children to trust or engage with a clinician. Managed care's limitations on the number of sessions can impede this therapeutic process. Once they do engage, the relationship often becomes very significant for the child, which can make termination difficult. This work is also challenging because it often requires collaborating with professionals from very different systems (i.e., legal, social services, and mental health); each with different methods, goals, and perspectives. Some of these professionals may not value mental health services in general or may not believe that the psychological treatment of children is necessary. Many clinicians find the oftentimes necessary involvement in the legal system to be quite stressful. Finally, treatment decisions are difficult to make given the paucity of literature evaluating treatment interventions with maltreated children. For physical abuse and neglect, most clinical work and empirical research focus largely on the maltreating parents, with relatively little attention paid to the child victims.

Treatment Children's involvement in treatment has usually occurred in the context of family-based services, making it difficult to determine the specific contribution of child treatment to outcomes. When victims are targeted, most studies include both physically abused and neglected children; few specify the numbers in each category (Oates & Bross, 1995) and even fewer differentiate between abused and neglected in terms of outcome. Within the sexual abuse area, there is a great deal of clinical literature describing the treatment of child victims of father daughter incest, but less has been written about children who have been abused by nonfamily members or about male victims. Even in the sexual abuse field, the effectiveness of sexual abuse treatment has not yet been proven (Becker et al., 1995; Finkelhor & Berliner, 1995). Even though there are over 2000 programs in the USA for the treatment of child sexual abuse, few programs use objective measures for assessment and even fewer conduct follow-up evaluations (Keller, Cicchinelli, & Gardner, 1989). Of those studies that used quantitative measures, most were pre±post designs, which cannot tell us if the improvement was due to the treatment or simply the passage of time. Thus, there are few, if any, guidelines for matching victims to types of treatments. Given the limited empirical knowledge about the differential effectiveness of various forms of treatment, along with the heterogeneity of child maltreatment victims, it may be most parsimonious to focus on specific symptoms or problems exhibited by victims of child maltreatment. Heterogeneity of child maltreatment requires heterogeneity of treatment. The following section presents treatment suggestions drawn from research with abused and nonabused children which addresses many of their typical presenting problems. In terms of process, clinicians should begin with a comprehensive assessment of the child and then, with input from the client(s), devise a therapeutic approach targeted at the identified problem areas. Treatment should be aimed at facilitating growth and competence in all developmental domains. Child-focused treatment modalities have included individual therapy, play therapy, drama therapy, art therapy, group therapy, cognitive-behavioral therapy, and behavior modification. While the child is in individual therapy, it is important to remember that she/he is being affected by home, school/daycare, and the broader community. As noted by Toth and Cicchetti (1993), ªtherapy with a maltreated child cannot be limited to the confines of the playroom, but must transcend the safety of the office to confront and impact upon the factors that may continue to assault

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the child in his or her daily lifeº (p. 415). Child maltreatment does not occur in a vacuum, nor should treatment. The effectiveness of treatment is bound to be strongly influenced by family and school contexts, and therapeutic interventions need to be directed at the system(s) in which the child is living. 9.21.3.1.1 Physical domain Within the physical domain, specific target behaviors might include developmental delays, motor delays, self-help skills, or toileting problems. For example, Project 12-Ways, an ecobehavioral approach to the treatment and prevention of child abuse and neglect, has evaluated treatments for child neglect dealing with hygiene, nutrition, home safety, cleanliness, infant stimulation, and teaching healthrelated skills (Lutzker, 1990). Some of the training has been directed at the children, for example, by teaching them proper hygiene and toilet training. The problem of developmental delays often seen in physically abused and neglected children has also been addressed by enrolling the children in a therapeutic preschool. Often, these programs focus on developing normal gross and fine motor, language, and social skills. For example, Parish, Myers, Brandner, and Templin (1985) demonstrated that a family development center, which combined services to parents (e.g., parenting skills classes) and preschool classes for children, produced substantial developmental skills gains, especially in fine motor and language skills. Developmental gains in abused preschoolers were also found by Oates, Gray, Schweitzer, Kempe, and Harmon (1995). Further, developmental gains relative to a control group have been reported in other studies (Culp, Heide, & Richardson, 1987; Culp, Little, Letts, & Lawrence, 1991). Unfortunately, the multifaceted nature of treatment and absence of follow-up assessments limit the conclusions that can be made about therapeutic day-care programs. Clinicians can also teach parents how to stimulate their infant's development. Walker, Bonner, and Kaufman (1988) suggested that clinicians assign parents stimulation tasks to carry out at home. These tasks should be assigned to remedy the specific deficits identified during the assessment process. Research is needed to determine the impact of such infant stimulation programs on children victimized by neglect. Cases of extreme neglect, or failure to thrive (FTT), require medical diagnosis and management, nutrition intervention, and psychosocial intervention, often in a hospital setting. Drotar

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(1995) also emphasized that clinical care of FTT should involve not only the management of current physical, psychological, and behavioral disturbances, but also the prevention of future problems. 9.21.3.1.2 Cognitive Domain Given the findings documenting academic difficulties among maltreated children (Eckenrode et al., 1993), addressing this problem would appear warranted and should occur early (e.g., in elementary school; Kendall-Tackett & Eckenrode, 1996). Therapists can attend to academic problems in various ways. Clinicians can: (i) consult with teachers to help them understand the relationship between the child's behaviors and abuse-related experiences; (ii) conduct a thorough assessment of the child in order to formulate an intervention plan; (iii) design an educationally beneficial environment for the child; (iv) provide individual and family therapy; and (v) ensure that the child receives special programs or services to promote successful school adaptation and prevent school failure. Depending on the extent of child maladaptation, educational intervention may best take place in a specialized school or preschool setting. Suggestions for making preschool classrooms function as therapeutic environments can be found elsewhere (Ayoub, 1991; Crittenden, 1989; Koplow, 1996). In this setting, mental health professionals can provide therapeutic services to victims, maltreating parents, and serve as educational consultants. They can also assist the child in making the transition to more conventional learning environments. Clearly, the role of the educational system in addressing the special needs of maltreated children must be stressed. Findings that abuse-related attributions and perceptions are predictive of psychological symptoms in sexually abused girls (e.g., Mannarino & Cohen, 1996) suggest that these factors need to be addressed in therapy. It is believed that group therapy is particularly effective in helping victims deal with issues of blame, responsibility, and feeling different from peers. One advantage of the group format over individual therapy or family therapy is that victimized children have the opportunity to interact with peers who have experienced similar abuse. They can form positive images of other abused children, receive feedback and support from their peers, and have their distorted beliefs about themselves and the abuse challenged by group members. Several descriptions of group treatment models for sexually abused children and adolescents are available, but the reader should note that the relative

efficacy of group therapy compared with other modalities has not been determined (e.g., Hack, Osachuk, & De Luca, 1994; McGain & McKinzey, 1995; Sinclair et al., 1995; Zaidi, & Gutierrez-Kovner, 1995). During individual sessions, cognitive therapy can be employed to identify and correct any distortions or irrational beliefs a child has related to the abuse. Berliner and Wheeler (1987) emphasized the importance of identifying why children believe they were responsible for the abuse and then helping them understand the distinction between characterological selfblame, which can be maladaptive, and behavioral self-blame, which may be an adaptive coping response. They also encourage therapists to have the children recall the events or behaviors that preceded the actual abuse, with the goal being to help the child client recognize indications of abuse early to avert another incident. This strategy would appear to help reduce the child's feelings of powerlessness, while simultaneously empowering child victims to act responsibly and assertively in the future. 9.21.3.1.3 Socioemotional Domain Although many theorists agree that attachment problems are central to all forms of child maltreatment, effective interventions to ameliorate attachment disorders are few in number and are mostly directed toward the periods of infancy and toddlerhood. For example, dysfunctional relationships during toddlerhood have been treated using infant-parent psychotherapy (Lieberman, 1992). Sessions are conducted with the parents and child in the office and at home. The therapist provides developmental guidance, helps the mother explore her perceptions, feelings, and reactions to the child, assists her in understanding how her own attachment and developmental experiences affect her relationship with her child, and stimulates changes in her internal representational models. Significant improvements in child, mother, and dyadic functioning have been found using this approach with high-risk families (Lieberman, Weston, & Pawl, 1991). To treat peer relationship difficulties, behavioral approaches have been utilized to decrease aggressiveness and social withdrawal. For example, Fantuzzo et al. (1988) used peerinitiated social interaction to increase the positive social behavior of withdrawn, maltreated preschool children. More recently, Kolko (1996) noted the limited effectiveness of teaching interpersonal skills with physically abused children involved in individual therapy, and suggested the use of group or peer-based interventions to enhance social competence.

Treatment There is also an extensive literature on social skills interventions with nonabused children and adolescents that could be applied to abused children with social interaction deficits (Beelmann, Pfingsten, & Losel, 1994; La Greca, 1993). Aggressive and impulsive behavior has also been treated successfully using cognitive behavioral strategies (Lochman, Dunn, & Klimes-Dougan, 1993; Pepler & Rubin, 1991). Inclusion of teachers and parents in intervention planning is important because of their role in arranging opportunities for peer interactions, for monitoring peer behaviors, and providing appropriate consequences. To treat anger and aggression, many clinicians encourage sexual and physical abuse victims to talk about their maltreatment and to express their angry feelings during play or verbal therapy. This strategy is believed to serve as a helpful form of catharsis and as an opportunity for gaining insight and to learn alternative social behaviors (e.g., Walker & Bolkovatz, 1988). Unfortunately, there is no empirical support for this practice, and there is the concern that making child maltreatment victims discuss their victimization may be potentially harmful (Weinbach & Curtiss, 1986). The impact of this practice must be empirically determined. Given the frequent finding of lack of empathy among physically abused and neglected children, it would appear very important to provide empathy training in therapy. Unfortunately, problems with empathy, attachment, trust, and affect regulation are difficult to measure and persistently resistant to therapeutic intervention experiences (Carlson et al., 1989). Friedrich (1996) suggested that group treatment should be an effective therapeutic modality to learn empathy, but this assumption needs to be tested empirically. Therapeutic interventions for anxiety will depend on how the child expresses the anxiety. For children who experience intrusive thoughts, anxiety, or fears/phobias, interventions such as systematic desensitization, guided imagery, relaxation training, controlled breathing, selfhypnosis, and thought-stopping have been recommended (Lipovsky, 1991; Walker et al., 1988). Children who exhibit PTSD symptoms have been found to benefit from participating in cognitive-behavioral treatment programs that include modeling, cognitive restructuring, coping skills training, gradual exposure to feared stimuli, and sexual abuse education and body safety skills training (Berliner & Saunders, 1996; Deblinger, Lippmann, & Steer, 1996). Others have found anxiety levels among sexually abused girls to decrease significantly as a function of group therapy (McGain & McKinzey, 1995)

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and abuse-focused individual therapy (Lanktree & Briere, 1995). Severely traumatized children may require adjunctive pharmacotherapy to reduce their levels of anxiety (Bernstein, 1994). Finally, an additional therapeutic focus should be to encourage support networks for the child, and to teach nonoffending parents/caretakers appropriate responses to the child's expressions of distress (Deblinger et al., 1996; Lipovsky, 1991). For children suffering from depressive symptomatology, individual or group therapy can be conducted (e.g., using cognitive-behavioral therapy, interpersonal therapy, self-control therapy, or increasing response-contingent positive reinforcement via pleasant events). Antidepressant medication may be considered if depressed youth exhibit very significant symptomatology or have not responded to nonpharmacologic interventions. 9.21.3.1.4 Behavioral Domain As discussed earlier, maltreated children as a group have more behavioral problems than nonmaltreated children. The types of problems range from excessive dependency, withdrawal, and clinginess, to aggression and delinquency. In the general child clinical area, behavioral approaches have been shown to be effective for symptoms such as aggressiveness, social withdrawal, and conduct problems. Within the sexual abuse area specifically, anger and aggressiveness have been difficult to reduce, suggesting that some therapeutic approaches (e.g., group therapy) may not be particularly effective for treating this type of problem (Finkelhor & Berliner, 1995). Given that aversive behaviors displayed toward parents (e.g., aggression, impulsivity) may serve as ªtriggersº for abusive behavior, Walker et al. (1988) suggested that abused children be taught anger management skills to reduce their angry outbursts and increase their self-control. They also suggested that abused children should learn to obey commands promptly and earn rewards for adaptive behaviors. Also recommended is making sure that the child is given opportunities to actually practice these techniques in anger-arousing situations. Altering behaviors that contribute to the abusive cycle may lower the likelihood for subsequent abuse. Aggressive and impulsive children may also benefit from training in problem-solving strategies. Kendall and Braswell (1985) discussed commonly used approaches with children and provide a useful intervention manual. There is also a large body of literature on cognitive and behavioral self-control training paradigms for

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teaching impulse control (e.g., Schweitzer & Sulzer-Azaroff, 1988) and anger management (e.g., Dangel, Deschner, & Rasp, 1989). For children who exhibit anger, impulsivity, or aggression in school, Cohen and Fish (1993) described interventions with demonstrated or potential value for school settings. 9.21.3.1.5 Psychosexual Domain Children who exhibit sexually inappropriate behavior, especially if there is a compulsive, aggressive, or coercive quality to the behavior, are at risk for victimizing others, being revictimized themselves, and if they exhibit these behaviors at school or day care setting, then they may be in jeopardy of being suspended or expelled. Treatment of sexual behaviors in sexually abused children is thus highly recommended, but extremely challenging (Friedrich, 1990). For example, Finkelhor and Berliner (1995) found sexualized behavior problems, along with aggressiveness, to be particularly resistant to change. Given the serious consequences of this symptom, research clearly is needed to determine what works to eliminate inappropriate sexual behavior and simultaneously enhance normal sexual development. Clinicians have suggested several therapeutic goals when working with children who have been traumatized sexually (Cunningham & MacFarlane, 1991; Gil & Johnson, 1993). One goal is to correct the child's thinking about sexual behavior, and this can be achieved by teaching age-appropriate sexual knowledge. Clinicians can help children understand the concepts of consent and mutuality, know the reasons why people are sexual, and define readiness to be sexually active. A second goal is to help increase children's internal inhibitions and external controls against unacceptable sexual behavior. Children can be helped to identify the behaviors, emotions, and thoughts that precede acting out sexually, and can be taught strategies to challenge cognitions and generate alternative behaviors to avoid repeating the behavior. A third goal is to attend to, and if necessary, modify the parents' attitudes and behaviors related to their children's sexual behavior. A fourth goal, if appropriate, would be to address the youth's own history of victimization. Given the relationship between child sexual abuse and adolescent pregnancy, an additional goal would be to discuss pregnancy prevention issues. Clinicians treating abused children who engage in sexual activities with other children may benefit from the work being done at treatment programs for child perpetrators (see review by Pithers et al., 1995). For example, in

the Support Program for Abuse Reactive Kids (SPARK; Johnson & Berry, 1989), group therapy focuses on helping children learn about their behavior patterns as well as to be aware of their feelings and actions in relation to others. They are also taught problem-solving and social skills, they learn impulse control and perspective taking, develop victim empathy, and increase frustration tolerance. Unfortunately, a paucity of empirical data exists to support the efficacy of intervening with young sexual offenders (see Chapter 28, this volume).

9.21.4 PREVENTION In addition to providing direct intervention with child maltreatment victims, prevention efforts aimed at reducing the incidence of child maltreatment are critical to ultimately eliminating this problem. Along with targeting communities and high-risk families, prevention programs should also target children. For example, in the sexual abuse field, several reviews have concluded that behaviorally oriented educational programs can help children gain in knowledge about sexual abuse and in personal safety skills thought to be effective in preventing abuse (Tutty, 1993; Wurtele & Miller-Perrin, 1992). Child-focused educational programs intended to prevent physical abuse and neglect are fewer in number and even fewer have been evaluated. One reason for the dearth of physical abuse prevention programs is the concern that telling children that corporal punishment is wrong may conflict with parents' views on this issue. There have, however, been efforts directed at teaching children home safety skills, which could be relevant to the abused and neglected population (Mori & Peterson, 1986; Peterson, 1984a, 1984b). Clinicians can play a role in promoting and recommending educational programs. Continued efforts to prevent abuse and neglect are clearly justified, as the key to the solution of the child maltreatment problem is prevention. In addition to targeting presenting symptoms, clinicians should also focus their efforts on the prevention of reabuse among their child maltreatment victims. Abused children, perhaps even more than nonabused children, need to be educated about prevention concepts and skills. There are numerous books, games, videos, and pamphlets designed to educate children and their parents about personal safety. Such education can take place either during individual or group work with the children. Topics to be covered might include a discussion of the

Future Directions ªtriggersº for abuse or neglect, safe strategies to resist abuse, and helpful people/agencies to contact in a crisis.

9.21.5 FUTURE DIRECTIONS Despite numerous methodological advances related to measurement, sample selection, and research design, a major methodological issue to be addressed in future child maltreatment research is the operationalization of the independent variable; the maltreatment itself. Although there is consensus that maltreatment is a heterogeneous phenomenon, much of the research continues to view maltreatment as a dichotomous variable. A categorization methodology obscures differences in the severity of abuse and ignores the fact that different types of maltreatment often co-occur. There have been limited attempts at measuring the diverse range of maltreatment experiences present in the histories of victimized children. For example, Barnett, Manly, & Cicchetti (1993) developed a maltreatment classification system to quantify such dimensions as subtype, severity, frequency, chronicity, perpetrator characteristics, the developmental period(s) during which the maltreatment occurred, and out-of-home placement history. In addition to more completely assessing the child's experiences, assessment strategies need to be broadened to include the whole child. Across studies, researchers have considered the impact of maltreatment on several developmental domains, including physical, socioemotional, cognitive, behavioral, and psychosexual. Yet within studies, few researchers have explored the effects on multiple domains; most limit their exploration to the behavioral domain. The effects of maltreatment on children would be better understood through examining additional domains of functioning. Within the cognitive domain, more research on the coping and appraisal processes of maltreated children is needed. Further examination of maltreated children's general attributional styles, along with their abuse-specific attributions and coping strategies, should have significant research and practice implications. Future studies could focus on whether attributional factors affect symptomatology, and on whether cognitive therapy approaches can be utilized to alter victims' attributions and enhance their recovery. Within the socioemotional domain, research efforts must continue to develop methods to assess the quality of children's attachments to both parents and to a variety of relationship figures. Knowing the extent and quality of support in the child's environment

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will help elucidate the impact of abuse and also suggest intervention approaches. We also need to learn a great deal more about how maltreatment affects the immunological, neuroendocrinological, and psychophysiological systems of maltreated children. This research will undoubtedly demonstrate the profound and pervasive impact of child maltreatment. The choice of measures needs to be determined by hypotheses about maltreatment effects and with consideration of the expenses involved (including burden on families). The recommendation for an expanded assessment strategy is contingent upon the development of reliable, valid, and clinically useful instruments, especially instruments that are sensitive enough to detect abuse-specific effects, along with assessing changes over time. Better measurement will allow researchers to unravel the processes contributing to maladaptive outcomes, and to explicate the processes that serve to moderate the adverse consequences of maltreatment. Thus, future directions in clinical practice will depend on the advances made in the measurement area. Although research directed toward assessing the harmful consequences of child maltreatment has burgeoned, treatment outcome studies for all three types of maltreatment are much fewer in number. In order to convince others of the importance of providing intervention for maltreated children, data on the effectiveness of such services must be collected. Granted, there are a host of difficulties confronting clinicians and researchers in this area. Despite the difficulties inherent in implementing and evaluating therapy for maltreatment victims, it is crucial that children be provided with effective services. And it is important that interventions be methodologically rigorous, with all variables operationalized, including the type(s) of maltreatment experienced and the exact nature of treatment. Basic recommendations for future research include identifying the type(s) of maltreatment experienced, ensuring adequate sample sizes, performing routine assessments both before and after treatment, randomly assigning victims to treatment (when possible), specifying the type of treatment employed and consider using manuals to ensure treatment integrity, and conducting follow-up assessments to determine the stability of therapeutic change. Clinicians and researchers need to collaborate in identifying effective treatment modalities for victims of child neglect, given its widespread occurrence and demonstrated link to serious negative consequences. With school-aged children, effective interventions to increase their chances of academic success are sorely needed, especially for physically abused and neglected

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children. In general, research is desperately needed to determine the applicability of intervention strategies with older children and adolescent victims of child maltreatment. Another treatment question that needs to be addressed is whether a symptom-focused treatment approach is more effective than more generic therapies. Clearly, much empirical work needs to be conducted to be able to answer the important question, ªWhat type of therapy works best with which types of children who exhibit what types of problems and who have experienced which types of maltreatment?º Focusing on this complicated question holds exciting possibilities for collaboration between researchers and clinicians.

and methodologically sound studies. To this aim, collaboration between psychotherapy researchers, practitioners, and researchers in developmental psychopathology will be needed to realize the true potential of psychosocial treatment for child maltreatment victims. Though fraught with difficulties, the potential value of therapy to child maltreatment victims warrants its conduct. Services for victims of child maltreatment have untested potential for treating the immediate problems, preparing the child for successful resolution of future developmental challenges, and for interrupting the intergenerational transmission of child maltreatment. Child maltreatment impacts the victims, and ultimately us all. Providing effective therapeutic services to maltreatment victims will benefit the children, as well as society.

9.21.6 SUMMARY It is clear that being neglected or abused negatively affects children's development. But maltreated children are a heterogeneous group; they exhibit a wide variety of physical, cognitive, behavioral, and emotional responses. There is no ªsyndromeº or specific set of symptoms that characterize all victims of maltreatment. Nor is there a standardized instrument available that adequately evaluates the diverse symptomatology associated with child maltreatment. This characterization highlights the need for clinicians to: (i) use multiple instruments; (ii) obtain data from multiple informants in multiple settings; (iii) use multiple times of assessment (initial assessment, pretreatment, posttreatment, follow-up); (iv) assess across the principle domains of development; (v) measure both global adjustment and problems specific to the abuse; and (vi) consider the multiple influences on the child. Although a number of instruments and approaches are currently available to evaluate the diverse symptomatology associated with child maltreatment, there is clearly a need to develop additional instruments to measure abuse-specific effects. The documentation of a diverse set of psychological problems in maltreated children, which can persist into adulthood, dramatizes the need to develop effective therapeutic interventions with child victims. Although many clinicians provide therapeutic services to maltreated children and their families, systematic evaluation of these efforts has been limited. Thus, our knowledge about treatment has lagged behind that of our knowledge of the effects of abuse and neglect on children. Further development of treatment outcome research will require empirically based definitions of child maltreatment, better descriptions of the treatment, more abuse-specific assessment methods,

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Copyright © 1998 Elsevier Science Ltd. All rights reserved.

9.22 Victims of Hate Crimes CHERYL S. AL-MATEEN, DAWN K. LEWIS, and NIRBHAY N. SINGH Virginia Commonwealth University, Richmond, VA, USA 9.22.1 INTRODUCTION

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9.22.2 HATE CRIMES

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9.22.2.1 Definition 9.22.2.2 Categorization and Typology 9.22.2.3 Reporting of Hate Crimes 9.22.3 PREVALENCE

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9.22.4 REACTIONS OF VICTIMS

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9.22.5 CULTURAL FACTORS AND HATE CRIMES

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9.22.5.1 Gays, Lesbians, and Hate Crimes 9.22.5.2 College Students and Hate Crimes 9.22.6 INTERVENTIONS

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9.22.6.1 Mental Health Treatment 9.22.6.2 Advocacy 9.22.7 PREVENTION

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9.22.8 FUTURE DIRECTIONS

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9.22.9 SUMMARY

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9.22.10 REFERENCES

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blamed immigrants for job shortages. In France, the strong right wing has enormous hostility towards immigrants, particularly dark-skinned Muslims, Arabs, and Africans. Similar hostility has been evident in other countries, such as in Italy and Austria. Violence due to hatred develops from prejudice and bigotry. In terms of a developmental pathway, it is thought that violence due to hate begins with avoidance, leads to negative speech, and is followed by discrimination and physical attack, ultimately ending in ethnic cleansing and extermination (McLaughlin, Brilliant, & Lang, 1995). Hate crimes are not restricted to people of other racial or ethnic groups and may involve people with various cultural differences. For example, in some segments of the United States,

9.22.1 INTRODUCTION Hate crimes are an international problem. During the twentieth century, mass hatred has resulted in genocide in several countries, including Turkey, Germany, Nigeria, Bangladesh, Bosnia, and Cambodia, among others (Kressel, 1996). It also occurs on a daily basis and takes various forms. In several countries, violent offenses against foreigners have increased related to issues of marginalism, ethnocentrism, and economics (Schneider, 1994). For example, skinhead youths have assaulted foreigners in Germany and urged the eviction of immigrants from France. West European countries have had their highest unemployment rates since World War II, and many people in these countries have 359

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hate crimes are perpetrated on people who are gay and lesbian because they are seen as being sexually deviant. In this chapter, we focus on the victims of violence due to hate crimes. 9.22.2 HATE CRIMES Hate crimes are characterized by the symbolic status of the victim (Schneider, 1994). The victim of a hate crime belongs to an ªoutgroup,º the existence of which symbolizes what the ªin-groupº does not want to be. The ingroup can be defined as any group of people who share a sense of belonging and common identity. The out-group is perceived as being distinctly different in some way from the ingroup (McLaughlin et al., 1995) and often is subjected to negative stereotypes (Craig & Waldo, 1996). Weiss (1990) has used the term ethnoviolence to describe acts directed against an individual, group, or institution because of race, religion, ethnicity, or sexual orientation. In this context, the in-group does not have to be in the majority and the out-group does not necessarily have to be in the minority (Hidden Hate Crime, 1996). 9.22.2.1 Definition The US Federal Government has defined hate crimes as, ªCrimes motivated by hatred against a victim based on his or her actual or perceived race, color, religion, national origin, ethnicity, gender, or sexual orientationº (United States Congress, 1992). The US Attorney General is required to collect data and publish an annual summary on crimes that manifest prejudice based on race, religion, sexual orientation, and ethnicity (McLaughlin et al., 1995). In 1994, physical and mental disabilities were also recognized as a basis for hate crimes in the United States (United States Department of Justice, Federal Bureau of Investigation, 1997b). Indeed, people with disabilities are over-represented as victims of violence and hate crimes when compared to their numbers in the general population. For example, the incidence of child abuse, domestic violence, rape, and other violent crimes are far higher in people with disabilities than in people without physical and mental disabilities (Waxman, 1991). Although crimes committed because of gender are not included in the US Federal definition, it must be noted that many crimes against women (e.g., stranger rape) share some of these characteristics (Levin & McDevitt, 1993). For example, a few years ago, a Caucasian female jogger was attacked in Central Park in New York City by a group of young men. It was initially

thought that the attack was related to racial hatred because the attackers were AfricanAmerican and Hispanic-American teenagers. However, it was later discovered that these teenagers had thrown rocks and bottles at cars, cyclists, joggers, and homeless people. They had yelled racial slurs at a couple on bicycles, attacked several Latinos, and then they had decided to ªget a woman joggerº (Levin & McDevitt, 1993), suggesting that it was a deliberate act of violence perpetrated on a person because of her gender. A review of the phases of ethnopolitical activity shows that in the advanced stages of development, groups which intend to overthrow an existing regime become increasingly violent. In the first and second phases of development, leadership develops and begins to attract a following, isolating these supporters from competing organizations. In the third phase, ethnically- and politically-based marches and demonstrations take place. In the fourth phase, sporadic, spontaneous ethnically-based riots, murders, or bombings occur and, in the final phase, premeditated ethnically-based riots, assassinations, terrorism, and coups occur (Dutter, 1987). Ethnic violence often occurs when material interests are a significant concern, economic problems are externally imposed, and interethnic disputes are not successfully resolved (Denemark, 1994). A hate incident is an event that may involve the use of ªharmful words or actions motivated by prejudice against a person or property which do not fall into any criminal categoryº (McLaughlin & Brilliant, 1997). Even though the physical sequelae of the hate incident may not be as great and the perpetrator is not punishable by law, hate incidents may have the same impact as hate crimes on the individual and the community. However, there may be an emotionally intensifying factor because legal recourse is not available for the victims. Although this chapter is primarily about victims of hate crimes, it should not be overlooked that victims of hate incidents have a similar sequelae. Verbal harassment is a symbolic form of violence which reminds the victim of the potential of physical assault. It reinforces the sense of being a member of an out-group, and emphasizes the fact that the individual is a socially sanctioned target for violence and hate. Despite the fact that there is no physical injury, the victim's sense of security is violated and, although some victims of verbal assault may minimize its effects, the resultant emotional scarring may be more difficult to heal than physical wounds. This minimization may make it more difficult for the victim to understand any ensuing feelings of fear or self-hatred that he or

Hate Crimes she may experience. In instances of physical assault, the fact that there is some objective measure of how severely the victim has been injured can serve as a concrete springboard for understanding its emotional sequelae. The factors involved in the victim's response to hate speech are complex and variable (Cowan & Hodge, 1996). Further, frequent experience with verbal assault can lead the victim to restrict behaviors and become isolated, just as an actual incident of physical assault might, because of the resultant fear that physical violence will soon follow (Garnets, Herek, & Levy, 1990). Further, actual or perceived tolerance of verbal assaults by law enforcement officials ªcan easily lead to more serious forms of assault. Youths who get away with screaming racial epithets and urinating on the lawn of a family that has recently moved into a neighborhood may well move on to engaging in physical violence and arsonº (Wexler & Marx, 1986, p. 220).

9.22.2.2 Categorization and Typology There are several characteristics of hate crimes which distinguish them from other types of crimes. Hate crimes most often are excessively brutal. There is a greater likelihood of personal violence in a hate crime as opposed to other types of crimes. Further, force is used in a hate crime beyond that which is needed to subdue, disarm, rob, or ensure compliance of the victim. For example, while approximately 75% of victims of hate-related assaults sustain some physical injury and 30% require hospital treatment, only 29% of victims of assault not related to hate sustain injury and only 7% require hospital treatment (Levin & McDevitt, 1993). In general, victims of hate crimes are total strangers, picked at random, and are seen by the perpetrators of violence as interchangeable objects rather than as people like themselves. The global characteristic of the person is the focus of the attack, whether it be racial (i.e., African-American, Chinese, Asian-Indian), religious (e.g., Jewish, Amish), or based on gender or sexual orientation. Hate crimes are usually perpetrated by multiple offenders who have come together for the purpose of attacking the members of an out-group. For example, reviews show that about two-thirds of all reported hate crimes involve two or more perpetrators, and many with four or more perpetrators (Levin & McDevitt, 1993). There are several forms of hate crimes, including verbal harassment, posting symbols or slogans of hate, the destruction of religious property, cross burnings, arson, personal as-

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sault, and homicide. For example, in a study of victims of hate violence, Barnes and Ephross (1994) reported that 44% of the victims had experienced only one attack, another 10% had experienced multiple unrelated attacks, and the remaining 46% had experienced multiple attacks that were connected in some way. The most frequently reported crimes were physical assault, verbal harassment, and mail or telephone threats, followed by the posting of symbols of hate on or near the victim's property, and attacks on victim's homes, including firing shots and throwing things on the property. In another study, Weiss, Erlich, and Larcom (1991) found that 27% of all ªprejudicedbasedº incidents occurred in the workplace. These incidents included property damage, robbery, harassing language, physical assault, sexual harassment, and rapes. Further, Weiss et al. (1991) reported that 34% of those who experienced such incidents at work did not know the perpetrator, and an additional 10% had never met the perpetrator before the incidents occurred. Hate crimes can be categorized according to the perpetrators' motivation for committing the crime. Approximately two-thirds of hate crimes are motivated by thrill-seeking, in which the perpetrators are seeking excitement through terrorizing and bashing. The majority of these crimes are perpetrated by teenagers and young adult males who do not have a criminal record and who live at a distance from the scene of the hate crime. The other third of the hate crimes, categorized as defensive crimes, are perpetrated by people who are reacting to a particular set of outsiders that has infiltrated their turf (e.g., neighborhood or university). These perpetrators are likely to be adults who live or work near the scene of the hate crime. Neighbors or coworkers may share the sympathies of these perpetrators and hinder police investigations. Fewer than 1% of hate crimes, categorized as true believer crimes, are perpetrated by members of an organized group who are carrying out a mission to rid the world of a target group of people (Levin & McDevitt, 1995).

9.22.2.3 Reporting of Hate Crimes The reporting of hate crimes is related to several factors, including the local definition of hate crime. Different countries classify a hate crime as one which is based on one or more of these characteristics: race, religion, ethnicity, sexual orientation, gender, or disability, or that the motivation for the crime is based on hate. For example, the Ottawa Police Service in Canada uses the criterion that the crime is

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motivated in whole or in part by hate. In Great Britain, crimes are classified on the basis of racial hatred and do not include other factors (Roberts, 1995). It is estimated that only 10±30% of hate crimes are reported to law enforcement (Roberts, 1995). It is possible that victims or witnesses fear retaliation by the perpetrators. In the case of property crimes, only increased police surveillance can prevent further episodes. However, data from several European countries suggest that reporting property crimes only serves to provoke further episodes of vandalism because police cannot provide continual surveillance (Roberts, 1995). In some cases, members of groups being victimized may feel that their concerns regarding the hate crimes committed against them will not be taken seriously. In other cases, immigrants may have only negative experiences with law enforcement in their home countries and be afraid to approach the police about hate crimes committed against them. In addition, many new immigrants may experience communication barriers with the police and be unable to report hate crimes. Finally, members of some groups being victimized, such as closeted members of the gay community, may not wish to report hate crimes against them for fear that their secret may be revealed (Weiss, 1990). In terms of prejudice-based incidents which occur in the workplace, Weiss et al. (1991) found that only 38% of their respondents reported the incident to an authority. Reporting of such incidents was even less likely if the perpetrator was known to the victim or if the perpetrator was the victim's supervisor. Many respondents who did not report these incidents noted that reporting ªcouldn't help the situationº (Weiss et al., 1991, p. 26), although of those who did report these incidents, about three-quarters of them indicated satisfaction with how the situation was handled. This study indicated that, like hate crimes, prejudice incidents are also under-reported. It is sometimes difficult to determine if a crime is truly motivated by hatred. In some instances, racial or other epithets are used, or symbols of hatred are posted, enabling law enforcement authorities to assume hatred as the motivation for the crimes committed. In instances where this assumption cannot be made, and assault without specific denigrating phrases occurs, the motivation is not often readily apparent. For example, in the case of the Central Park jogger, there is ambiguity in whether she was attacked because of her race, her gender, or both, or whether she was simply in the wrong place at the wrong time (Levin & McDevitt, 1993). Further, in some instances, an

individual may not be aware that he or she has been the victim of hate because other events, such as robbery or burglary, have occurred simultaneously (Kelly, Maghan, & Tennant, 1993). Certain characteristics of the crime are used as indicators to determine that a hate crime has been committed. For instance, if the perpetrator and the victim belong to different racial, ethnic, or religious groups, or have a different sexual orientation, the likelihood of a hate crime is very high. If there is historical animosity between the two groups represented by the perpetrator and victim, this may indicate that hate was involved. Similar conclusions can be drawn if hate-related comments are uttered or written, gestures are made, or drawings or markings are left at the scene of the crime. Hate is strongly considered if the victim is in a neighborhood which is overwhelmingly populated by people from a different racial, ethnic, religious, or sexual orientation. If the victim or members of the community in which the crime was committed perceive the crime to be related to hate, this is considered a likely motivation for the crime. Another indicator is that the incident or crime occurred on a date of particular significance to the out-group, such as a religious holiday. If the victim was engaged in promotional activities for his or her group, or was a member of an advocacy group that supports the victim's group, this could also indicate hate as the motivation. Finally, if the perpetrator has a history of involvement in hate crimes or is a member of an organized hate group, then the motivation for the crime or incident can be considered to be based on hate (Levin & McDevitt, 1993; McLaughlin et al., 1995). In the USA, it is only necessary for hate to be a contributing factor to the incident or crime for it to be defined as a hate crime (McLaughlin et al., 1995).

9.22.3 PREVALENCE The US Federal Bureau of Investigation compiles annual statistics on hate crimes (Bishop & Slowikowski, 1995; United States Department of Justice, Federal Bureau of Investigation, 1997a, 1997b). The number of states and law enforcement agencies reporting data on hate crimes continues to grow. For example, in 1995, 45 states were included in the FBI database and, by 1996, this had increased to 49 states and the District of Columbia. These statistics indicate that there is clearly an increase in the reporting of these crimes. In 1993, there were 7587 hate incidents, 8987 hate offenses, 9372 victims, and 8610 known

Prevalence offenders. Of the hate incidents, at least 16 were murders and 15 were rapes, and the majority of offenses were categorized as intimidation, crimes against property, vandalism, and assaults. The numbers in 1995 were 7947 hate incidents, 9895 hate offenses, 10 469 victims, and 8433 known offenders, indicating a slight decrease in the number of known offenders but an increase in the number of incidents, offenses, and victims. There were a total of 10 702 hate crimes reported in 1996. In all years, over 60% of the offenses were motivated by racial hatred and about 15% by religious hatred. Sexual orientation was the motivation in about 13%, and ethnicity or national origin accounted for about 12% of the hate crimes (Bishop & Slowikowski, 1995; United States Department of Justice, Federal Bureau of Investigation, 1997a, 1997b). A similar pattern of hate crimes was reported in Canada (Roberts, 1995). In 1993, 85% of victims of hate crimes were individuals, with the remainder being mostly businesses and organizations (Bishop & Slowikowski, 1995). These figures were very similar in 1995, with 83% of these crimes being against individuals. In 1995, 61% of the victims of racemotivated hate crimes were African-American and 24% were Caucasian. About 67% of the victims of crimes based on ethnicity were Hispanic. Of crimes related to religion, about 76% of the victims were Jewish. Of crimes related to sexual orientation, about 72% were directed specifically towards gay males (United States Department of Justice, Federal Bureau of Investigation, 1997a, 1997b). These numbers were consistent with those reported for 1993 (Bishop & Slowikowski, 1995). In 1995, the race of offenders was reported for 62% of the registered hate crimes; 59% of these perpetrators were Caucasian and 27% were AfricanAmerican. The remaining perpetrators were from other racial groups or had a multiracial heritage. Unfortunately, data on crimes related to disability have only been collected since January 1997, and summary statistics are unavailable at this time (United States Department of Justice, Federal Bureau of Investigation, 1997b). About 17±26% of all hate crimes can be attributed to juveniles (i.e., those under the age of 18 years), and approximately half of the individuals arrested for hate crimes are between 16 and 25 years of age (Bishop & Slowikowski, 1995). Further, there may be a correlation between involvement in hate crimes and other gang-related crime; this relationship appears most clearly with skinhead gangs and other hate groups (Bishop & Slowikowski, 1995). Since the late 1980s there has been a significant increase in hate crimes in high

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schools and on college campuses (Chun & Zalokar, 1992). For example, a Harris poll in 1990 found that over half of high school students witnessed racial confrontations either ªvery oftenº or ªonce in a while,º with 25% of the students having been a target of racial confrontation (Center for the Study of Sport in Society, 1990). In another study, it was found that violent hate-related incidents had occurred in 34% of elementary schools, 47% of middle schools, and 42% of high schools in Los Angeles county (Merl, 1989). These incidents had been reported against students of all races and ethnic groups, as well as against Jewish, gay, lesbian, and immigrant students. Only 5% of reported incidents involved members of formalized hate groups, such as white supremacist organizations, and 47% of all incidents had involved ªracial slurs and name calling.º Physical violence occurred in 25% of the incidents. Some hate-based incidents in schools and colleges are retaliatory, perpetrated by victim groups. For example, some Asian-American and Hispanic-American youth have either joined or formed gangs in order to defend themselves from hate crimes (Chun & Zalokar, 1992). While it is understandable that victims of hate crimes need to feel safe in school and colleges, retaliation and gang membership often serve only to reinforce racial and ethnic stereotypes and to escalate the tension between opposing groups. The prevalence of violence in the United States is related to its apparent glorification in television, movies, and contact sports, as well as in other aspects of mainstream American culture (Chen, 1994). This cultural preoccupation with violence often contributes to antiethnic and other forms of hate crimes. Other societal factors contributing to violent hate crimes include the presence of overt and institutional racism, poverty, and inequality which may contribute to internal and interpersonal conflict (Chen, 1994). Although it is difficult to determine the exact prevalence of hate crimes in the USA, it is likely that this type of crime has increased in the past several years. In her review, Weiss (1990) noted six factors which may have contributed to the increased rate of hate incidents and crimes in the United States. These include: (i) increased migration of foreign-born people to the United States since the late 1980s; (ii) increased pace of social changes, such as those due to the second wave of the women's movement, the gay± lesbian rights movement, and the implementation of affirmative action programs; (iii) elimination of many federally funded social programs that benefitted the poor, a disproportionate number of whom are from culturally

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diverse populations; (iv) housing segregation has continued, and violence has been directed against people of diverse cultures new to a neighborhood; (v) increasing gap between the rich and the poor, leading to intense competition for scarce resources and violence among minority groups in inner cities; and (vi) increased reporting in the media of ethnoviolence as dramatic and spectacular events rather than everyday phenomena which occur when large numbers of people live together. Individually and interactively, these factors may contribute to increased violence due to hate crimes.

9.22.4 REACTIONS OF VICTIMS There are several known reactions that a person who is a victim of personal crimes might experience. These include intense rage or anger, fear of injury, death, and future victimization, sadness, depression, and lowered self-esteem. These reactions have been found in victims of personal crimes, such as assault and rape (Burgess & Holmstrom, 1974). Although victims of different types of crimes use different coping methods, many are also used by victims of hate crimes (Wirtz & Harrell, 1987). However, one major difference is the absence of lowered self-esteem in victims of hate crimes as a result of the attack. Victims of hate crimes often associate the crime with the perpetrator's prejudice and racism, and not with their own personal characteristics. In general, anyone who is the victim of violence questions a certain basic life assumptionÐthe everyday denial of vulnerability which allows the person to feel safe and secure. The survivor of violence asks: ªwhy me?º and may internalize the stigma attached to violence and question his or her own self-worth (Garnets et al., 1990). There are three stages of reaction to victimization, which may take years to complete (Bard & Sangrey, 1979; Sales, Baum, & Shore, 1984). The first stage is impact, in which the victim feels vulnerable, helpless, and dependent on others. The second stage is recoil, in which the victim may experience mood swings, the waxing and waning of feelings of fear, rage, and revenge fantasies, as well as displacement of anger. In the third stage, reorganization, the experience of victimization is assimilated and put into perspective; the person is able to move on from the experience. In studies of victims of sexual assault, a victim's personal characteristics, including age, socioeconomic status, race, psychological problems, life stressors, and relationships are all factors which may contribute to the individual's

reaction to victimization. A higher degree of violence in the assault is positively related to increased emotional recovery time after the assault. Similarly, the use of weapons increases the strength of the reaction. The role of the victim's relationship to the perpetrator is unclear. The postassault factor of criminal justice involvement and reactions of the victim's support system are also contributing factors (Sales et al., 1984). The process of pressing charges against the perpetrator can result in a decrease in postassault symptoms, although there may be a recrudescence as the legal process proceeds (Sales et al., 1984). Schultz (1987) noted that the legal system is a means of channeling ªnatural vengeance and retaliationº (p. 819). The role of family support may differ with the progression of time after an assault and with the severity of the assault. Further, as Sales et al. (1984) noted the ª... impact of violent assault must be viewed within the context of the victim's total life experience. If other conditions are benign, the victim can be expected to weather the crisis more easily. If they have never stockpiled resources, or if their psychic capital is temporarily depleted, they may be more vulnerableº (p. 132). Victims of various types of crimes have similarities in symptomatology, but may also experience diverse stressful feelings. For example, Garnets et al. (1990) noted that ªcommon reactions to victimization include sleep disturbances and nightmares, headaches, diarrhea, uncontrollable crying, agitation, and restlessness, increased use of drugs, and deterioration in personal relationshipsº (p. 365). In addition to these reactions, victims of hate crimes also experience a significant amount of psychological distress. For most victims, there is an experience of severe psychopathological aftermath. For people of color, gays and lesbians, and members of some religious groups, there is often the problem of society's continued hostility toward them. First, the victimization of the person involves interference with daily activities. The individual believes that the world is unpredictable and unsafe. Bard and Sangrey (1979) noted that because their victimization did not occur as a result of accidental or natural forces but with malevolent intentions perpetrated against them, victims developed a significant reduction in basic trust. Second, the ªexperience of victimization interferes with perceptions of the world as an orderly and meaningful placeº (Garnets et al., 1990, p. 368). Often, victims blame themselves for the act. Third, the victim's view of him or herself is important in order to deal with the victimization. The individuals may view themselves as weak, which may reinforce a negative

Cultural Factors and Hate Crimes self-image. For all victims of hate crimes, the difficulties in dealing with vulnerabilities, meaningfulness, and positive or negative self-perception are important factors in how he or she will deal with inevitable psychological stressors. In terms of the perpetrator's motivation for hate crimes, the victim of a ªthrill seekingº crime feels more vulnerable to random attack. The typical victim of the ªdefensiveº crime is a person of color. This victim is aware that his or her particular situation may have precipitated the attack and that he or she could be attacked again. This victim feels frustrated because he or she knows exactly why the incident occurred (she ªtook a standº when she moved into a new home, accepted a promotion, transferred to a new school, or dated someone of a different race, ethnicity, or religion). For these individuals, ªtaking a standº may result in a cross burning on their lawn, a student getting beaten up at school, or an employee getting harassed at the workplace (Levin & McDevitt, 1993). There is no specific literature on the victim of the ªtrue believerº crime. It is reasonable to assume that because these can be the most radical of hate crimes, the surviving victims will endure sequelae that are of the same nature, but more extreme than other victims of hate crime. Barnes and Ephross (1994) studied victims of hate violence from several cities in the USA. They found that the most frequent emotional response was anger at the perpetrator, followed by fear of injury, sadness about the incident, powerlessness, suspicion, and fear of being killed. About one-third of the victims reported that they changed their behavior in some way to cope with, as well as to avoid, future victimization. These behaviors included changing jobs, moving out of the neighborhood, decreasing social participation, purchasing a gun or feeling more ready to use a gun, getting more home security, and increasing their children's safety precautions. The initial, or primary, victimization suffered by the victim of the hate crime is multidimensional. These victims recognize that because of the nature of the motivation of a hate crime, there is almost nothing that can be done to alter their vulnerability to the situation as the crime is a result of a core aspect of their identity (McLaughlin et al., 1995; Roberts, 1995). As the attack is based on an immutable aspect of their identity, this can lead to a sense of increased vulnerability and resultant hopelessness. Further, there may be a temporary rejection of that aspect of their personality. As such, there can be a more devastating psychological impact when compared to those who are victims of other crimes. These crimes are meant to send the message that fear and

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terror can follow at random. The message is received by the individual victim as well as members of the victim's cultural group. The victim may perceive the perpetrator as a representative of the opinion of society at large and feel like an outcast. Members of other groups that are often targeted for hate crimes are reminded of their own vulnerability and may feel victimized as well (Craig & Waldo, 1996). The message can be compounded if the hate crime is inadequately handled by law enforcement officials, or by the general community, who can unwittingly exacerbate the trauma (McLaughlin et al., 1995). The victim may encounter institutional prejudice or individuals who share similar biases or stereotypes as the perpetrator. Unfortunately, society has responded more slowly to hate crimes than to other forms of crime. This can result in the victim feeling a loss of a sense of belonging to the community and a feeling of betrayal by ªthe system.º The victim may not receive the kind of support he or she might have expected had the crime not been related to hate. This secondary victimization results from the victim's perceived rejection by the community as well as by the lack of expected support. Members of victimized groups are generally under-represented among criminal justice professionals (Roberts, 1995). If the criminal justice system does not recognize that a crime is related to hate, then the true extent of harm to the victim and the community cannot be taken into account, thus failing the community as well as the victim. 9.22.5 CULTURAL FACTORS AND HATE CRIMES Cultural factors determine whether a crime victim chooses to report a hate crime to the police or other law enforcement officials and whether the victim connects the crime to any psychological sequelae from the event. Culture also affects how the victim views pain that is experienced, including a sense of hopefulness or hopelessness. Further, it affects the victim's decision as to whether, and from whom, to seek assistance. Certain cultural groups have a sense that life is predetermined and unalterable, with an external locus of control of incidents that happen in their life. Members of these groups react differently from those who have an internal locus of control and a sense of being masters of their own destiny. Victims may have different reactions to hate crimes related to their own demographic characteristics (Craig & Waldo, 1996). Members of certain racial groups have a strong fear of being victims of crimes. For example, Parker, McMorris, Smith, and Murty (1993) found that

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both Latinos and African-Americans reported significantly high levels of feeling victimized. They also found that Latinos and women tend to have the highest levels of fear of crime. Explanations for these findings may include being previous victims, location of neighborhoods with high crime rates, and racial discrimination. Following a racially divisive court verdict, the Korean-American victims of rioting in South Central Los Angeles in 1992 experienced financial loss and sustained severe emotional trauma (Kim-Goh, Suh, Blake, & Hiley-Young, 1995). Four months after the riot, the KoreanAmericans suffered symptoms similar to posttraumatic stress disorder (PTSD). In addition, there was a gender difference in their reaction to the riots; the women reported high rates of somatization and the men reported a significant increase in alcohol intake after the riots. Janson and Ryder (1983) found that, although the elderly are less victimized than younger people, they too are highly fearful. Miethe and Lee (1984) noted that the elderly consider fear of crime their most serious personal problem before issues of income, health, and housing. Another common research finding is that women are more afraid than men of crime, although men are more likely than women to be victims of all types of crime, except for sexual assault (Clemente & Kleimen, 1976; Ferraro, 1996). Despite gender differences in the prevalence of various crime victimizations, women are more afraid of all types of crime. For example, once a woman is raped, she fears future face-to-face types of crimes (e.g., burglary, robbery), including the fear of being raped again. Ferraro (1996) also found that fear of rape is very high among younger women, reflecting national victimization data. Ferraro noted that it did not matter whether females had been personally victimized or not; the imagined horror of sexual assault is sufficient to increase such fear. Snell and Godwin (1993) reported that men are quick to blame women for being raped, particularly if it is an acquaintance rape. Victims of rape are often reluctant to report to law enforcement officials or to disclose their victimization to family members, due in part, to their ªconcern that their allegations will be discredited or that they will be blamed for the assaultº (Foley, Evancic, Karnik, King, & Parks, 1995, p. 7). Acquaintance and date rapes are even less likely to be reported and the assailants less likely to be sentenced by the criminal justice system than cases of stranger rape. As in classic forms of hate crime, it appears that women in our society are less likely to report rape crimes due to their fear of being ªpersecutedº again in the criminal justice system

9.22.5.1 Gays, Lesbians, and Hate Crimes Gays are the most frequent victims of thrillmotivated attacks and hate crimes (Levin & McDevitt, 1993). For thrill seekers, gays are easy to find as gay and lesbian establishments are often concentrated in certain districts of major cities. Gay males, who are more frequently victimized than lesbians, are often seen as a sort of psychosexual affront or threat to the sexual identity development of young adult men, who are frequently the perpetrators of thrill-motivated crimes. Gays may be less likely to report an attack because of the fear that their sexual orientation may be revealed as a result of publicity of the crime. Berrill and Herek (1992) used the term secondary victimization to ªhighlight negative treatment of gay people that is legal and widely condonedº (p. 290). Reports of the event may ªoutº the person with their family, friends and employer, resulting in rejection because of their sexual orientation. This is a form of secondary victimization specific to the gay community (Levin & McDevitt, 1993). A victim who is ªoutedº is vulnerable to secondary victimization in housing, the military, employment, foster care, and child custody, among others (Berrill, 1991). Often there is no legal recourse if an employer learns of the victim's sexual orientation and fires him. Further, members of the criminal justice system may actively victimize individuals in the gay community due to their own biases against gays. Gays may feel vulnerable to a criminal justice system that is often against them. For example, Berrill and Herek (1992) cited an example in which an Asian-American gay man was beaten to death and the Judge jokingly asked the prosecuting attorney, ªthat's a crime now, to beat up a homosexual?º (p. 294). Similar to rape victims, gay victims report feeling blamed by the judicial system for the hate crime. ªHomosexual panic defenseº is an example of blaming the gay victim (Berrill & Herek, 1992). Homosexual panic defense alleges that the defendant's violent actions were committed in self-defense against the victim's unwelcome and aggressive sexual overtures or were part of an acute psychological panic resulting from those overtures (Chuang & Addington, 1988). The blame is then shifted from the defendant to the victim for causing the hate crime. The homosexual panic defense has resulted in lenient sentences for those charged with assaulting or murdering gays. The judicial system's biased stance against gay people also affects whether gays will report crimes committed against them. Gays may feel that it is better to remain quiet than cause any

Cultural Factors and Hate Crimes further problems for themselves because the system appears to be against them. Because many gay and lesbian victims do not report hate crimes related to their stigmatized status, they are viewed as ªeasy targetsº by perpetrators of hate crimes (Berrill, 1991). Clearly, many gays who are victims of hate crimes feel that they are unsupported by the judicial system, and a judicial system that does not protect all individuals regardless of their race, religion, or sexual orientation is in effect contributing to their victimization. Although we might expect that universities and colleges would value diversity on their campuses, antigay harassment flourishes in these environments. Verbal harassment, intimidation, and vandalism are the primary forms of hate, although physical assault is not uncommon, occurring in 5% of cases (Berrill, 1991). Up to 25% of gay college students have been threatened with violence and up to 75% have experienced verbal harassment (Berrill, 1991). A survey of gays and lesbians found that 20% had experienced an antigay assault and another 20% had been victims of a property crime (Herek, Gillis, Cogan, & Glunt, 1997). Half of the respondents had suffered verbal harassment or threats in the year before the study, with the majority having experienced at least one episode of harassment since age 16. Those who survived an assault had high levels of anxiety, anger, and symptoms of depression and PTSD. In terms of perpetrators of hate crimes against gays and lesbians, ªactivistsº are the smallest group of individuals who will seek gays out, even in out of the way places, in order to assault them. ªOpportunistsº will assault gays when the opportunity presents itself. The victims in these cases are most likely people who are overtly homosexual and conform to the perpetrator's image of how a gay person ªshouldº appear (i.e., effeminate or hypermasculine appearance or behavior). Unlike other target groups, gays and lesbians experience hate and violence in the home as well as in society generally (Hunter, 1992). Surveys have shown that up to 41% of gays have been the victim of insults or intimidation by family members and about 8% have experienced physical violence (Berrill, 1991). In a review of the victimization literature, Herek et al. (1997) reported that victimization has deleterious effects on the mental health of gay and lesbian youth, both directly and through effects on family support and self-acceptance. Antigay violence is highly concentrated in prisons and jails. This form of hate crime is difficult to avoid in prisons because many law enforcement officials see it as an inevitable consequence of incarceration (Berrill, 1991).

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The risk of violence to gays and lesbians of color is higher because of what seems to be a higher rate of homophobia in minority populations when compared to people in society generally (Mays, Cochran, & Rhue, 1993). As most of the gays and lesbians of color who have been studied are African-American or Latino, it is also possible that these higher rates of victimization are related to the higher risk of violent crime experienced by these groups in the United States (Berrill, 1992a). For example, Comstock (1989) found that gays and lesbians of color were more likely to be chased, followed, have objects thrown at, and physically assaulted than the majority population. They were also more likely to be victimized in gay-identified areas. Lesbians of color are more likely to experience physical violence, rape, threats, and vandalism, while White lesbians are more likely to experience verbal assault (von Schulthess, 1992). As adolescents are more frequently victims of violent crime than adults, adolescent gays and lesbians have a higher risk for being victimized because of their sexual orientation. Gay and lesbian adolescents are also at a higher risk of violence because of the endemic homophobia that is seen in the teen population. Some of this homophobia is related to the epidemic of human immunodeficiency virus (HIV) infection and the association of contagion with homosexual behaviors. This population of gays and lesbians is also at greater risk for victimization because of their increased visibility in society. Gays and lesbians face an additional challenge, often referred to as ªheterosexismº (Garnets et al., 1990). This has been defined as an ªideological system that denies, denigrates, and stigmatizes any nonheterosexual form of behavior, identity, relationship, and communityº (Herek, 1990, p. 316). The gay individual who is attacked must deal with our society's heterosexism in organized religion, law, media, and the military.

9.22.5.2 College Students and Hate Crimes Racism, sexism, heterosexism, ethnocentrism, and other similar biases are prevalent on college campuses (Berrill, 1992b; Herek, 1993). As in society at large, majority vs. minority and minority vs. majority conflicts are present on college campuses. Incidents may include racial jokes, as well as ªracist slurs and posters, racial harassment, intimidation; anti-Semitic remarks, graffiti, posters; and threatening statements toward lesbians and gaysº (US Commission on Civil Rights, 1990a, p. 4). The US Commission on Civil Rights (1990a) has noted four

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categories of contributing factors to hate incidents on campus: (a) deficiencies on college campuses that exacerbate existing tensions; (b) society's failure to keep up with the change; (c) competition for limited resources; and (d) extremist speakersº (p. 7). This commission noted that isolation, perceived ethnically- and racially-based hostility on campuses, and defunding of federal programs directed towards minorities are among the factors considered deficiencies on campus. Deficiencies also include the perceived inadequacies of the institution in recruitment and retention of minority students and faculty. As college campuses become more multicultural, ignorance of others' cultures becomes more unacceptable in our society. Insensitive comments and behaviors are a result of society's failure to keep up with this change. As the size of any group of people grows, demands for recognition of the group's needs by the institution are more likely to occur, with ensuing conflict (US Commission on Civil Rights, 1990a). In the United States, there is often an oversimplification of racial differences into a ªblack vs. whiteº dichotomy, neglecting other ethnic groups which are also minorities on campus (Nebraska Advisory Committee to the United States Commission on Civil Rights, 1990). When financial resources on campuses decrease and the number of groups who qualify for these funds increase, competition for these funds develops, adding fuel to the fire of racial bigotry. In addition, high school students often enter college without a familiarity with their country's civil rights history, which resulted in the appropriation of funds to correct for institutional racism. Based on this limited knowledge, they develop a perception of being discriminated against in favor of a minority student population, thus contributing to campus tension between majority and minority students. Many campus hate incidents occur not only after the presentation of a socially extremist speaker, but also in the months preceding the presentation. During this time, the polarized controversy that is generated may increase both negative and positive publicity for the speaker and the campus, heightening the tension between opposing cultural groups (US Commission on Civil Rights, 1990). There are at least three levels of racism on college campuses: ª(1) students who, out of ignorance or deliberate insensitivity use different comments, actions, and hold a particular attitude towards [a minority group]; (2) an administration which is sometimes not sympathetic to [minority] groups and rights; and (3) law enforcement actionsº (California Advisory

Committee to the United States Commission on Civil Rights, 1991, p. 9). Each of these factors, individually and collectively, contribute to hate incidents and crimes. Farrell and Jones (1988) described three types of racial incidents on campus: White insensitivity, environmental racism, and minority and majority student characteristics. They noted that a ªsizable proportion of white students, white staff, and white faculty at predominantly white institutions of higher education have experienced minimal contact with and exposure to minorities, particularly blacks, Hispanics, Asians, and American-Indians. In addition, the general white population has not been encouraged or required to expand its social and cultural vistas in order to be sensitive to the social, economic, and cultural backgrounds of minority studentsº (p. 215). In addition, they noted that business establishments in the university's immediate surroundings may be racially intolerant, thereby contributing to increased discrimination within the university. Examples include campus bars deterring minority students by not playing ªminority-oriented musicº or not hiring minority students as workers, restaurants being slow to serve or outwardly hostile towards minority students, local police ªclosely monitoringº minority male students when they are in the surrounding community's predominantly White establishments or neighborhoods, and local public officials rarely speaking out against racism in the community. Chih (1994) studied undergraduate AsianAmerican students to assess their coping and symptomatology following an episode of racially motivated violence on campus. He interviewed the 10 victims of a combined physical and verbal assault and 11 other students who were not present but were very familiar with the incident. About 80% of those surveyed had experienced some sort of hate incident because of their race. Half of the students had been stared at because of their race or had been mistaken for another person of their race. In the incident, an Asian-American student organization sponsored a dance on campus. As 10 Asian students were cleaning up after the dance, four young White men approached them, yelling ethnic slurs. As the incident escalated, one Asian-American student was assaulted and required hospital treatment. Chih (1994) reported that those who were present at the time of the incident experienced more somatic symptoms than those who were not. They felt helpless and sad, experienced headaches and nightmares, and had difficulty concentrating on their studies. They were more concerned with loss of face than the nonvictims. This group used

Interventions more internal coping methods to overcome the effects of racial victimization. Over half of the victims did not use their family members as a support, with some indicating that their parents would not understand because of intergenerational differences. Some students felt partially responsible for the incident because it had occurred at their dance on campus, and they expected that their parents would feel that this social event should not have interfered with their education. These students also indicated that they did not want to worry their parents. Most students used their friends for emotional support. Some students indicated that they felt partially responsible for the incident because they yelled back or did not simply walk away from the assailants. They noted that ªAsians are targets of this sort of violence because it's sort of expected that we will not fight backº (Chih, 1994, p. 35). Some students had never been exposed to such blatant racism and were psychologically unprepared for it. Those subjects who were not present at the incident displayed more passion, indignation, and anger about the incident, and wrote letters to the campus paper deploring the racially motivated incident. Farrell and Jones (1988, p. 220) listed the following several risk factors for hate incidents on predominantly White college and university campuses: (i) Large enrollments in general terms or in residential enrollment as a percentage of the student population. (ii) Campuses located in isolated college towns. (iii) Unclear rules for student conduct and weak or nonexistent sanctions for racist or sexist behavior. (iv) Substantial numbers of low-income, working-class majority students whose previous residence has been in majority or nearly majority cities and towns. (v) Weak leadership at the central administrative level of the university with respect to a consistent and clear commitment to racial and gender equity. (vi) Failure by the university administration to act swiftly and decisively once a racial incident has occurred. (vii) Ineffective minority student support programs. (viii) Small numbers of minority faculty and staff at the institution. (ix) Lack of university programming or initiatives to bridge the cultural and social gap between majority and minority students. Clearly, one or more of these risk factors are present in most, if not all, university campuses.

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9.22.6 INTERVENTIONS 9.22.6.1 Mental Health Treatment Specific interventions can be targeted for specific phases of a victim's reaction to hate crimes (Garnets et al., 1990). During the impact phase, the mental health professional engages in crisis intervention and assessment of the victim's coping resources. Crisis intervention is focused on ensuring safety, including referral for any required acute medical treatment. This intervention also involves assessing the emotional meaning the victim gives to the event, and the victim's self-assessment in general. The coping resources which should be assessed include learned methods of coping and support networks (i.e., family, friends, significant other). The mental health professional may also connect the individual with community networks, such as victim assistance programs. During the recoil phase, the mental health therapist's role is to allow ventilation and to provide support. The victim needs to ventilate the horror and terror he or she has experienced, express anger towards his or her assailants in a constructive manner, and progress towards understanding the incident or crime in terms of global hatred. Encouraging involvement in self-defense classes or activist groups formed to prevent violence or support members of a particular outgroup is often a constructive means of directing anger. For certain individuals, the issue of whether or not to report the hate crime is discussed at this stage in therapy, and the issue of potential secondary victimization is addressed. Emotional support is needed as the victim regains his or her self-confidence and processes feelings of guilt, shame, and helplessness. Building additional support networks is beneficial at this stage. Initial treatment of specific psychiatric syndromes, such as PTSD, also occurs during this phase. At times, work with the victim's significant other, as well as family members, may be necessary in order to help support the victim's psychological and social well-being. This may take the form of education about the causes of violence and hate crimes, and how victims cope with the violence and hate crime they have been subjected to. In the final phase, the reorganization period, the mental health therapist's goal is to help the victims integrate the traumatic experience into his or her world view, and to move on with his or her life. 9.22.6.2 Advocacy The US Department of Justice and other such agencies compile statistics which show that

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crime is a major worldwide problem. Greenberg and Ruback (1984) noted that our society has become increasingly aware of and concerned by the problems encountered by victims of crimes. As a response, victim service programs have been developed (Schultz, 1987). These are general victim service programs, with no particular attention paid to victims of hate crimes (Barnes & Ephross, 1994). We review some of the services provided by these programs, with the understanding that additional services may be required by those who are victims of hate crimes. Victim assistance programs have several responsibilities in working with victims of hate crimes. In her review, Young (1988) noted eight stages in victim support services: emergency response, victim stabilization, resource mobilization, after arrest, precourt appearance, court appearance, presentence, and postsentence. Emergency response includes ensuring the provision of first aid and medical services, as well as the initial availability of food and shelter. Acute emotional support includes comforting statements, counseling, and home visits immediately after the person has been victimized (McLaughlin et al., 1995). Young noted three important messages that must be conveyed to the victim in the first stage: ªI'm sorry it happened. I'm glad you weren't killed. It wasn't your faultº (p. 334) and suggested that these statements can be used as a ªpsychological first aid.º Victim stabilization generally occurs at the crime scene or within the first few days. During this time, the victim is struggling with the initial feelings of being out of control while police are gathering statements. Thus, enabling control by the victim, by offering choices whenever available, is helpful: ªwhat would you like me to call youÐMr. Mertz or Fred?º ªIs there anyone I can reach to help you now?º During resource mobilization, practical needs are met, such as providing new locks on doors, replacing windows, or assisting in the retrieval of stolen property from police custody. Short-term counseling services may be offered through the advocacy program, and referral may ultimately be made for longer term treatment. Similarly, referrals may be made, at any phase, for legal and social service assistance on an as-needed basis. The final five stages are only experienced by those victims whose assailants are arrested. Increasingly, victim services programs are available to provide services through these last painful and often confusing stages. In the postarrest stage, victims want to know as much as possible about bail, pretrial hearings, and plea bargaining, with the hope that their experience at the hands of the defendant will not be discounted for the defendant's rights. In the precourt appearance stage, the victim still

has the ªneed to know.º Frustration occurs when court dates are changed without notice when the victim is to testify, when the victim does not clearly understand what is expected of him or her in the courtroom, and with the difficulty of cross-examination. At the time of court appearance, the victim must ªrelive the facts of the criminal incident itself. The very recounting of the trauma, especially in that setting, often triggers a reexperiencing of the crisis and all its manifestationsº (Young, 1988, p. 342). The confrontation of the assailant is also an emotional hurdle, particularly if the victim is fearful of retaliation should the defendant be released or receive a brief sentence. The arguments of the defense attorney presenting the assailant as deserving of release also may be difficult for the victim to deal with. Advocacy may include ensuring that there are few, if any, repercussions from the employer as the victim spends time in court. The victim assistance program may have the victim observe other trials in order to become familiar with the system or provide an escort on the day he or she is to testify to help him or her through the process. In the presentence phase, the programs may assist the victim in preparing impact statements for the court. There may be compensation and restitution forms with which the victim may need assistance. In the postsentence phase, there may again be an intense need for mental health services (McLaughlin et al., 1995). Young (1998) has aptly noted that, ªMany victims essentially put themselves and their needs aside while they pursue justice through prosecution and conviction. Their sense of mission, of seeking the restoration of fairness in their lives, overwhelms other aspects of their emotional lives. Hence, it is common for victims to return from a sentencing hearing, even when the sentence is exactly what the victims wanted, feeling depressed and isolated from the world. They suddenly feel alone and detached from other things. The flurry and frustration of the trial are over. There is nothing more to be done. Their purpose either has been accomplished or has been flouted. And the activity that kept their grief from surfacing has ceasedº (pp. 344±345). The advocate for the victim is aware that the victim will want information over time about the parole and probation status of the assailant. Some victims may be allowed to give input at parole hearings, and there may be civil suits after criminal proceedings are concluded. Victims of heinous crimes and the survivors of murder victims must continue the process as appeals are filed, with repeated calls to testify, and a prolonged inability to find closure to the legal sequelae of their experience.

Future Directions In terms of campus hate crimes, the welfare of the victims of the incident should be the foremost focus of the advocacy group, and this should include the decision whether or not to publicize the incident. The advocacy group should support the victim regardless of the decision made, particularly in the case of antigay and lesbian incidents. The use of a facilitated discussion group may be helpful for members of the victim's group on campus. Emotional support, including reminding the student of the availability of counseling, is also important because of the sense of isolation felt after a hate incident. Scrupulous documentation of discrimination serves to prove to campus administration that the event is not an isolated one. This helps to build a case that official policies, if they do not exist or are not effective, must be set in place and fully implemented. Such documentation includes careful recording of each incident, including names or descriptions of perpetrators, keeping photocopies of hate mail, and taping hate messages on answering machines. The victim's written permission should be obtained if there is any identifying information. The advocacy group must clearly set goals and establish strategic planning in order that group members agree and are able to work together effectively. Developing alliances with other minority or women's groups are important, as all these groups have similar concerns. It is recommended that the advocacy group have a clear understanding of the institution's procedures for setting policy on hate concerns. The comprehensive documentation gathered must be presented at any meeting with the administration, including presentations by any victims who are willing to describe their experiences. If the administration is not responsive, it may be necessary to seek legal action, involve the media, or have a demonstration (Berrill, 1992b). In general, college and university administrations must prohibit any form of discrimination, encourage the reporting of hate incidents, have clear policies and procedures for addressing these incidents, developing a taskforce if necessary, collect data about incidents, assist victims, discipline perpetrators, and educate the campus and the community at large (Berrill, 1992b). There would be far fewer hate crimes if all colleges and universities were to follow these guidelines.

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Government has sponsored research towards the development of a curriculum, ªHealing the Hate,º designed specifically for this purpose (McLaughlin & Brilliant, 1997). Pilot-tested in several settings, this middle school curriculum is directed towards young adolescents and focuses on the following general principles: (i) Violence and prejudice are preventable. In these lessons, the teacher fosters the knowledge that prejudice and violence are learned and, as such, can be prevented. (ii) Early intervention. This principle addresses the knowledge that early education and intervention can prevent prejudice. (iii) Empathy building and perspective taking. For these principles, through the promotion of respect for diversity, the curriculum helps students develop empathy skills. Empathy skills have been shown to be effective in reducing prejudice. (iv) Awareness and appreciation of differences. In the process of helping youth understand and appreciate their own identity, the ability to also respect and appreciate others is inculcated. (v) Cooperative learning, critical thinking, and interactivity. With these principles, several students work together in small groups using critical thinking principles to understand the other concepts. (vi) Media literacy. Students learn critical viewing skills while exploring how relevant issues are presented in the media. (vii) Inequality and institutional violence and prejudice. Recognizing that injustice and inequality are often at the root of hate crime, the curriculum explores institutional racism and other such factors. (viii) Social responsibility. The final principle involves encouraging students to make a difference in attempting to reduce hate incidents and crimes. These principles provide holistic guidelines for teaching our children to nonjudgementally accept others who may be different from them in some way. Diversity and acceptance training are imperative in the prevention of hate crimes. Education about bigotry and resultant hate crimes should occur at all levels: elementary, middle, and high schools, as well as at colleges, universities, and continuing education sites. 9.22.8 FUTURE DIRECTIONS

9.22.7 PREVENTION An excellent means of helping victims of hate incidents and crime is through prevention. School prevention programs are an important component in teaching children about prejudice and its alternatives early in life. The US Federal

Much progress has been made over the last few decades in our knowledge of hate victims and their treatment. However, the sum total of our knowledge about every facet of hate victims is still meager. Some areas of future research include the following:

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(i) Issues of definition. There is little agreement across legal and service agencies, as well as advocacy groups, as to who is a victim of hate crimes. Federal, state, and advocacy datagathering agencies need to develop an operationally defined set of criteria that can be used to identify victims of hate crimes. As with the definition of a hate victim, all agencies involved in the collection of data on hate victims need to agree on the criteria to be used for classifying a crime as an instance of hate crime. (ii) Minimum data set. All agencies involved with hate crimes should agree on the minimum data set that should be collected on the characteristics of perpetrator(s) and the victim(s) because such an agreement would allow for aggregation and comparison of data across agencies and geographical boundaries. (iii) Interventions. There is a paucity of literature on interventions with victims of hate crimes. First, there are few well-tested treatment methods that have been empirically validated as effective in reducing the psychological trauma associated with being a victim of a hate crime. Second, few interventions have been described fully enough for independent replication of the procedures. Third, few current interventions sufficiently address the cultural issues that the majority of the victims bring with them. There is an urgent need to understand cultural norms and differences in the victims' methods of coping with the hate crime. Unless psychologists and other mental health professionals adequately deal with the cultural nuances of the victims, no intervention will fully address the psychological and other mental health needs of the victims. Further, there is a need to obtain long-term follow-up data on the effects of hate crimes on the victims, regardless of whether the victims have been in treatment or not. (iv) Prevention. Broad-based, culturally appropriate, prevention efforts with young children are urgently needed. Prevention efforts should begin with children as early as possible so that they do not develop the precursors to violence generally and hate crimes in particular. Although this is not an exhaustive list, these four general areas cover the core issues that psychologists need to deal with. Fortunately, psychologists have the training and expertise to provide leadership in researching these issues in a systematic and scientific manner. 9.22.9 SUMMARY Victims of hate crimes are found in every nation and virtually anyone can be the victim of a hate crime. This area of research and intervention has been fraught with problems. The literature is unclear as to the criteria that

can be used to classify a crime as an instance of hate crime, thereby making it very difficult to aggregate data on the prevalence of hate crimes. The literature is also unclear as to who is a victim of a hate crime, and what constitutes a ªvictim.º These are critical issues in determining the extent of the problem, and unless we have a fairly good understanding of the extent of the problem, policymakers generally will not take the initiative to formulate policies that will protect and fund treatments for victims of hate crimes. What we do know is that regardless of how a hate crime is defined, it is increasing in our society and better methods for assisting the victims of hate crimes are needed. 9.22.10 REFERENCES Bard, M., & Sangrey, D. (1979). The crime victim's book. New York: Basic Books. Barnes, A., & Ephross, P. H. (1994). The impact of hate violence on victims: Emotional and behavioral responses to attacks. Social Work, 39, 247±251. Berrill, K. T. (1991). Anti-gay violence: Causes, consequences, and responses. In R. J. Kelly (Ed.), Bias crime: American law enforcement and legal responses (pp. 151±164). Chicago: University of Illinois at Chicago. Berrill, K. T. (1992a). Anti-gay violence and victimization in the United States: An overview. In G. M. Herek & K. T. Berrill (Eds.), Hate crimes: Confronting violence against lesbians and gay men (pp. 19±45). Newbury Park, CA: Sage. Berrill, K. T. (1992b). Organizing against hate on campus: Strategies for activitsts. In G. M. Herek & K. T. Berrill (Eds.), Hate crimes: Confronting violence against lesbians and gay men (pp. 259±269). Newbury Park, CA: Sage. Berrill, K. T., & Herek, G. M. (1992). Primary and secondary victimization in anti-gay hate crimes: Official response and public policy. In G. M. Herek & K. T. Berrill (Eds.), Hate crimes: Confronting violence against lesbians and gay men (pp. 289±305). Newbury Park, CA: Sage. Bishop, E., & Slowikowski, J. (1995). Hate crime. Washington, DC: Office of Juvenile Justice and Delinquency Prevention. Burgess, A. W., & Holmstrom, L.L. (1974). Rape trauma syndrome. American Journal of Psychiatry, 131, 981±986. California Advisory Committee to the United States Commission on Civil Rights (1991). Fair and open environment? Bigotry and violence on college campuses in California. Washington, DC: Author. Center for the Study of Sport in Society (1990). Youth attitudes on racism. Boston: Northeastern University. Chen, S. A. (1994). Sociocultural factors in anti-ethnic violence. In J. Y. Fong (Ed.), Proceedings of the Asian American Psychological Association 1994 Convention (pp. 22±31). Atascadero, CA: Gold Shadow Press. Chih, D. W. (1994). College student's coping with antiAsian violence. In J. Y. Fong (Ed.), Proceedings of the Asian American Psychological Association 1994 Convention (pp. 32±37). Atascadero, CA: Gold Shadow Press. Chuang, H. T., & Addington, D. (1988). Homosexual panic: A review of its concept. Canadian Journal of Psychiatry, 33, 613±617. Chun, K., & Zalokar, N. (1992). Civil rights issues facing Asian-Americans in the 1990s. Washington, DC: US Commission on Civil Rights. Clemente, F., & Kleiman, M. B. (1976). Fear of crime among the aged. The Gerontologist, 16, 207±210.

References Comstock, G. D. (1989). Victims of anti-gay/lesbian violence. Journal of Interpersonal Violence, 4, 101±110. Cowan, G., & Hodge, C. (1996). Judgments of hate speech: The effects of target group, publicness, and behavioral responses of the target. Journal of Applied Social Psychology, 26, 355±374. Craig, K. M., & Waldo, C. R. (1996). ªSo, what's a hate crime anyway?º Young adults' perceptions of hate crimes, victims, and perpetrators. Law and Human Behavior, 20, 113±129. Denemark, R. A. (1994). Toward a theory of ethnic violence. Humboldt Journal of Social Relations, 20, 95±120. Dutter, L. E. (1987). Ethno-political activity and the psychology of terrorism. Terrorism 10, 145±163. Farrell, W. C., & Jones, C. K. (1988). Recent racial incidents in higher education: A preliminary perspective. The Urban Review, 20, 211±226. Ferraro, K. F. (1996). Women's fear of victimization: Shadow of sexual assault? Social Forces, 75, 667±690 Foley, L. A., Evancic, C., Karnik, K., King, J., & Parks, A. (1995). Date rape: Effects of race of assailant and victim and gender of subjects on perceptions. Journal of Black Psychology, 21, 6±18. Garnets, L., Herek, G. M., & Levy, B. (1990). Violence and victimization of lesbians and gay men. Journal of Interpersonal Violence, 5, 366±383. Greenberg, M. S., & Ruback, R. B. (1984). Criminal victimization: Introduction and overview. Journal of Social Issues, 40, 1±7. Herek, G. M. (1990). The context of anti-gay violence. Journal of Interpersonal Violence, 5, 316± 333. Herek, G. M. (1993). Documenting prejudice against lesbians and gay men on campus: The Yale sexual orientation survey. Journal of Homosexuality, 24(4), 15±30. Herek, G. M., Gillis, J. R., Cogan, J. C., & Glunt, E. K. (1997). Hate crime victimization among lesbian, gay, and bisexual adults. Journal of Interpersonal Violence, 12, 195±215. Hidden Hate Crime (1996, April 8). National Review, 48, 18. Hunter, J. (1992). Violence against lesbian and gay male youths. In G. M. Herek & K. T. Berrill (Eds.), Hate crimes: Confronting violence against lesbians and gay men (pp. 76±82). Newbury Park, CA: Sage. Janson, P., & Ryder, L. K. (1983). Crime and the elderly: The relationship between risk and fear. The Gerontologist, 23, 207±212. Kelly, R. J., Maghan, J. & Tennant, W. (1993). Hate crimes: Victimizing the stigmatized. In R. J. Kelly (Ed.), Bias crime: American law enforcement and legal responses (pp. 23±47). Chicago: The University of Illinois at Chicago. Kim-Goh, M., Suh, C., Blake, D. D., & Hiley-Young, B. (1995). Psychological Impact of the Los Angeles riots on Korean-American Victims. American Journal of Orthopsychiatry, 65, 138±146. Kressel, N. J. (1996). Mass hate: The global rise of genocide and terror. New York: Plenum. Levin J., & McDevitt J. (1993). Hate crimes: The rising tide of bigotry and bloodshed. New York: Plenum. Levin, J., & McDevitt, J. (1995, August 4). The research needed to understand hate crime. The Chronicle of Higher Education, 41, B1±B2. McLaughlin, K. A., & Brilliant, K. J. (1997). A national bias crime prevention curriculum for middle schools. Newton, MA: Education Development Center, Inc. McLaughlin, K. A., Brilliant, K., & Lang, C. (1995). National bias crimes training for law enforcement and victim assistance professionals. Newton, MA: Education Development Center, Inc. Mays, V. M., Cochran, S. D., & Rhue, S. (1993). The impact of perceived discrimination on the intimate

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relationships of black lesbians. Journal of Homosexuality, 24(4), 1±13. Merl, J. (1989, Oct. 26). Survey of Schools Finds Hate Crime Widespread. Los Angeles Times, A1, S43. Miethe, T. D., & Lee, G. R. (1984). Fear of crime among older people: a reassessment of the predictive power of crime-related factors. The Sociological Quarterly, 25, 397±415. Nebraska Advisory Committee to the United States Commission on Civil Rights (1990). Bigotry and violence on Nebraska's college campuses. Washington, DC: US Government Printing Office. Parker, K. D., McMorris, B. J., Smith E., & Murty, K. S. (1993). Fear of crime and the likelihood of victimization: A bi-ethnic comparison. Journal of Social Psychology, 133, 723±732. Roberts, J. (1995). Disporportionate harm: Hate crime in Canada. Http//www1.denizkor.org/nizkor/hweb/orgs/ canadian/canada/justice/disproportionate-harm/. Sales, E., Baum, M., & Shore, B. (1984). Victim readjustment following assault. Journal of Social Issues, 40, 117±136. Schneider, H. J. (1994). Violence against foreigners in the Federal Republic of Germany. International Journal of Offender Therapy and Comparative Criminology, 38, 179±182. Schultz, L. G. (1987). Victimization programs and victims of crime. In A. Minahan (Ed.), Encyclopedia of social work (18th ed., Vol. 2, pp. 817±822). Silver Spring, MD: National Association of Social Workers. Snell, W. E., & Godwin, G. (1993). Social reactions to depictions of casual and steady acquaintance rape: the impact of AIDS exposure and stereotypic beliefs about women. Sex Roles, 29, 599±616. United States Commission on Civil Rights (1987). Recent activities against citizens and residents of Asian descent. Washington, DC: US Government Printing Office. United States Commission on Civil Rights (1990a). Bigotry and violence on American college campuses. Washington, DC: US Goverment Printing Office. United States Commission on Civil Rights (1990b). Intimidation and violence: Racial and religious bigotry in America. Washington, DC: US Government Printing Office. United States Congress (1992). H.R. 4797. 102d Congress, 2d Session. United States Department of Justice, Federal Bureau of Investigation (1997a). Uniform crime reports: Hate crime, 1995. Washington, DC: United States Government Printing Office. United States Department of Justice, Federal Bureau of Investigation (1997b). Crime in the United States, 1996: Uniform crime reports for the United States. Washington, DC: United States Government Printing Office. von Schulthess, B. (1992). Anti-lesbian assault and harassment in San Francisco. In G. M. Herek & K. T. Berrill (Eds.), Hate crimes: Confronting violence against lesbians and gay men (pp. 65±75). Newbury Park, CA: Sage. Waxman, B. F. (1991). Hatred: The unacknowledged dimension in violence against disabled people. Sexuality and Disability, 9, 185±199. Weine, S., Becker, D. F., McGlashan, T. H., Vojvoda, D., Hartman, S., & Robbins, J. P. (1995). Adolescent survivors of ethnic cleansing: Observations on the first year in America. The Journal of the American Academy of Child and Adolescent Psychiatry, 34, 1153±1159. Weiss, J. C. (1990). Ethnoviolence: Violence motivated by bigotry. In L. Ginsberg (Ed.), Encyclopedia of social work (18th ed., 1990 Suppl., pp. 307±319). Silver Spring, MD: National Association of Social Workers. Weiss, J. C., Ehrlich, H. J. & Larcom, B. E. K. (1991). Ethnoviolence at work. The Journal of Intergroup Relations, 18, 21±33

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Wexler, C., & Marx, G. T. (1986). When law and order works: Boston's innovative approach to the problem of racial violence. Crime and Delinquency, 32, 205±223. Wirtz, P. W., & Harrell, A. V. (1987). Victim and crime characteristics, coping responses, and short- and long-

term recovery from victimization. Journal of Consulting and Clinical Psychology, 55, 866±871. Young, M. A. (1988). Support services for victims. In F. M. Ochberg (Ed.), Post-traumatic therapy and victims of violence (pp. 330±351). New York: Brunner/Mazel.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

9.23 Victims of Disasters NIGEL LONG, KEVIN RONAN, and JOYCE PEREIRA-LAIRD Massey University, Palmerston North, New Zealand 9.23.1 INTRODUCTION

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9.23.2 NATURE OF DISASTER

376 376 377 378

9.23.2.1 Definition of Disasters 9.23.2.2 Classification of Disasters 9.23.2.3 Definition of Victims 9.23.3 METHODOLOGICAL AND ASSESSMENT ISSUES 9.23.3.1 9.23.3.2 9.23.3.3 9.23.3.4

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Sampling Issues and Design Instruments of Assessment Timing of Assessments Assessment Variables

9.23.4 PREVALENCE AND MENTAL HEALTH CONSEQUENCES OF DISASTERS 9.23.4.1 Prevalence of Disasters and Other Traumatic Events 9.23.4.2 Prevalence of Psychological Symptoms and Disorders 9.23.5 TREATMENT APPROACHES

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9.23.5.1 Multiple Gating and Methodology 9.23.5.2 Supportive Therapeutic Environment and Normative Information 9.23.5.3 Critical Elements Across Therapy Approaches 9.23.5.3.1 Exposure and related techniques 9.23.5.3.2 Cognitive intervention components 9.23.5.4 Research on Efficacy and Integrated Treatment Description

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9.23.6 CONCLUSIONS

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9.23.7 REFERENCES

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A number of studies have investigated factors that contribute to the long-term mental heath outcomes following disasters. This chapter reviews the findings from a diverse group of studies and suggests that the absence of unifying themes in disaster research is associated with difficulties in delineating the salient dimensions of the event and the victims. The chapter then discusses the various definitions and classifications of disasters and victims and shows how the wide variation in methodology and measurement and assessment instruments can impact research findings. These variations also make estimations of the prevalence levels of mental health very difficult to determine and some of these issues are also reflected in the consequent

9.23.1 INTRODUCTION Humans have been victims of disasters throughout recorded history. Tornadoes, fires, floods, earthquakes, airplane crashes (and other transportation accidents), hazardous material spills, building collapses, nuclear reactor leaks, terrorist bombings, hostage taking, ice storms, blizzards, and many other accidental, natural, or technological disasters occur throughout the world each year. Disasters, therefore, present one of the most significant concerns among people today and they are a predominant contributing factor to the development of health and mental health problems for millions of people. 375

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treatment approaches. Many of these are not comprehensive or well controlled and the effectiveness of any treatment approach is also difficult to evaluate. Finally, it is suggested that a multiple gate methodology coupled with a cognitive behavioral approach has the best potential for dealing with the wide range of contingencies which disasters present. 9.23.2 NATURE OF DISASTER Research into the effects of disaster on humans has advanced since the mid-1980s, however, there are inconsistencies in the research findings reporting the psychological consequences of disaster on victims (Paton & Long, 1996). This is because most individuals when exposed to traumatic events react with a wide range of physiological and psychological responses which are often transient and dissipate over time. While the number and intensity of symptoms may vary over time, some disaster victims remain more vulnerable to future stressors and may be prone to reactivation of psychological disorders (Long, Chamberlain, & Vincent, 1994). Other inconsistencies in the research may be due to (i) the plethora of definitions used to operationalize the key concepts of disaster, victims, and psychological consequences (Baum, 1991; Warheit, 1988); (ii) diverse research orientations (e.g., psychologists and psychiatrists focus on the psychic components of trauma and mental health of the victims, while sociologists tend to focus on macro-level variables such as general symptoms of distress and ªproblems of livingº) (Bolin, 1988; Green, 1991; Warheit, 1988); (iii) confusion between agent-generated (disaster) and response-generated (organizational response efforts) consequences (Warheit, 1988); and (iv) the absence of an integrated theoretical framework among different research groups (Hartsough, 1985; Warheit, 1988). In addition, some of the diversity in disaster research can be attributed to researchers failing to systematically investigate fundamental issues over an extended period of time. 9.23.2.1 Definition of Disasters Although many people share a common understanding of what is meant by the term disaster, operationally defining disaster for research purposes has proved difficult (Quarantelli, 1985). It is reasonably clear that the term disaster implies a diverse set of circumstances involving physical destruction and psychological distress, property loss, serious injury, and death. Other more specific definitions have been

advanced but many of these are imprecise as they involve qualititative statements. Problems of definition are further exacerbated by the inconsistent use of terminology (e.g., catastrophe, calamity, crisis, trauma, cataclysm, stress, and emergency). Clearly, the field lacks consensus on the use of terminology, a definition of disaster, as well as a definite typology of disaster characteristics and consequences. In earlier definitions, the focus was either on the physical agents of the disaster or on its impact in terms of the physical or social damage it caused. Many of these had a singular focus and did not consider interaction effects (Harshbarger, 1974). For example, by considering the effect of impact alone, there is the danger of encompassing so many situations that the concept of disaster is rendered meaningless. Although the nature of the event must be considered in any formulation of a definition, it should not be exclusively focused on as there are a set of unique characteristics which are common to all disasters. Damage caused by any sudden, powerful event that is beyond the realm of everyday experience could be considered a disaster, but this narrow definition presents a problem as it could encompass individual stressors which are not what is generally considered as a disaster (e.g., assault). A number of researchers have suggested that the concept of magnitude or scope must be added to the definition so that in order for an event to be a disaster, a substantial number of people must be involved (Baum, 1991; Quarantelli, 1985). An alternative approach in formulating a definition is to view a disaster as a specific cataclysmic event, that is, a stressor depicted by immense power, large scope, suddenness, and placing excessive demands on individual coping (Lazarus & Cohen, 1978). Such a characterization of disaster has emerged as a unifying theme in discussions of disaster (Baum & Davidson, 1985; Bolin, 1988). In conceptualizing disasters as stressful events, one can use theory and research on stress to understand and predict the effects of disasters. A review of definitions of disaster has revealed that researchers have tended to focus on one or more of the following factors: (i) the specific events or physical agents of disasters themselves; (ii) the peculiar nature of the event, especially its suddenness, power, and enormity; (iii) the potential of the event to disrupt many factors in the everyday life of an individual; (iv) the way in which victims respond; (v) the loss of daily life structure; (vi) the large degree of destruction and human suffering; (vii) the collective nature of the stress situation; and (viii) the degree of social disruption on group and community functioning.

Nature of Disaster Baum's (1991) conceptualization of disaster appears to encompass many of these factors: ªevents or impacts that cause substantial disruption of psychological or physical functioning. They may be thought of as stressors, tending to be more intense, more powerful, and universal than most threatening or demanding events. They affect relatively large numbers of people and pose heavy demands on coping. In addition, they threaten property and life, whether directly or by virtue of long-term threatº (p. 44). This definition is fairly comprehensive and has an underlying theoretical framework which is useful in conceptualizing disaster research.

9.23.2.2 Classification of Disasters Accurately classifying disasters has several advantages as it allows comparison between different types of events, enables one to assess the differential psychological effects, and helps with treatment planning (Smith, North, & Price, 1988). In an effort to identify the critical elements of disaster, a variety of taxonomies have been proposed (Barton, 1969; Berren, Santiago, Beigel, & Timmons, 1989). Examination of these classification systems suggests that there are a variety of possible dimensions that might assist in predicting which disasters are likely to have the most impact on mental health. However, these approaches are not consistently used and researchers still focus mainly on the differences between human-made and natural disasters. Although this distinction may represent a parsimonious classification scheme, it may be limited to answering the question of who or what is responsible for the disaster. On the other hand, the natural vs. human-made distinction may be a potentially important factor in determining mental health effects (Baum, Fleming, & Davidson, 1983; Green, Lindy, & Grace, 1994). Natural disasters, often referred to as acts of God, can eliminate human agency and culpability from consideration as they may be assumed to be uncontrollable. Conversely, attributions of responsibility following human-made disasters (acts of man) often implicate human negligence, fallibility, or deliberation, and offer victims a target for blame. Baum (Baum 1991; Baum et al., 1983) has made attempts to delineate specific characteristics which distinguish natural from humanmade disasters. These characteristics include suddenness of onset, predictability of the event, extent of damage, persistence of effects, perceptions of control, and absence of an identifiable low point. The notion of a low point denotes

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that from the victim's perspective, the ªworst is overº and this assumption now allows attention to be turned to the recovery process. Researchers have claimed that natural disasters have an identifiable low point (Baum, 1991; Baum et al., 1983; Bolin, 1988). In contrast, some humanmade disasters, especially those which occur over a protracted period (nuclear accidents, toxic and chemical spills) have an indistinguishable low point with hardly any noticeable or short-term negative physical effects on victims. Some researchers have also attempted to provide specific classification schemes within the natural or human-made category. A number of differences between types of natural disasters have been identified using a variety of factors (Alexander, 1993; Belter & Shannon, 1993). It is important to note that although most researchers use the terms human-made and technological disasters synonymously, others have made attempts to delineate the difference between technological related accidents involving chemical and toxic spills and nuclear accidents from other human-made disasters such as those involving structural failures (bridge or building collapses) or transport accidents (Hodgkinson & Stewart, 1991; Taylor, 1996). Beigel and Berren (1985) classified human-made disaster acts as acts of omission (negligence) such as building collapses due to poor infrastructure, and intentional acts of commission, such as terrorism or hostage taking. It is clear that although there may be important differences between natural and human-made disasters, there are also significant differences between disasters within each of these classes. Although disasters within the same class may have many elements in common, no two disasters present the same logistical and psychological challenges to their victims. For example, although hurricane Hugo in 1989 and hurricane Andrew in 1992 were comparable in terms of the damage and loss produced, they were distinct in that they varied on cultural, socioeconomic, geographical, political, and even meteorological factors. As a result, some researchers emphasize the importance to approach each disaster environment so as to acknowledge its uniqueness (Saylor, 1993). One shortcoming in the various definitions of disasters is that there are no clear boundaries between natural and human-made disasters (Beigel & Berren, 1985; Green & Solomon, 1995). In many disasters, technology and/or human failure and natural forces all combine to create the disaster. For example, while most people would tend to classify the 1985 Mexico City earthquake as a natural disaster, aspects of it might be regarded as having human-made characteristics, such as the ineffective anti-

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earthquake structural architecture which led to the collapse of a major hospital where so many died (Smith et al., 1988). This highlights the difficulty in examining the differential effects of disasters because disasters frequently contain mixed typological elements. An important aspect of disaster research is delineating the salient dimensions of the event which the subjects are responding to. A number of researchers have emphasized the importance of understanding and identifying these dimensions in order to predict the scope and magnitude of psychological and psychosocial dysfunction resulting from the experience of a disaster (Bromet & Dew, 1995). Earlier discussion suggests that the distinction between natural and human-made disasters is often artificial and may not be adequate in predicting disaster consequences. In addition, it is difficult to draw valid conclusions about disasters because they vary on a large number of other crucial dimensions (e.g., scope, severity) that could affect outcome. Without a clear understanding of the salient dimensions that differentiate disasters and how these variables can act individually or in collaboration, it is difficult to predict the psychological and psychosocial consequences of disasters. Although some attempts have been made to develop disaster classification typologies consisting of salient dimensions to provide a conceptual framework for better understanding the concept of disaster (Berren et al., 1989), these classification schemes are rarely used in discussing the psychological effects of disasters.

9.23.2.3 Definition of Victims At the centre of the notion of disaster is the concept of victims, the individuals who are affected by the event and its consequences. It is not surprising to find a diversity of opinions on how best to conceptualize a disaster victim given the wide disagreement as to what constitutes a disaster. Early efforts at classification categorized victims according to the extent to which they suffered bereavement, injury or sickness, and loss of property; or to the methods used for coping; or to their experiences of social disruption (e.g., Barton, 1969). Researchers have extended their definition of victims to include emergency personnel and also to those victims who were not directly involved but who may have experienced adverse reactions from the disaster (Hodgkinson & Stewart, 1991). A number of models have been developed to define the different types and degrees of victimization following disasters. For example, Taylor (1996) proposed a six-fold classification

of victims which defined victims as any people who suffered an adverse and severe reaction to the disaster, irrespective of the level of exposure. However, the simplest definition differentiates primary victims (directly exposed) from secondary victims (indirectly affected) (Bolin, 1985). Raphael (1986) suggested that the specific dynamics and outcomes of a disaster event depend on a number of factors. These include the disaster itself, the individual victims, the role expectations for that specific victim situation, and the circumstances of the victimization. Although there is literature suggesting that disaster helpers also experience psychological trauma (Taylor, 1996), due to space limitations, this chapter is limited to primary and secondary victims.

9.23.3 METHODOLOGICAL AND ASSESSMENT ISSUES Accurate assessment of disasters is important given the range of possible psychological, physiological, and psychosocial outcomes which occur as a result of the disaster. The emphasis and nature of assessment depends on the phase of the disaster (e.g., impact vs. recovery) and on its objective regardless of whether it is prevention, treatment, or a compensation claim. McFarlane (1995) suggested that assessment of the disaster impact is crucial given the variability in response and trauma of individuals and communities involved. Three broad approaches have been identified in the field of disaster research (Baum, 1991; Solomon, 1989). These include: (i) clinicaldescriptive studies which document the symptomatology of disaster victims; (ii) epidemiological studies which measure levels of impairment in population groups and communities following a disaster; and (iii) quasi-experimental studies which focus on psychological variables as mediators of response and subsequent effects of disasters. For an excellent review of the goals and the advantages and disadvantages of these three theoretical approaches, the reader is referred to Solomon (1989). These competing theoretical approaches are accompanied by divergences in the methodologies used. The differences include variation in sample size and sampling procedures, research designs, timing of assessments, and choice of measurement instruments. It is difficult to draw valid conclusions regarding the extent of impairment resulting from different kinds of disaster experience as the methodological diversity across studies hinders cross-study comparisons, replication, and generalization

Methodological and Assessment Issues (Baum et al., 1993; Green, 1991; Smith et al., 1988). The study of disasters is further confounded by the nature of the phenomenon under investigation. For instance, predisaster data are rarely available because of the unpredictable and infrequent nature of many types of disasters and this hinders accurate or systematic assessment of preimpact behavior and health (Baum, 1991). Research has rarely obtained pre- and postdisaster data prospectively (Baum, 1991; Baum et al., 1993; Bromet & Dew, 1995; Smith et al., 1988). Most studies that have examined predisaster information have relied upon retrospective reports, and these may present problems regarding reliability. Other useful predisaster information such as prior psychiatric records may also be unreliable due to inexact diagnostic criteria and incompleteness, or may have been destroyed in the disaster (Baum, Schaeffer, Lake, Fleming, & Collins, 1986). In addition, ªthe population under study as well as the phenomena under study are widely dispersed and must be sought out rather than screened at a treatment facilityº (Baum et al., 1993, p. 126), and this makes access to disaster victims one of the greatest practical problems (Baum et al., 1993; Solomon, 1989). For instance, the disruptive events of a disaster might cause substantial dislocation of the victims. Also, potential subjects may be reluctant to recall their painful experiences or they may be involved in pending legal litigation. Conducting blind studies with regard to traumatized and untraumatized subjects is often impossible, given that the comparison group of untraumatized individuals are unlikely to live in the vicinity of the disaster area (Baum et al., 1993). For a more complete examination of methodological and conceptual issues concerning disaster assessment, the reader is referred to several reviews (Baum et al., 1993; Bromet & Dew, 1995; Green, 1991). In the next section, a brief examination of methodological issues concerning sampling, design, timing of assessments, instruments of assessment, and what to assess follows. The major purpose in delineating these conceptual and methodological problems is not to denigrate existing research efforts, but rather to raise these issues in the hope that the reader will consider the adequacy of research studies when considering the mental health impact of disasters.

9.23.3.1 Sampling Issues and Design Many disaster studies in the last decade have utilized a modified cohort design and most have

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been cross-sectional retrospective studies (Bromet & Dew, 1995). Although longitudinal studies have also been conducted, they varied in their timing of initial and follow-up assessments and this makes any cross-study comparisons difficult. One important methodological aspect of disaster research, which affects psychological impairment estimates, concerns the group of victims who are investigated, as it is often difficult to differentiate between a disasteraffected population and an unaffected one. This difficulty arises because a variety of victims may result from the same disaster and the main differentiating feature is their exposure levels to the disaster experience (e.g., injured victims and their close relatives, rescue workers, and body handlers). Most disaster research selects individuals that fall into the primary and secondary victim classes reported earlier (Baum et al., 1993). Although traditional descriptive studies of disaster generally have not employed a control group (e.g., Lifton & Olson, 1976), others have attempted this (e.g., Dew & Bromet, 1993) so that credible conclusions can be reached concerning disaster-associated differences in individual psychological and psychosocial outcomes. Due to the difficulty of obtaining an appropriate control group, researchers have often included less affected individuals rather than unaffected individuals in their comparison group (Baum et al., 1993). This presents a problem as research has indicated that individuals indirectly exposed to disasters also experience adverse psychological experiences (Melick, 1985). Another important aspect of disaster research concerns sample size. Several reviews (e.g., Bromet & Dew, 1995; Hartsough, 1985; Smith & North, 1993; Smith et al., 1988; Wilson & Raphael, 1993) suggest that sample size varies markedly across disaster studies (N = 17 160, Ahearn, 1981; N = 7, Henderson & Bostock, 1977). In a review, Bromet and Dew (1995) suggested that the majority of sample sizes in studies in the 1990s continue to be small and of questionable representativeness.

9.23.3.2 Instruments of Assessment A review of the existing literature on disasters reveals the use of a wide range of instruments to measure the effects of disasters. Several studies have utilized home-made scales, open and nonstructured interviews, structured diagnostic interviews, retrospective medical record reviews, telephone surveys, standardized diagnostic instruments, and behavioral, self-report,

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and biologically based measures (Baum et al., 1993; Hartsough, 1985; Smith et al., 1988). The failure to use comparable instruments across studies has hindered cross-study comparisons and has made it difficult to draw valid conclusions from the available literature. Fortunately, the field of disaster is converging with regard to instrumentation for assessing psychological symptomatology. Since the mid1980s, the use of home-made instruments designed as one-off assessment tools for a particular study has been on the decline. A number of researchers have stressed the importance of using standardized instruments (Baum et al., 1993; Green, 1991; Hartsough, 1985) to facilitate generalization and to improve accuracy of findings. For instance, some researchers have suggested that higher rates of psychological impairment are found in studies employing self-report or in-depth, open format interviews than those using standardized instruments (Melick, 1985; Smith et al., 1988). Several disaster investigators have listed and/ or described a number of measures that have been used in disaster studies with the aim of recommending ppropriate instrumentation and in the hope of encouraging consistency of measures across studies to facilitate replication of results (e.g., Baum et al., 1993; Bolin, 1988; Hartsough, 1985; Smith et al., 1988). The instruments recommended include diagnostic instruments such as the Diagnostic Interview Schedule/Disaster Supplement (DIS/DS; Robins & Smith, 1983) and the Structured Clinical Interview for DSM-IV (SCID; First, Spitzer, Gibbons, & Williams, 1994), standardized symptom checklists such as the Symptom Checklist-90-R (SCL-90-R; Derogatis, 1983), or standardized self-report scales such as the Beck Depression Inventory (BDI; Beck & Steer, 1984) and the Impact of Event Scale (IES; Horowitz, Wilner, & Alvarez, 1979). However, the application of standardized instruments is not without problems. For instance, it has been shown that the correlation between standardized instruments measuring related constructs within a single study is low, suggesting that the same instrument might have to be used on both populations for cross-study comparisons. In addition, the specificity and sensitivity of standardized instruments may be unacceptably low even within the same study population. These problems can be addressed by using multiple instruments and multimethod approaches for obtaining data. In their review, Baum and co-workers (1993) stated that although most researchers used measures of psychological functioning that were psychiatric symptom-oriented, some researchers have attempted to measure family, social,

and vocational functioning as well as biological correlates of exposure. Since the mid-1980s, there has been much focus on post-traumatic stress disorder (PTSD) measurement in disaster studies. However, one problem with the use of diagnostic PTSD instruments is that the diagnostic criteria for PTSD are frequently changing (Green, 1991), and research findings of cross-study comparisons may be unreliable or invalid. Although disaster research and assessment of functioning has often incorporated either selfreport or clinical assessment of psychological symptoms (e.g., symptom experience, ratings of distress, depression), there has been a trend toward complementing these subjective indices with more objective physiological (e.g., sympathetic arousal), biochemical (e.g., pituitary± adrenal axis arousalÐcortisol), and behavioral measures (coping, motivation). Such multimethod assessment approaches have been advocated by a number of researchers (e.g., Baum et al., 1993; Green, 1991; Smith et al., 1988). It has been argued that the concurrent assessment of self-report, performance, and biologically based responses constitutes an optimal measurement strategy that would enhance our knowledge and understanding about the sequelae of disasters (Baum, Grunberg, & Singer, 1982). The utility of such an approach has been demonstrated by a number of researchers (Baum, 1990; Davidson & Baum, 1986).

9.23.3.3 Timing of Assessments No agreement on the most appropriate time for assessment has been established, and studies vary widely on the timing of data collection (Bromet & Dew, 1995). Reviews (Bromet & Dew, 1995; Green, 1982; Smith & North, 1993; Smith et al., 1988) show that timing of assessments have varied from immediately after the disaster (Friedman & Linn, 1957) to up to five years later (Gleser, Green, & Winget, 1981), with the majority of assessments occurring within one year. Early, long-term, and multiple measurement is essential for the understanding of the course of responses to disaster stress (Baum et al., 1993; Smith et al., 1988; Solomon, 1989). However, the timing of assessment is often dependent on practical (e.g., funding) rather than scientific considerations (Green, 1982). In addition, measuring victim reactions in the immediate aftermath of a disaster is also ethically questionable and the accuracy of victim's answers may be in question since individuals in acute distress are unlikely to provide complete and

Prevalence and Mental Health Consequences of Disasters accurate responses (Solomon, 1989).Research has indicated that both the nature and intensity of psychological sequelae appear to vary as a function of the time at which they are measured. For instance, the prevalence of anxiety and depression varied fourfold from month to month following the Three Mile Island accident, with the largest peak occurring immediately after the event (Bromet, Parkinson, Schulberg, Dunn, & Gondek, 1980). Overall, there have been few long-term studies and even fewer systematic studies providing assessments of psychological sequelae at multiple points in time. Multiple-method assessments are important as the different methods tap various aspects of disaster effects. In addition, we suggest these different methods should be used in conjunction with multiple assessment periods which employ a multiple gate strategy, particularly with treatment-related assessment because assessment is part of early intervention efforts. The multiple gate approach involves the use of a less accurate and less extensive screening test (e.g., a self-report inventory) to identify people at risk who could be followed up later for more accurate diagnostic testing. The initial use of self-report questionnaires is helpful in screening populations and identifying those who are at risk for mental health problems and those who may benefit from intervention. Such an approach may be necessary in situations where intervention cannot be provided to all who are exposed due to lack of resources or practical problems, and where it may be premature to use time-consuming diagnostic tests. More comprehensive assessments can be used at the later gates if increasing psychopathology is demonstrated.

9.23.3.4 Assessment Variables Research attempts involved in identifying mechanisms, predictors, and mediators of response to trauma in disasters are likely to yield more informative and useful findings than research which is purely descriptive. Researchers suggest that to achieve a full understanding of the impact of disaster on subsequent adjustment it is important to measure both the generic and situationally specific features of disaster events (Baum et al., 1993; Bolin, 1988), as well as the anticipatory, acute, and long-term responses to the disaster (Ursano, Fullerton, & McCaughey, 1994). Ursano et al. (1994), who used a stress model for studying trauma and disasters, suggested that evaluation of psychological, physiological, and sociocultural responses to a disaster is

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important for the accurate assessment of mental health outcomes. A detailed assessment of the nature and severity of the stressors to which an individual was exposed is necessary, in addition to personal factors (e.g., demographic factors, predisaster psychological functioning, coping style, and appraisal) that might affect posttrauma processing of the event. It is also important to determine whether the victim has suffered prior trauma, because multiple traumatic events may put them at higher risk for developing PTSD and other related symptomatology (Kramer & Green, 1991). Assessment of environment-recovery factors (e.g., social support, extent of network disruption caused by the disaster, societal attitudes about the disaster event) that may inhibit or enhance recovery of the victims is also essential (Ursano et al., 1994). Assessment represents the first step in any intervention effort. In addition, the assertion made in this chapter and supported by data is that continuing use of assessment-related techniques throughout a treatment application will often translate into more beneficial outcomes. Of course, treatment-related assessment should include multiple methods and multiple gating (see Section 9.23.5). 9.23.4 PREVALENCE AND MENTAL HEALTH CONSEQUENCES OF DISASTERS The psychological response following exposure to trauma or disaster is a complex interaction of the event and the individual (Paton & Long, 1996). The interaction may be modified by an individual's previous history, his or her physiological response, and the social context of the event (Ursano et al., 1994), and these can alter significantly over life span (Alexander, 1993) and time of assessment (Davidson & Foa, 1991). Many of the difficulties concerning problems with definitions of terms, methodology, and assessment are ultimately reflected in wide variations in the prevalence levels reported. The next section reviews some of the rates reported and suggests that caution should be exercised when extrapolating prevalence estimates from affected populations. 9.23.4.1 Prevalence of Disasters and Other Traumatic Events The occurrence of disasters and traumatic events may vary across geographic location, in terms of severity and risk, and in their physical attributes (Seaman, 1984). Internationally, there is growing evidence which suggests that

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the prevalence of death and damage following natural disasters is increasing and that 95% of all deaths occur in countries of the third world (Alexander, 1993). Major floods and hurricanes are the most frequently reported disasters, followed by earthquakes, tornados, and severe storms and the mortality rate of these is also rising (Ursano et al., 1994). Other lowfrequency natural catastrophes, such as famines, have been shown to cause millions of deaths over a short period of time (Hodgkinson & Stewart, 1991; Seaman, 1984). Similar to many of the third world disasters, catastrophe can also have severe impact in developed countries, (e.g., the Kobe earthquake), and even though the total number of people affected has not been relatively large, the psychological disorders have been extensively researched (Breslau, Davis, Andreski, & Peterson, 1991; Bromet & Dew, 1995; Norris, 1992). In all situations, the prevalence of psychological disorders has varied across the variety of natural diasters regardless of whether life-time or current rates were reported (Breslau et al., 1991; Norris, 1992). Community surveys reporting life-time prevalence levels of exposure to at least one major natural disaster have ranged between 1% and 28% (Breslau et al., 1991; Norris, 1992; Vrana & Lauterbach, 1994) and many people had been exposed to a wide range and number of other disasters or traumatic events (Breslau et al.). Within these groups the prevalence levels for exposure to any traumatic event was between 39% and 82% (Breslau et al.; Norris, 1992; Vrana & Lauterbach, 1994). Higher prevalence levels (e.g., 92%) have also been reported for clinical samples (Barnard, Hankins, & Robbins, 1992). Prevalence levels of technological disorders have not been widely reported. However, it has been suggested that chemical pollution, transportation accidents, explosions, structural failures, terrorist acts, and other major threats to the environment do represent increasing concern to physical and mental health (Green & Solomon, 1995).

9.23.4.2 Prevalence of Psychological Symptoms and Disorders Prior to DSM-III (American Psychiatric Association, 1980), research into prevalence levels centered mainly on evaluating the nature and extent of the psychological response following exposure to a wide range of disasters. The wide variability in prevalence levels reported across studies results from a variety of factors, including severity and nature of the

disaster, and differences in sampling and methodology (Smith & North, 1993; Ursano et al., 1994). Earlier studies focused on evaluating the prevalence of a wide range of symptoms and disorders following exposure to one trauma within psychiatric populations or community samples. Although initially many of these studies concentrated on PTSD (Green, 1993) and PTSD symptoms (Norris, 1992; Smith & North, 1993), studies in the 1990s have evaluated other psychological disorders including acute stress disorder (Koopman, Classen, Cardena, & Speigel, 1995). Other studies have evaluated many disorders over varying periods of time (Bland, O'Leary, Farinardo, Jossa, & Trevisan, 1996) and some have studied the impact on children and families (Belter & Shannon, 1993). Rubonis and Bickman's (1991) review of disasters which had a sudden onset, showed that disasters, on average, increased the prevalence rate of consequent psychopathology by 17%. Higher levels of disaster psychopathology was also predicted by clinical interviews, being female, and immediacy of data collection. In many of the studies reviewed, the magnitude of the disaster was correlated with symptom severity and some of these can be considered generic while others are disaster specific. Results from clinical and community studies have shown that many victims of disasters meet the criteria for PTSD as defined in DSM-IV (American Psychiatric Association, 1994) and other victims may have many of the symptoms of PTSD but fail to meet the full diagnostic criteria (Breslau et al., 1991; Bromet & Dew, 1995; Green, 1993; Norris, 1992). Some studies have shown that in addition to PTSD, victims may also meet the full criteria for other cooccurring DSM-IV disorders such as generalized anxiety disorder, obsessive-compulsive disorder, dysthymia, depression, and phobic disorders (Breslau et al.). Other outcomes have also been investigated and these included other anxiety or somatic disorders, substance abuse, poor health, treatment seeking, and other psychosocial variables (Bland et al., 1996). Studies of disasters have reported prevalence rates for both physiological and psychological symptoms, clusters of symptoms, precisely defined psychological disorders, and anecdotal syndromes (e.g., disaster syndrome, and survivor guilt) and many have reported combinations of these (Seaman, 1984). Accurate estimations of prevalence levels are therefore often confounded by confusion between comorbidity (separate disorders) and consanguinity (both disorders one and the same) (Tyrer, 1996).

Treatment Approaches In addition, estimating psychiatric morbidity following disasters is not the same as estimating the number of cases of particular psychiatric disorders. This is highlighted when the number of symptoms which only partially meet the full set of diagnostic criteria for a specific disorder also contribute to the level of another disorder and this is extremely common especially when generalized anxiety and major depression are present (Long, Chamberlain, & MacDonald, 1996). In evaluating the prevalence levels of psychiatric disorders, researchers have used a wide range of standard health assessment tools to assess a variety of clinical and subclinical mental health effects of disasters. Few studies were designed with representative samples, comparison groups, systematic and reliable outcome measures, and/or multivariate analysis of exposure effects that took into account other known risk factors, moderators, or mediators of the disorders under study (Bromet & Dew, 1995). These difficulties make comparisons of psychological outcomes among and between disasters particularly problematic and many of these issues have been reviewed (Bromet & Dew, 1995; Green, 1994). In an attempt to overcome some of these difficulties, one meta-analytic study has summarized the impact of different stressors across many studies (Rubonis & Bickman, 1991). Disaster victims seeking treatment in clinical settings also inflate prevalence levels because they often present a major diagnostic problem because chronic PTSD nearly always occurs in conjunction with a range of psychiatric disorders and especially with depression and anxiety (Davidson & Foa, 1991). In addition, other research in clinical settings has shown that comorbidity increases the likelihood of treatment utilization and reported symptoms (Galbaud du Fort, Newman, & Bland, 1992). It is therefore important to evaluate prevalence levels in populations not seeking treatment because levels are less likely to be inflated by other comorbid disorders. Comparisons of the psychological impact resulting from natural and human-made disasters have been made (Green & Solomon, 1995). However, these need to be interpreted cautiously since they do not involve equivalent comparisons. It has been argued that human-made disasters (e.g., chronic technological-related events involving toxic and radiation contamination) are inherently more stressful than natural disasters (Baum et al., 1983; Solomon & Smith, 1994; Weisaeth, 1994), because of their unpredictability, uncontrollability, culpability, and their lack of a low point. In their comparison of disaster studies, Green and Solomon (1995)

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found that victims of acts of commission disasters experienced higher disorder rates than victims of high-death-rate natural disasters. The implication of these comparisons is that natural disasters may be more readily accepted than technological failures. On the other hand, human-made disasters especially those deliberately perpetuated may have an even more significant impact on ensuing psychopathology and would require long-term medical and psychotherapeutic intervention.

9.23.5 TREATMENT APPROACHES Treatment approaches assume a familiarity with the factors concerning definitions, assessment, and prevalence levels. Knowledge of data-based literature addressing normative effects of disasters on individuals and communities is an important step before any intervention process. Familiarity with the nature of the traumatic experience, developmental course of the disorder, personal background factors, cognitive processing, coping style and ability, and the relationship among these interpersonal factors, and the social milieu are important variables when the treatment of any individual victim is considered (Wilson & Raphael, 1993). This knowledge will allow the therapist to apply treatments in flexible ways so as to meet the individual needs of the client. While a considerable data base is available concerning individual treatment factors, it is important to note that methodologically treatment outcome-based research is the exception rather than the rule. Treatments for victims of disasters range from those focused on predisaster readiness and primary prevention to a myriad of treatment approaches focused on postdisaster adaptation and coping. In this latter cluster, approaches range from community-based prevention in the immediate aftermath to longer-term group and individual approaches for those who are not adapting effectively. In addition, individual and group treatment approaches vary tremendously. For example, one comprehensive text included treatment approaches with an emphasis on a wide range of factors: psychobiological, neurocognitive, psychoanalytic, behavioral, holistic, group, family, peer-mediational, and other approaches (Wilson & Raphael, 1993). For the majority of these treatments, the results are rarely reported from controlled clinical trials. Discussion of treatment first focuses on issues important to the development of both practice and research. This includes multiple gating and methodology followed by a focus on elements common to a variety of approaches. Following

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this discussion, the focus moves to a review of controlled evaluation research assessing the effectiveness of cognitive-behavioral approaches in helping those affected by traumatic events.

9.23.5.1 Multiple Gating and Methodology The issue of multiple gating raised earlier is an important consideration within treatment applications. Treatment provided to victims of disasters should also follow a gating methodology. The first step is primary prevention. Predisaster readiness, when possible, has been shown to be effective in helping people cope more effectively when a disaster does strike (Wilson & Raphael, 1993). While some disasters can be anticipated (e.g., high-risk areas), others happen without warning. In these latter cases early intervention is vital (Vernberg & Vogel, 1993). Early intervention can help victims reestablish a sense of control which is instrumental in preventing future problems (e.g., PTSD, major depression). In addition, with some planning these interventions can be implemented to maximize coverage of victims. For example, school-based and community-based interventions (e.g., postincident debriefing) can provide rapid dissemination of information, coping skills education, a chance for the normalizing of reactions to the disaster, and a forum for the activation of social support networks (Hodgkinson & Stewart, 1991). For example, a brief school-based cognitive-behavioral large group intervention was shown to reduce symptoms of distress and increase perceived coping ability in 7- to 14-year-old children following a series of volcanic eruptions (Ronan & Johnston, 1996). These children continued to show reduced distress at follow-up seven months after the initial disaster. For those who do not benefit from initial efforts, however, the next intervention gate would focus on secondary prevention (i.e., intervention at early signs of disorder). At this stage, group or individual interventions can provide additional help that focuses on premorbid and other factors impinging on postdisaster coping and resolution. Finally, if required, additional intervention would focus on helping reduce symptoms of disorder at the same time as attending to increasing adaptive functioning. Further research that utilizes such a gating methodology is needed to assess effectiveness of a continuum of services following a disaster. Of course, appropriate focus on other aspects of treatment outcome methodology is also warranted in this area (Rothbaum & Foa, 1993).

9.23.5.2 Supportive Therapeutic Environment and Normative Information While support is a given in psychotherapeutic approaches, some attention to this nonspecific factor is warranted as victims of disasters need support. One element of support following disasters includes helping clients become aware of important information as soon as possible after the disaster. The nature of support given depends on the nature of the particular intervention. However imparted, information provision needs to be a part of predisaster education campaigns, crisis-related postincident debriefing (Busuttil et al., 1995), peermediated groups (Keane, Fairbank, Caddell, Zimering, & Bender, 1985), psychoanalytic (Brom, Kleber, & Defares, 1989), and cognitivebehavioral approaches (Foa, Hearst-Ikeda, & Perry, 1995). With the information provided, clients can begin to regain control as they begin to understand the normal effects of trauma on their psychological well-being and coping skills, and how to access assistance and multiple levels of support. Within supportive environments, the client can learn about, and begin to cope with personal and material loss in a way that is individually appropriate. The information provided should contain up-to-date research material that includes myths associated with coping with loss. For example, despite some reports to the contrary, some beliefs continue to be held by mental health professionals concerning one normal process of coping that includes the necessity of working through the tasks of grieving. These entail accepting the reality of the loss, experiencing the pain of the loss, adjusting after the loss, withdrawing from that which is lost (e.g., loved one) and beginning to reinvest in new relationships and activities. However, at least three other normative patterns of coping have been identified (Wortman & Silver, 1989). Misinformation presented to clients mourning in ways other than that prescribed by the professional has the potential to exacerbate, rather than relieve, feelings of distress. Regarding loss, ªthere is no prescription for how to grieve properly . . . , and no research-validated guideposts for what is normal versus deviant mourningº (Zisook & Schuchter, 1986, p. 288). As Wortman and Silver (1989, p. 355) point out, ªrecognition of this variability (in coping with loss) is crucialº in order that people can feel supported as they mourn in individual ways without the added concern that their grieving is in some way deviant. However, some do develop pathological grief and related conditions (major depression), and additional intervention in these cases

Treatment Approaches may be warranted (e.g., cognitive or interpersonal therapy for depression). 9.23.5.3 Critical Elements Across Therapy Approaches The variety of approaches that have been advocated for use with victims of disaster tend to use terminology common to the particular theoretical paradigm. However, common elements tend to find their way across the wide range of approaches. Within a supportive environment, treatment is aimed at helping the client cope with trauma by looking back at the traumatic event itself (Kendall & Hammen, 1995). For example, a psychodynamic approach (Horowitz, 1986) tends to begin with a focus on establishing a relationship between therapist and client while emphasizing an increasing selfawareness. This awareness specifically includes recognizing the impact of the traumatic event, increasing acceptance of its effects, and a consequent reduction in symptoms of distress. Psychodynamic techniques tend to explore the reasons underlying avoidance with the aim of helping the client release the need to avoid. These approaches have been used with some success following traumatic events (Brom et al., 1989). A cognitive-behavioral approach (Foa et al., 1995) specifically emphasizes directly breaking through avoidance by more direct confrontations with trauma-related images, feelings, and stimuli. Despite differences, both of these approaches, together with many others (Hodgkinson & Stewart, 1991; Wilson & Raphael, 1993), emphasize an increase in well-being by looking back at the traumatic event and dealing with the distressing thoughts and feelings associated with it. 9.23.5.3.1 Exposure and related techniques An essential issue underlying treatment is the length of time one is exposed to the traumatic stimulus and to treatment as well as the interval between treatments. Rather, efficacious treatments tend to involve exposure intervals that are sufficiently long enough to reduce arousal and distress. Briefer exposure intervals, particularly when they elicit high levels of arousal, have the potential to exacerbate problematic functioning. Apart from this issue, variation exists along the dimensions of level of arousal (high vs. low) and type of exposure (imaginal vs. in vivo) (Rothbaum & Foa, 1993). For example, systematic desensitization has the client arrange a number of fears along a hierarchy and this procedure is usually carried out in an office setting. The essential features of this approach include imaginal exposure, low levels of arousal,

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and relatively brief exposure intervals (though long enough to reduce anxiety). By direct contrast, in vivo flooding has the client exposed to the feared stimulus in the real environment. The aim is to provoke maximal (flooded) anxiety. With continued and prolonged exposure intervals, the anxiety then begins to diminish. Of course, any approach using exposure can vary along these dimensions, depending on the nature of the problem (e.g., severity of trauma), availability of real-world stimuli, safety, and pragmatic concerns. For example, intervention following a disaster cannot utilize in vivo exposure in the classic sense. Despite this, exposure to stimuli related to the disaster can take place in a variety of ways (e.g., Rothbaum & Foa, 1993). For example, video excerpts have potential in exposure approaches following particular disasters. Ronan and Johnston (1996) used a videotape of a series of volcanic eruptions in an exposure- and school-based cognitive-behavioral prevention program. Finally, with respect to variations in approach, an examination of the available literature indicates that desensitization appears to be used more than flooding in treatments following traumatic events. This could be associated with a sensitivity to the potential of ªtoo much too soonº in the wake of a disaster (Wilson & Raphael, 1993). Interventions that utilize exposure often include other components. These components are generally designed to provide the individual with coping skills which adds to effects of the exposure or to counteract excess arousal. For example, systematic desensitization employs relaxation (e.g., breathing relaxation, deep muscle relaxation) as an alternative, and competing, response to excess arousal. Imaginal and in vivo exposure approaches often use modeling (overt and covert) and role play to help the client practice coping more effectively. Self-reinforcement is used to buttress success and encourage continued attempts at coping. Homework exercises are aimed at helping the client focus on practicing skills learned, continuing to manage activities of daily living, and engaging in pleasurable activities. These prescribed exercises can be designed to help the client reduce avoidance and withdrawal and, importantly, generalize the benefits of treatment to everyday living. Finally, as discussed below, cognitive-behavioral approaches include cognitive coping techniques. In summary, it is essential to emphasize that all variations of exposure treatments, whether graded or flooded, imaginal or in vivo, require the client to remain in the presence of the feared, or traumatic, stimulus until arousal and distress reduce to acceptable levels. While prolonged

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exposure appears necessary, it is still unclear what actual psychological mechanisms (e.g., counterconditionig, habituation) account for the beneficial effects of such exposure. For example, systematic desensitization, which is based on the concept of gradual counterconditioning, has been shown to work without the relaxation component and without a hierarchy (Kazdin & Wilcoxon, 1976). These techniques have shown some promise with traumatized victims (Brom et al., 1989). 9.23.5.3.2 Cognitive intervention components Suggestions have been made that one process underlying exposure-based treatments includes a cognitive component which involves a growing sense of mastery, or self-efficacy, in fearful situations. In similar manner, cognitive techniques equip the clients with a means by which they can gain an increased sense of control when faced with distressful thoughts and feelings and these include techniques which are aimed at both cognitive distortions and cognitive deficiencies. In treating distorted processing, cognitive restructuring approaches help the client examine unrealistic beliefs and negative automatic thoughts in a collaborative therapeutic relationship. The essential concept is to help the client anticipate, identify, and modify arousal and thinking that is largely colored by the expectation that bad things will happen (Kendall et al., 1992). For example, following a disaster, a person's cognitions can be dominated by themes of ongoing threat, loss and grief, guilt, and anger. These reactions can keep the disaster alive as well as negatively influencing future events. In most circumstances, distress and coping following disasters unfold in normal and healthy ways and this information is important for clients to understand. It is stressed again that knowledge of the developmental course of postdisaster reactions and normal variation is a primary issue in any pre- or postdisaster intervention. For those who develop conditions such as PTSD, pathological grief, and depression, related problems may be linked with distorted thinking. Combined with normative information, the therapist and client(s) focus on this thinking through the process of collaborative empiricism. That is, they work together to examine the realistic nature of beliefs and automatic thoughts associated with the traumatic event. Thus, explanations based on realities is the continuing theme. Cognitive restructuring can be particularly valuable for those whose trauma includes maladaptive anxiety and depression. Deficiencies in thinking are addressed through problem-solving approaches. The concept advanced is that cognitive skill-building

which helps the client learn systematic strategies can be used to deal with a wide variety of conditions (D'Zurilla, 1986) including trauma. Problem-solving is generally divided into logically-related steps that involve the following components: identifying the nature of the problem, generating alternative solutions and evaluating consequences, deciding on a response, and evaluating the merits of the response. Following traumatic events, this problem-solving sequence will involve identifying realistic and irrational stimuli that are related to the traumatic event and resultant distress. Problem-solving then can be combined with other techniques including exposure to help the client reduce distress by directly facing and systematically coping with problematic situations. For example, in working with anxiety-disordered children, some of whom have experienced traumatic events, Kendall et al. (1992) use a FEAR acronym to help children remember to address the following issues: identifying arousal as the first step to coping and relaxation (Feeling frightened?), engaging in cognitive restructuring (Expecting bad things to happen?), implementing cognitive and behavioral coping plans (Attitudes and actions that can help), and practicing self-reinforcement (Results and rewards). This problem-solving approach, once learned, is then applied in a variety of hierarchically organized imaginal and in vivo situations. A variety of other techniques including, coping modeling, reinforcement, homework, and parent education are used to help the child learn and generalize these skills. Such an approach may have some promise for children traumatized by disasters (Ronan & Johnston, 1996). Other techniques are designed to help the client cope with intrusive symptoms. Thought stopping is a technique designed to help the client cope with intrusive thoughts more effectively. Other distracting techniques have been utilized (Hodgkinson & Stewart, 1991). For example, the use of personal stereos helped children get to sleep at night following the Zeebrugge disaster by distracting them from intrusive and distressing reminders of the trauma (Yule & Williams, 1990). While distraction and temporary avoidance can be effective, the client may benefit most by learning additional skills which are designed to assist in a sense of longer-term control.

9.23.5.4 Research on Efficacy and Integrated Treatment Description The treatment literature in the area of disasters is sparse. In addition, much of the

Conclusions research on the effectiveness of treatment following disasters is limited to case reports or, if using defined groups, does not utilize random assignment or adequate controls. As a result, generalizability of results is often limited. However, some controlled research has begun to examine the effectiveness of treatments for PTSD following a range of trauma (Rothbaum & Foa, 1993; Wilson & Raphael, 1993). For example, Brom et al. (1989) compared trauma desensitization with behaviorally-oriented hypnotherapy, brief psychodynamic therapy (Horowitz, 1986), and a wait-list control condition for clients diagnosed with PTSD. Randomly assigned clients were first taught relaxation followed by imaginal exposure to a hierarchy of situations related to the traumatic event (e.g., accidents). During exposure, clients were encouraged to confront directly (imaginally) the fear-arousing stimulus. The three active treatments were found superior to the wait-list control condition. However, contrary to predictions, the intervention was found to have most beneficial impact on intrusive symptoms and lesser impact on avoidance symptoms. While speculative, the suggestion is that imaginal, rather than some form of in vivo, exposure was utilized may have contributed to this pattern of results. Another study examined the effectiveness of what has been considered by some to be a controversial treatment (Wilson, Becker, & Tinker, 1995). Eye-movement desensitization and reprocessing (EMDR; Shapiro, 1995) works as follows: . . . the client is asked to hold in mind an image of the trauma, a negative self-cognition, negative emotions, and related physical sensations about the trauma. While doing so, the client is instructed to move her or his eyes quickly and laterally back and forth for about 15 to 20 seconds, following the therapist's fingers. Other forms of left±right alternating stimulation (auditory, tactile) are sometimes used. The client then reports the images, cognitions, emotions, and physical sensations that emerged. This recursive procedure continues until desensitization of troubling material is complete and positive self-cognitions have replaced the previous negative self-cognition. (Wilson et al., 1995, p. 928)

This therapy has reported positive results but these findings have been criticized on methodological grounds (e.g., Shapiro, 1989). However, a study using a randomized, controlled methodology found three-session EMDR to be more effective than a wait-list condition in a number of areas which included presenting complaints, anxiety, and positive cognition (Wilson et al., 1995). Wait-list participants

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evidenced no improvement during the control condition on any outcome measure. However, once treated, these same participants evidenced improvement similar to those initially treated on all measures. While the underlying mechanisms of EMDR are unknown, the procedure does incorporate sound behavioral and cognitive techniques and appears to show some promise in treating traumatic memories (Wilson et al.). Foa, Rothbaum, Riggs, and Murdock (1991) have looked at brief cognitive-behavioral programs for treating established PTSD following a traumatic event (e.g., assaults, rapes). They found a cognitive-behavioral treatment and a prolonged exposure condition both to be more effective than a wait-list control and an alternative treatment for persons who had recently experienced a traumatic event. A brief cognitive-behavioral program was found to be superior to an assessment control condition on a variety of indicators (Foa et al., 1995). This included treated (vs. control) clients hastening recovery as indicated by a significantly reduced frequency of diagnosed PTSD at two-month follow-up (i.e., 70% vs. 10% no longer diagnosed with PTSD). This approach, with modification appropriate to the event, appears to hold promise for use in early intervention with disaster victims. With the advent of controlled studies, evidence has appeared that supports the use and continued examination of cognitive-behavioral approaches. It must be noted, however, that following disasters as defined earlier in this chapter, there have not been any comprehensive, controlled studies examining the effectiveness of any treatment approach. Thus, while the cognitive-behavioral approach discussed in this section clearly has promise, controlled clinical trials will prove to be the final arbiter.

9.23.6 CONCLUSIONS Some important methodological and conceptual considerations in the design of disaster studies have been highlighted. For example, problems with sampling, procedure, consistency of measures, and inclusion of appropriate control groups are common. Although knowledge about disasters has greatly increased in the last decade because of methodological improvement in research studies, integration of findings from this line of research has been hampered by its largely atheoretical nature. Many disaster studies focus on the disaster event itself rather than on the theoretical underpinnings of the research. The field needs to base itself on a conceptual framework and utilize a multi-

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method approach to obtaining data. In addition, there is a need for greater emphasis on the underlying generic and unique dimensions that differentiate responses to different disasters being studied. We live in increasingly complex societies in which large-scale technological and humaninduced disasters are more likely to occur. Research has shown a growing respect for the physical dimensions and effects of disasters, but this knowledge often fails to give the insights into their psychosocial costs. A comprehensive typology of victims and disasters is a prerequisite for the development of this field of study, as it provides the framework within which any systematic evaluation may proceed. Considerable attention has been given to the development and delivery of support and treatment interventions but this has not been matched by a corresponding effort on evaluation, and this needs to be addressed. Professionals working in this area will find increasing external pressures to justify the services they provide. The evaluation of these interventions will require a greater understanding of the relationships between environmental factors, impact, and recovery. Intervention in the future will need to move away from the clinical approach that treats all survivors in relative isolation to one in which treatment is managed by accommodating the social, organizational, and community influences prevailing in the recovery environment. Finally, many disasters cannot be prevented but the magnitude of their physical and psychosocial impact can be reduced by better community preparedness and response. 9.23.7

REFERENCES

Ahearn, F. L., Jr. (1981). Disaster mental health: A preand post-earthquake comparison of psychiatric admission rates. Urban and Social Change Review, 14, 22±28. Alexander, D. (1993). Natural disasters. London: UCL Press. American Psychiatric Association (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Barnard, G. W., Hankins, G. C., & Robbins, L. (1992). Prior life trauma, post-traumatic stress symptoms, sexual disorders, and character traits in sex offenders: An exploratory study. Journal of Traumatic Stress, 5, 393±420. Barton, A. H. (1969). Communities in disaster. Garden City, NY: Doubleday. Baum, A. (1990). Stress, intrusive imagery, and chronic distress. Health Psychology, 9, 653±675. Baum, A. (1991). Toxins, technology, and natural disasters. In G. R. VandenBos & B. K. Bryant (Eds.), Cataclysms, crises, and catastrophies: Psychology in action (pp. 9±53). Washington, DC: American Psychological Association. Baum, A., & Davidson, L. M. (1985). A suggested

framework for studying factors that contribute to trauma in disaster. In B. J. Sowder (Ed.), Disasters and mental health: Selected contemporary perspectives (pp. 29±40). Rockville, MD: US Department of Health and Human Services, National Institute of Mental Health. Baum, A., Fleming, R., & Davidson, L. M. (1983). Natural disaster and technological catastrophe. Environment and Behavior, 15, 333±354. Baum, A., Grunberg, N. E., & Singer, J. E. (1982). The use of psychological and neuroendocrinological measurements in the study of stress. Health Psychology, 1, 217±236. Baum, A., Schaeffer, M. A., Lake, C. R., Fleming, R., & Collins, D. L. (1986). Psychological and endocrinological correlates of chronic stress at Three Mile Island. In R. William (Ed.), Perspectives on behavioral medicine (pp. 201±217). New York: Academic Press. Baum A., Solomon, S. D., Ursano, R. J., Bickman, L., Blanchard, E., Green, B. L., Keane, T., Laufer, R., Norris, F., Reid, J., Smith, E., & Steinglass, P. (1993). Emergency/disaster studies: Practical, conceptual, and methodological issues. In J. P. Wilson & B. Raphael (Eds.), International handbook of traumatic stress syndromes (pp. 125±133). New York: Plenum. Beck, A. T., & Steer, R. A. (1984). Internal consistencies of the original and revised Beck Depression Inventory. Journal of Clinical Psychology, 40, 1365±1367. Beigel, A., & Berren, M. R. (1985). Human induced disasters. Psychiatric Annals, 15, 143±150. Belter, R. W., & Shannon, M. P. (1993). Impact of natural disasters on children and families. In C. F. Saylor (Ed.), Children and disasters (pp. 85±103). New York: Plenum. Berren, M. R., Santiago, J. M., Beigel, A., & Timmons, S. A. (1989). A classification scheme for disasters. In R. Gist & B. Lubin (Eds.), Psychosocial aspects of disaster (pp. 40±58). New York: Wiley. Bland, S. H., O'Leary, E. S., Farinardo, E., Jossa, F., & Trevisan, M. (1996). Long-term psychological effects of natural diasters. Psychosomatic Medicine, 58, 18±24. Bolin, R. (1985). Disaster characteristics and psychosocial impacts. In B. J. Sowder (Ed.), Disasters and mental health: Selected contemporary perspectives (DHHS Publication No. ADM 85±1421, pp. 3±28). Rockville, MD: US. Department of Health and Human Services, National Institute of Mental Health. Bolin, R. (1988). Response to natural disasters. In M. Lystad (Ed.), Mental health response to mass emergencies: Theory and practice (pp. 22±51). New York: Brunner/Mazel. Breslau, N., Davis, G. C., Andreski, P., & Peterson, E. (1991). Traumatic events and posttraumatic stress disorder in an urban population of young adults. Archives of General Psychiatry, 48, 216±222. Brom, D., Kleber, R. J., & Defares, P. B. (1989). Brief psychotherapy for posttraumatic stress disorders. Journal of Consulting and Clinical Psychology, 57, 607±612. Bromet, E. J., & Dew, M. A. (1995). Review of psychiatric epidemiological research on disasters. Epidemiologic Reviews, 17, 113±119. Bromet, E. J., Parkinson, D. K., Schulberg, H. C., Dunn, L., & Gondek, P. C. (1980). Three Mile Island: Mental health findings. Pittsburgh, PA: Western Psychiatric Institute. Busuttil, W., Turnbull, G. J., Neal, L. A., Rollins, J., West, A. G., Blanch, N., & Herepath, R. (1995). Incorporating psychological debriefing techniques with a brief group psychotherapy programme for the treatment of posttraumatic stress disorder. British Journal of Psychiatry, 167, 495±502. Davidson, L. M., & Baum, A (1986). Chronic stress and posttraumatic stress disorders. Journal of Consulting and Clinical Psychology, 54, 303±308.

References Davidson, J. R., & Foa, E. B. (1991). Posttraumatic stress disorder: DSM-IV and beyond. Washington, DC: American Psychiatric Press. Derogatis, L. R. (1983). SCL-90-R version: Manual I. Baltimore: John Hopkins University. Dew, M. A., & Bromet, E. J. (1993). Predictors of temporal patterns of psychiatric distress during 10 years following the nuclear accident at Three Mile Island. Social Psychiatry and Psychiatric Epidemiology, 28, 49±55. D'Zurilla, T. (1986). Problem-solving therapy. A social competence approach to clinical intervention. New York: Springer. First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1994). Structured clinical interview for axis I DSMIV disordersÐpatient edition (SCID-I/P, version 2), New York: Biometrics Research Department. Foa, E. B., Hearst-Ikeda, D., & Perry, K. J. (1995). Evaluation of a brief cognitive-behavioral program for the prevention of chronic PTSD in recent assault victims. Journal of Consulting and Clinical Psychology, 63, 948±955. Foa, E. B., Rothbaum, E. O., Riggs, D., & Murdock, T. (1991). Treatment of PTSD in rape victims: A comparison between cognitive-behavioral procedures and counselling. Journal of Consulting and Clinical Psychology, 59, 715±723. Friedman, P., & Linn, L. (1957). Some psychiatric notes on the Andrea Doria disaster. American Journal of Psychiatry, 114, 426±432. Galbaud du Fort, G., Newman, S. C., & Bland, R. C. (1992). Psychiatric comorbidity and treatment seeking: Sources of selection bias in the study of clinical populations. Journal of Nervous and Mental Diseases, 181, 467±474. Gleser, G., Green, B., & Winget, C. (1981). Prolonged psychosocial effects of disaster: A study of Buffalo Creek. New York: Academic Press. Green, B. L. (1982). Assessing levels of psychosocial impairment following disaster: Consideration of actual and methodological dimensions. Journal of Nervous and Mental Disease, 17, 544±552. Green, B. L. (1991). Evaluating the effects of disasters. Psychological Assessment, 3, 538±546. Green, B. L. (1993). Disasters and posttraumatic stress disorder. In J. R. Davidson & E. B. Foa (Eds.), Posttraumatic stress disorder: DSM-IV and beyond (pp. 75±97). Washington, DC: American Psychiatric Press. Green, B. L. (1994). Psychosocial research in traumatic stress. An update. Journal of Traumatic Stress, 7, 341±362. Green, B. L., Lindy, J. D., & Grace, M. C. (1994). Psychological effects of toxin contamination. In R. J. Ursano, C. S. Fullerton, & B. G. McCaughey (Eds.), Individual and community responses to trauma and disaster: The structure of human chaos (pp. 154±176). New York: Cambridge University Press. Green, B. L., & Solomon, S. D. (1995). The mental health impact of natural and technological disasters. In J. R. Freedy & S. E. Hobfoll (Eds.), Traumatic stress: From theory to practice (pp. 163±180). New York: Plenum. Harshbarger, D. (1974). Picking up the pieces: Disaster intervention and human ecology. Omega, 5, 55±59. Hartsough, D. M. (1985). Measurement of the psychological effects of disaster. In J. Laube & S. A. Murphy (Eds.), Perspectives on disaster recovery (pp. 22±60). Northwalk, CT: Appleton-Century-Crofts. Henderson, S., & Bostock, T. (1977). Coping behavior after shipwreck. British Journal of Psychiatry, 131, 15±20. Hodgkinson, P. E., & Stewart, M. (1991). Coping with catastrophe: A handbook of disaster management. London: Routledge.

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Vancouver, BC: Proceedings of the Pan Pacific Hazards '96 Conference [CD-Rom]. Rothbaum, B. O., & Foa, E. B. (1993). Cognitive behavioral treatment of post-traumatic stress disorder. In P. A. Saigh (Ed.), Posttraumatic stress disorder: A behavioral approach to assessment and treatment (pp. 85±110). New York: Macmillan. Rubonis, A. V., & Bickman, L. (1991). Psychological impairment in the wake of disaster: The disaster±psychopathology relationship. Psychological Bulletin, 109, 384±399. Saylor, C. F. (1993). Children and disasters. New York: Plenum. Seaman, J. (1984). Epidemiology of natural disasters. Basel, Switzerland: Karger. Shapiro, F. (1989). Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories. Journal of Traumatic Stress Studies, 2, 199±223. Shapiro, F. (1995). Eye movement desensitization and reprocessing: Basic principles, protocols and procedures. New York: Guilford. Smith, E. M., & North, C. S. (1993). Posttraumatic stress disorder in natural disasters and technological accidents. In J. P. Wilson & B. Raphael (Eds.), International handbook of traumatic stress syndromes (pp. 405±419). New York: Plenum. Smith, E. M., North, C. S., & Price, P. C. (1988). Response to technological accidents. In M. Lystad (Ed.), Mental health response to mass emergencies: Theory and practice (pp. 52±95). New York: Brunner/Mazel. Solomon S. D. (1989). Research issues in assessing disaster's effects. In R. Gist & B. Lubin (Eds.), Psychosocial aspects of disaster (pp. 308±340). New York: Wiley. Solomon, S. D., & Smith, E. M. (1994). Social support and perceived control as moderators of response to dioxin and flood exposure. In R. J. Ursano, C. S. Fullerton, & B. G. McCaughey (Eds.), Individual and community responses to trauma and disaster: The structure of human chaos (pp. 179±200). New York: Cambridge University Press. Taylor, T. (1996). Disaster and victim classification. In D. Paton & N. Long (Eds.), Psychological aspects of disasters: Impact, coping, and intervention (pp. 26±39).

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Copyright © 1998 Elsevier Science Ltd. All rights reserved.

9.24 Victims of War NORMAN A. MILGRAM Tel Aviv University, Israel 9.24.1 INTRODUCTION

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9.24.2 STRESS AND COPING PARADIGMS

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9.24.2.1 9.24.2.2 9.24.2.3 9.24.2.4

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Person±Environment Encounters Cognitive Appraisals Normal Reactions to Extraordinary Stressors Stress-related Reactions and Disorders

9.24.3 WAR-RELATED STRESSORS

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9.24.3.1 Qualitative and Quantitative Features 9.24.3.2 Levels of Professional Intervention 9.24.4 ASSESSMENT AND TREATMENT IN DEVASTATED SOCIETIES 9.24.4.1 9.24.4.2 9.24.4.3 9.24.4.4 9.24.4.5 9.24.4.6 9.24.4.7 9.24.4.8 9.24.4.9

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Assessment Cross-cultural Considerations in Treatment Mental Health of Child Refugees Victims of Torture Prevalence Factors Affecting Adjustment Sequelae of Torture Treatment Guidelines Treatment Centers

9.24.5 THE EFFECT OF WAR ON CIVILIAN POPULATIONS IN INTACT SOCIETIES

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9.24.5.1 The USA and the Gulf War 9.24.5.2 Israel and the Gulf War 9.24.6 LONG-TERM ADJUSTMENT OF TRAUMATIZED HOSTAGES

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9.24.7 PROFESSIONAL RESPONSIBILITIES OF CLINICAL PSYCHOLOGISTS

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9.24.7.1 Ten Precautions 9.24.7.1.1 Problem of empathy with victims of human malevolence 9.24.7.1.2 Lack of concern for the client's cultural background 9.24.7.1.3 Misapplication of the psychodynamic orientation to traumatized clients 9.24.7.1.4 Nonmatching and inappropriate attributions 9.24.7.1.5 Professional bias against war victims 9.24.7.1.6 Discomfort with expressions of revenge 9.24.7.1.7 Reluctance to use lay support groups in treatment 9.24.7.1.8 Reluctance to accept the role of the outsider 9.24.7.1.9 Caution against professional burnout 9.24.7.1.10 Danger of being overly cautious 9.24.7.2 Responsibilities of Clinical Psychologists 9.24.8 REFERENCES

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9.24.1 INTRODUCTION War adversely affects the lives of millions of men, women, and children. There have been 471 wars since 1700 resulting in the death of over 100 million people, and more wars and casualties in the twentieth century than in any previous one. Since the end of World War II, there have been 150 wars, with 22 million dead and millions of survivors whose lives were disrupted by armed conflict (Goldson, 1993). Wars or armed conflicts take many forms. Armed conflicts have taken place between sovereign states (e.g., USA±Vietnam, Iran±Iraq), between warring ethnic and religious factions within a state (e.g., Hutu±Tutsi tribes in Rwanda, Serbs± Croats±Moslems in the former Yugoslavia), and between governments and their opposition (e.g., Greece and Argentina during the rule of the military juntas). There are 20 major ongoing conflicts (defined as over 1000 victims per year) in the world today, the majority in Africa and Asia. There are 25 intermediate and minor conflicts in these continents, Europe, and the Americas (International Federation of Red Cross and Red Crescent Societies, 1995). Many people suffer the consequences of an armed conflict, starting with the soldiers who fight in it and ending with children born long after the armed conflict has ceased. The first immediate consequence of war is that soldiers die or are maimed. The second is that unarmed civilians also die or are maimed, and increasingly so in the twentieth century. Cities are bombed as legitimate military targets because their inhabitants produce weapons for their army or because the destruction of cities will destroy the morale of the home front and eventually the morale of the armed forces of the country. The third is the displacement and flight of people from their homes to other areas in their country or to other countries. Their number is estimated at this time to be in excess of 18 million, with the largest number being African refugees, followed by Asian, Near and Middle Eastern, and European. The fourth is the predicament of the survivors of war who remain in their native countries and labor to repair the damage caused by war and to rebuild their homes and lives. The fifth is the severe psychological and psychiatric damage suffered by those exposed to war. The fallout of war is extensive. Innocent civilians are suddenly caught up in war when they are seized as hostages by one group and used as pawns in a deadly game of chess played before the eyes of the world. War reaches secondary victims, the families and friends of the primary victims who were directly affected by hostilities. War also affects the millions who read, hear, and view ongoing conflicts and their bitter fruits via

newspapers, radio networks, TV channels, historical and fictional novels, and films. The legacy of war extends well into the future. It affects children born after the war to primary and secondary victims. The material costs incurred by a country and its citizens for having engaged in war are paid in installments for 50 years or more. The books of World War I have not yet been closed, as veterans of that war continue to draw compensation and benefits of one kind or another. The books of World War II will not close for another 50 years. The psychological costs of wars are enshrined in the historical consciousness of a people and are manifest in its history books, cemeteries, war memorials, statues, emblems, and commemorative celebrations. The literature on victims of war is voluminous. The present chapter restricts itself to civilian populations who personally suffered traumatic experiences during armed conflict and/or subsequent to it: (i) civilians who remain in their war-devastated country; (ii) civilians forced to leave their country who seek refuge elsewhere; (iii) civilians in countries not devastated in the war in which their country was engaged; and (iv) civilian hostages released after harrowing experiences.

9.24.2 STRESS AND COPING PARADIGMS In order to understand the effects of war, it is necessary to become acquainted with the stress and coping paradigms used in the investigation and treatment of stress-related reactions and disorders in general. Mental health professionals who work with victims of natural or manmade disasters are familiar with the theories and concepts used in two complementary stress and coping paradigms (Hobfoll, 1989; Lazarus & Folkman, 1984). The Lazarus and Folkman (1984) paradigm deals with objective parameters of external stressors (e.g., intensity, duration, and recurrence of stressful life events), cognitive appraisals of these stressors, cognitive appraisals of the intrapersonal and interpersonal resources available to cope with these stressors, the consequent stress reactions, emotion-focused efforts to cope with these reactions, and problem-focused efforts to deal with the environmental stressors. The Hobfoll (1989) paradigm defines stress as a threat of loss of resources, loss of resources, or an insufficient return from the investment of resources. Resources refer to material possessions, personal characteristics, values, status, time, and money. The paradigm posits that resource loss has more adverse effect than the positive effect

Stress and Coping Paradigms of resource gain, and that a rapid depletion of resources leaves individuals, communities, and societies unable to protect their remaining resources. The first paradigm focuses on the demand character of a stressful situation (what kinds of adaptations and adjustments people are called upon to make). The second focuses on what is threatened or lost in a stressful situation. These paradigms have many points of similarity with psychodynamic and interpersonal theories of psychopathology, but their differences are of concern here.

9.24.2.1 Person±Environment Encounters The concepts of these paradigms are applied to three different kinds of person±environment encounters. The first is characterized by demands on people that are easily handled (e.g., a garage mechanic has to fix a flat tire). People have developed competencies that operate as automatic or habitual patterns in dealing with these kinds of situations and are not threatened when they have to deal with them again. If stress refers to the discrepancy between environmental demands and personal supplies or competencies (Lazarus & Folkman, 1984), these encounters are minimally stressful. Alternatively, if stress is defined as the threat of loss or the actual loss of valued resources (Hobfoll, 1989), these recurring encounters contain no threat of loss or actual loss, and are resolved with dispatch. The second kind of encounter is characterized by heavy demands on people's problem-solving competencies and the threat of loss of important resources (e.g., danger of bankruptcy). The demands of the encounter and the potential or actual losses evoke emotional reactions that depend on people's cognitive assessment of the situation. For example, there may be anxiety at the prospect of failing to handle the situation properly, depression when convinced one will fail and suffer dire consequences, anger at oneself for personal inadequacies or at others for being placed in this untenable situation, or any combination of these emotions. Conversely, there may be keen anticipation at the prospects of meeting the challenge successfully. Two kinds of perceived discrepancy affect one's subjective sense of well being or of distress, and thereby facilitate or interfere with one's efforts to deal effectively with the stressful situation at hand. A favorable discrepancy between situational demands and available resources is reassuring and facilitates optimal performance; an unfavorable discrepancy has the opposite effect. Favorable and unfavorable discrepancies between one's

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perceived and one's expected coping behavior have corresponding effects. Given favorable appraisal outcomes, people are likely to cope well with the demands of the situation and to remain free of intense, aversive emotions that are known to disrupt functioning in difficult circumstances. The third kind of encounter refers to extraordinary, highly aversive, or undesirable events (e.g., a drunken driver causes irreversible brain damage to his loved one). Such events are beyond the range of personal experience of most people and call upon cognitive and behavioral competencies that were hitherto not developed. Furthermore, these unfortunate events constitute grave threats to valued resources or cause the outright loss of valued resources (e.g., loss of financial security). Most people lack the competencies required for dealing immediately and effectively with these threats and losses. They are unable to assimilate these shattering experiences to preexisting assumptions and experiences (Janoff-Bulman, 1988), experience a sense of helplessness (Seligman, 1975), become overwhelmed, and suffer acute and possibly chronic stress reactions. 9.24.2.2 Cognitive Appraisals Emotional and behavioral responses to highly stressful situations are mediated by three interrelated kinds of cognitive appraisal: primary, secondary, and tertiary. Primary cognitive appraisals ascertain the parameters of the threatening situation, its imminence, anticipated impact, and consequences. Secondary cognitive appraisals ascertain what is required to avert a disaster altogether or to minimize its effects if it cannot be averted. Secondary appraisals also ascertain whether the coping person has the wherewithal to cope with the disaster or whether one can recruit others to work in one's behalf. Tertiary cognitive appraisal takes place in the course of a prolonged stressful situation (Milgram, 1998; Taylor & Lobel, 1989) and answers the question as to how well the coping person is handling the situation. People engage in interrelated primary, secondary, and tertiary appraisals many times over the course of an evolving crisis and its changing circumstances. 9.24.2.3 Normal Reactions to Extraordinary Stressors An implicit assumption of the stress formulations is that many well functioning people become distressed when exposed to stressful situations or become even more distressed and

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behave in a dysfunctional manner during and after exposure to extraordinary situations. Typically, stress reactions are more severe and long-lasting when the extraordinary situations are of human design. War is the epitome of a malevolent human encounter because it mobilizes all members of society in a united effort to kill other human beings, the enemies of the society (Weisath & Eitinger, 1993). War shatters cherished assumptions about people and human existenceÐthat people are good, that events in the world are meaningful and not random, and that the person making these assumptions is a person of worth (Janoff-Bulman, 1988). This unique character of war places both victimizers and victims of war at high risk for severe, chronic stress disorders and other comorbid disorders. This is not surprising because war imposes demands and requires adjustments for which people lack prior experience and competence and because war compels them to contend with actual or potential losses of the most important things in their lives. Given the enormity of warrelated stressors, severe stress reactions to these consensually extraordinary stressors may be regarded as commensurate and, in a sense, normal (Milgram & Hobfoll, 1986).

9.24.2.4 Stress-related Reactions and Disorders Clinical psychologists who work with war victims must become as familiar with the various stress-related disorders as they are with the kinds of family-related disorders they encounter in their conventional clinical practice. The Diagnostic and statistical manual of mental disorders (4th ed., DSM-IV) (American Psychiatric Association, 1994) lists five major stress-related disorders: adjustment disorder, acute stress disorder, post-traumatic stress disorder (PTSD), complex PTSD, and disorders of extreme stress. The first three have been formally incorporated into the DSM-IV diagnostic system. The fourth was proposed by Herman (1992) and the fifth by van der Kolk, Roth, Pelcovitz, and Mandel (1993). These five disorders range from a relatively mild disturbance in response to a common, mildly upsetting stressor to a profoundly severe disorder in response to an extraordinary stressor. Adjustment disorders occur in response to developmental crises or other predictable difficulties that emerge in the course of life. Symptoms and impairment arising from exposure to war-related stressors do not receive this diagnosis. Acute stress disorder and PTSD may appear following exposure to war-related stressors. They have several criteria in common:

(i) exposure to a traumatic event; (ii) experience of intense fear, helplessness, or horror in response to the above exposure; (iii) dissociative experiences; (iv) reexperience of the original traumatic event in recurrent images, thoughts, dreams, illusions, flashbacks, deÂjaÁ vu phenomena; (v) marked avoidance of stimuli that arouse recollection of the traumatic event and distress when exposed to reminders; (vi) marked anxiety and arousal patterns; and (vii) event-related distress or impairment in social, occupational, or other important areas of functioning. The two disorders differ in time of onset following the traumatic event, intensity and duration of symptoms, and prognosis. The former disorder is associated with less traumatic experiences, less severe symptoms, and greater probability of spontaneous and more rapid recovery. Many war victims, however, are anxious, or depressed, or easily startled without qualifying for either of these formal diagnoses. Complex PTSD and disorders of extreme stress are found in individuals who have experienced prolonged and repetitive exposure to traumatic stressors. Examples of war-related situations are periods of time characterized by starvation, deprivation, torture, and constant threat to life and limb. The DSM-IV clinical field trial indicated that interpersonal traumatization in the first decade of life gave rise to more complex PTSD symptomatology than later traumatization and that Herman's complex PTSD appears to be a combination of disorders of extreme stress and PTSD. Evidence of widespread somatization was also found in the field trial of disorders of extreme stress (van der Kolk et al., 1993). It took the form of manifestations of and preoccupation with a wide variety of somatic complaints including cardiopulmonary symptoms, digestive difficulties, chronic pain, sexual dysfunction, and conversion symptoms. Many psychiatric disorders co-occur with disorders of extreme stress as well as with the other stress-related disorders. These include substance abuse, recurrent depressive episodes, generalized anxiety, panic attacks, and explosive outbursts. 9.24.3 WAR-RELATED STRESSORS 9.24.3.1 Qualitative and Quantitative Features Some armed conflicts are restricted in scope and intensity leaving entire groups and regions relatively unaffected. The USA has fought several wars in the twentieth century with no harm to its civilian population or to the infrastructure of the country itself. Other countries (e.g., Cambodia, Vietnam, Afghanistan) have been devastated by war, with huge

War-related Stressors loss of life of civilians and heavy damage to the essential services of the society. Milgram (1986) proposed a brief checklist for assessing the cumulative stressful features of armed conflicts for individuals, specific groups within the society, and for the society as a whole. This included: (i) personal injury; (ii) loss of life and limb of loved ones; (iii) destruction of one's home, property, possessions; (iv) prolonged lack of food, water, shelter, communication, transportation, medical care, and other amenities; (v) incarceration, torture, threat to one's life; (vi) participation in atrocities or observation of atrocities inflicted by others; (vii) shelling, bombing, destruction of private dwellings as well as public buildings; and (viii) injury and death of strangers. Refugees may also be exposed to the following stressors: (i) expulsion from one's country or flight from it; (ii) conflict over leaving one's homeland and immigrating to an alien land and culture; (iii) the peril and the pain in the passage to the new country; (iv) the refugees' encounter with the language, people, culture, and economic system of the country of asylum; (v) relocation in the new country may entail new interpersonal loses as family members and friends become physically and psychologically separated; (vi) the loss of status in the home; (vii) loss of status in the work place. Many refugees may be forced to work at occupations far less attractive and prestigious than in their country of origin. To offer professional consultation or treatment to war victims remaining in their country of origin, it is necessary to assess the presence and intensity of these stressors in their war experiences, and to become familiar with these parameters in the group, community, and society to which these victims belong. Prognosis for one's rehabilitation, recovery, and return to prewar or optimal functioning is more favorable if one has been exposed to fewer stressors, if the society is largely intact and functioning effectively during and after the armed conflict, and if it is able and willing to identify its war victims and provide them needed support (Jerusalem, Kaniasty, Lehman, Ritter, & Turnbull, 1995). The reverseÐthe physical and psychological devastation of a societyÐconstitutes a grievous loss, personal and collective, by placing in jeopardy the society's way of life, its values, social and political system, and its national and religious observances.

9.24.3.2 Levels of Professional Intervention Kaplan and Sadock (1985) distinguish three levels of mental health intervention. Primary

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intervention aims to eliminate a disease or disorder before it occurs. Secondary intervention aims to shorten the course of an acute disorder by early identification and rapid, crisis intervention. Tertiary intervention aims to reduce chronicity through prevention of complications and active rehabilitation programs. Mental health treatment has typically focused on the tertiary level in the mental health intervention spectrum, that is treating the symptomatic patient or group of symptomatic clients (US Committee on Prevention of Mental Disorders, 1994). It is tempting for the clinical psychologist accustomed to individual psychotherapy to use the same approach with war victims, and it may even be appropriate in some settings with some clients. An example would be mental health centers in Western countries dealing with resettled refugees who continue to be distressed and/or unable to function productively in their new homes. Multimethod hierarchical intervention models have been developed by groups working with people in Third World countries devastated by war. The model developed by the Cross-cultural Division of the Institute for Psychosocial and Socioecological Research in The Netherlands (de Jong, 1995) describes primary and secondary intervention for refugees awaiting repatriation at the national, community, family, and individual levels. Intervention at the primary level takes the form of advocating and assisting in the implementation of political, social, psychological, and economic policies designed to reduce the probability of armed conflict, the adverse consequences of armed conflict during the conflict and after it has ended, and the numbers of displaced people seeking asylum elsewhere as a consequence of the conflict. Well-conceived and well-executed policies at the national and community levels may prepare groups at risk for displacement to withstand pressure to flee, to adapt better if and when they do flee or are forcibly displaced, and encourage repatriation after hostile actions have ceased. Secondary intervention consists of early identification of groups and individuals at high risk for traumatization, and rapid intervention. Early identification requires the establishment of a network of community resources that aid in early identification, prompt referral, and treatment. To expedite early identification, indigenous relief workers must be taught to recognize people in need of their services. In addition, all must be given information in advance about the availability of help if and when the need arises (Milgram, Sarason, Schonplug, Jackson, & Schwarzer, 1995). Secondary intervention provides self-help groups for war victims with

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common problems, fosters self-reliance, and ensures more effective utilization of the resources allocated by government or nongovernment agencies. The form that tertiary intervention takes with war victims depends on where they are at the time, and the ratio of potential clients to therapists. One may offer an intensive, highly individualized kind of treatment to a Southeast Asian refugee living in Boston (Mollica, 1988) and a far different kind of treatment to people in a crowded refugee camp in a hostile or indifferent Third World country (McIntyre & Ventura, 1996; Somasundaram, 1993). In the former instance, one attempts to restore the individual to optimal functioning and, in the latter, one attempts to strengthen survival skills and minimize interfering symptoms so that the afflicted people can move on to the next way station in their journey to a permanent residence. 9.24.4 ASSESSMENT AND TREATMENT IN DEVASTATED SOCIETIES 9.24.4.1 Assessment Historically, the investigation and treatment of war victims in general and refugees in particular began with Jews who survived the Nazi Holocaust in Europe. A vast literature has accumulated on the postwar adjustment of Jewish survivors from vastly different wartime settings: working with resistant partisan groups; physically hiding for years; living with concealed identities; working in labor camps; and surviving concentration camps and death camps. These settings undoubtedly differed in the kind, frequency, and intensity of stressful and traumatic events encountered, but there were also wide individual differences within each kind of setting. Moreover, many survivors had been in more than one setting. There were also major differences in the postwar settings in which these people found themselves. It is not surprising, therefore, with the best of methodological rigor available since the 1940s, that conclusions from one set of studies on Holocaust survivors are not necessarily consistent with those of another. Lomranz (1995) has provided a systematic analysis of this research and has drawn some cautious conclusions: (i) A salutogenic assessment (Antonovsky, 1979) that examines superficial indices of healthy functioning shows that the vast majority of these people lived reasonably productive lives. (ii) A pathogenic assessment that surveys the prevalence of subtle as well as overt psychiatric symptoms and disorders shows that a signifi-

cant number were anxious, angry, depressed, prone to somatic complaints, confined their social contacts to other survivors, and were otherwise isolated and alienated from society for most of their lives, notwithstanding their overall satisfactory adjustment (Harel, Kahana, & Kahana, 1993). (iii) Each person's experience during the Holocaust probably affected their family life and parenting behavior. These behaviors produced the complex phenomenon known as the transgenerational effect (Danieli, 1981, 1993). (iv) The postwar adjustment of Holocaust survivors was affected not only by the events that preceded their liberation but also by the events that followed it: where they settled after the war; the reception they received from Jews and Christians; the cultural and religious milieu in which they lived; and their own impact over time on the society in which they lived. All of these factors affected their life adjustment. (v) With advancing age there were more frequent intrusions into conscious awareness of frightening thoughts and images from the Holocaust. These intrusions were elicited by stimuli reminiscent of the Holocaust (e.g., the Demaniuk trials, the wearing of gas masks by all Israelis during the Gulf war) as well as by agerelated events that evoked feelings of helplessness. Many of these conclusions also apply to refugee groups who immigrated to Western countries following devastating wars in Vietnam and Cambodia (Kinzie, 1993). A recent three-year follow-up of Vietnamese refugees in Norway showed that very severe traumatic experiences were associated with mental health problems (Hauff & Vaglum, 1995). It was also found that stressful events preceding or following forced migration had an independent impact on subsequent mental health. Similar findings were noted in a recent study of Ethiopian Jews who migrated to Israel (Arieli & Aycheh, 1992). They showed a high frequency of stress-related symptoms associated both with the physical and psychological hardships endured in reaching Israel as well as with difficulties in adjusting to the secular life-style prevailing in Israel.

9.24.4.2 Cross-cultural Considerations in Treatment Cultural differences must be taken into account by mental health workers planning and implementing treatment policies for war victims belonging to cultural groups other than those of the planners and implementers (de Jong, 1995; Westermeyer, 1989). Western mental health workers who become familiar

Assessment and Treatment in Devasted Societies with the cultural practices of the groups with whom they are working are able to introduce traditional healing and rehabilitating practices into their program. For example, a group of adolescent boys from the Dingka of South Sudan wrote poems and composed songs about their traumatic experiences, and analyzed one another's dreamsÐall activities honored in that culture (de Jong, 1995). Unaccompanied Cambodian children brought to the USA were placed with families of the same ethnic origin and were encouraged to use Buddhist rituals to honor the dead, and were brought in contact with specially recruited Buddhist religious leaders (Duncan & Kang, 1985). Culturally inappropriate interventions are common. For example, adolescent Somali males from a persecuted ethnic group were encouraged by Western mental health workers in refugee camps to ªbring their experiences out in the open,º and talk about the atrocities they had witnessed. This activity neither achieved the expected emotional catharsis nor did it promote a peaceful resolution of the ethnic conflict that led to the atrocities. On the contrary, because Somali society emphasizes collective responsibility over individual, the use of ventilation techniques increases the desire for revenge and gives it further legitimacy (Zarowsky, 1995). When adolescents in El Salvador were encouraged to talk about the death of their father (killed by the government) and to come to understand the circumstances of his deathÐa reasonable therapeutic strategy in many Western countriesÐlocal psychologists labeled this approach foolhardy. They pointed out that the government was likely to interpret this approach as a threat to its authority and to react aggressively against the mental health workers as well as their patients (Marsella, Bornemann, Ekblad, & Orley, 1994). Western mental health workers may be more sensitive to cultural problems when working in the countries in which the armed conflict occurred. They may be more tempted to use ªorthodoxº Western approaches to trauma when they treat refugees who have come from these war-torn countries to Western countries of asylum. Urging their clients to talk at length about their traumatic experiences, for example, is ill-advised for refugees for whom denial and silence were effective survival strategies in their own country and are not easily put aside in their new country. The use of a native interpreter is recommended not only in the country of origin whose language Western mental health workers have not mastered, but also in the country of asylum whose language the refugees have not mastered. The use of an interpreter is even recommended

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for initial interviews with refugees who have already mastered the language of the asylum country because certain terms possess different connotations in different languages and cultures. An interpreter is necessary, but not sufficient. The interpreter's presence may delude the psychologist into thinking that cultural barriers to therapeutic communication have been removed. In order to work around these barriers and take into consideration culturally bound attitudes toward pain, suffering, loss, and communicationÐwith strangers in general and practitioners of a strange healing art in particularÐit is necessary for mental health workers themselves to become knowledgeable about the cultural concepts, rituals, and amenities of their clients (Richman, 1993). The diagnostic categories used in the stress field have been challenged as culture-laden. Eisenbruch (1992) has argued that the PTSD criteria are based on a Western ethnocentric view of health that prescribes how non-Western refugees should express stress and how their distress should be ameliorated. He suggested that the post-traumatic reaction of many cultural groups should be regarded as a normal and constructive existential response to their predicament rather than as a psychiatric disorder. Ong (1995) has argued that conventional mental health treatment invalidates refugee patients' cultural understanding of their own lives and thereby causes them harm. Most workers in the field do not take this extreme position and cautiously use pharmacological and psychotherapeutic treatments, and at the same time encourage the use of the treatments and rituals indigenous to the clients' cultural background.

9.24.4.3 Mental Health of Child Refugees Children make up half of the world's refugee population. Some researchers consider them at greater risk for physical and psychiatric disability than adults for several reasons: (i) They are developmentally more vulnerable to the adverse effects of malnutrition, on the one hand, and traumatic experiences, on the other. (ii) They may experience cultural uprooting before the process of acculturation in their native culture is completed. (iii) They often experience traumatic separations, temporary or permanent, from their parents, extended families, and familiar surroundings. (iv) They are less able to fend for themselves and are more easily exploited by friend and foe alike.

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(v) As a consequence, they may be implicated in the commission of violent acts, including murder, torture, and other atrocities. (vi) They are correctly regarded as the future of their respective societies, as a consequence of which organizations with different ideological agendas may compete for their education and indoctrination (Goldson, 1993; Rousseau, 1995). Respect for children's cultural background is not always consistent with Western democratic traditions. Some interventions may place Western mental health workers in a quandary: how to react, if at all, to an ideologically undemocratic tradition promoting mental health. For example, Centlivres (summarized in Rousseau, 1995, pp. 320±321) compared two kinds of school programs established in Afghan refugee camps. The United Nations schools provided the children with materials taken from a world far removed from their own. The traditional Moslem schools immersed the children in the military and political atmosphere of Afghan society. Not surprisingly, the students from the latter schools appeared more confident of themselves and their role in a future Afghanistan. The greater success of the latter schools must be seen in the context of the calamity that befell their countryÐone and a half million dead, hundreds of thousands injured, thousands of towns and villages destroyed, five million living as refugees in neighboring countries. The Moslem schools held out the promise of reconstruction of all aspects of Afghan lifeÐ physical, social, economic, and religiousÐand of the lives of these students in the process (Wardak, 1993). Western mental health workers may not be ideologically comfortable with this particular alternative. It may, however, be more conducive to the restored mental health of these children than what was offered by the United Nations program. 9.24.4.4 Victims of Torture The complex character of torture is better appreciated when the act is defined comprehensively. The United Nations Convention Against Torture and Other Cruel, Inhuman, and Degrading Treatment or Punishment provided the following definition: Any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or confession, punishing him for an act he has committed or is suspected of having committed, or intimidating him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering

is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity. Torture does not include pain or suffering arising only fromÐ inherent in or incidental toÐlawful sanctions. (Vesti & Kastrup, 1995a, p. 214)

There are some key differences between torture and other traumatic events of human design: (i) the torturer has complete control over the victim; (ii) the victim is alone and has no recourse, legal or otherwise, to prevent the torturer from doing what he wishes; (iii) from the victim's perspective, what transpires in torture is wholly unpredictable; and (iv) torture is a more deliberate malevolent act with clearly defined goals than other acts of human malevolence. Its purpose may range from making the victim conform to the will of the torturer to destroying the humanity and personality of the victim. Torture may be used not only to obtain information but also to punish, guarantee the victim's future cooperation, forcibly indoctrinate the victim, and control an entire society by letting the public become aware of the use of torture. 9.24.4.5 Prevalence It is estimated that at least 80 nations systematically employ torture and that between 5% to 15% of the world's refugees have suffered torture. Consequently, mental health workers are likely to encounter post-traumatic phenomena associated with torture in people who continue to live in their own country, notwithstanding their torture experience, as well as in refugees who migrated to Western countries of asylum (Vesti & Kastrup, 1995a). 9.24.4.6 Factors Affecting Adjustment In order to prepare treatment programs for those seeking help, it is important to consider the major factors that determine the long-term effects of torture. (i) Parameters of the torture experience. These include the nature and duration of the torture, intensity of the pain, the extent of permanent physical damage and dysfunction (sensory, motor, sexual), the inclusion of sexual torture and rape of male and female victims, and the psychological manipulation of the victim during torture and incarceration. (ii) Availability of intrapersonal resources during and after torture and incarceration. These include a commitment to a political ideology, religious faith, the placing of the experience in some rational context, and the search for meaning in this painful experience.

Assessment and Treatment in Devasted Societies (iii) Immediate aftermath of torture. Depending on the political climate of their country, some victims will experience social isolation and be stigmatized as subversives with whom it is dangerous to associate. Others may enjoy the support of family and friends, extended social networks, and access to rehabilitative agencies. (iv) Subsequent course of the torture victim's life. Some achieve a degree of rehabilitation in their own country and others must seek asylum elsewhere with varying degrees of success. (v) Pretorture factors. Prior positive adjustment and low levels of prior trauma exposure facilitate eventual recovery. 9.24.4.7 Sequelae of Torture Many torture victims present avoidance and intrusion patterns consistent with torture-based PTSD. These symptoms lend themselves to the various learning therapies and to cognitive behavior modification therapies used to treat PTSD symptoms acquired in other kinds of traumatic situations (Dattilio & Freeman, 1994; Kanfer & Goldstein, 1991; Meichenbaum, 1994). Other torture victims may suddenly come to professional attention when they behave in a bizarre manner in reaction to innocuous situations. For example, some people have frightening flashbacks in reaction to standard medical examinations or encounters with people that are in some way similar to the original traumatic experiences. Still others experience brief psychotic episodes after taking anesthesia in preparation for surgery. Given knowledge of patients' backgrounds, these inexplicable reactions are seen as conditioned reactivation of feelings of terror associated with these earlier experiences. Reorienting the distraught person to people, time, and place is often sufficient to alleviate these acute symptoms. At the very least, knowledge of the history of torture prevents misdiagnosis and inappropriate treatment.

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others adjust by shutting down emotional expression altogether (psychic numbing), putting memories of these experiences out of mind, and assiduously avoiding the many situational cues that might activate the primal emotions associated with the torture trauma. Some refugees may freely acknowledge torture in their initial contact with a mental health worker because evidence of torture endows people with certain rights by international law, not the least of which is the right not to be sent back to the country in which they were tortured. Many government officials are unfamiliar with the widespread character of torture and are inclined to reject these accounts out of hand. Mental health workers with a background in this field are able to provide expert opinion in support of the victims' claims, to prepare them to give credible testimony on these painful matters, and to refer them to legal representatives. They are also able to help these people to come to terms with their torture experiences and to deal more effectively with some of the intrapersonal and interpersonal fallout of torture. Some refugees may ask for symptomatic relief of their distress or for help in becoming better adjusted, without mentioning their torture experiences. Interviewers should be aware of this possibility and gently follow up leads, but should not press the issue. When clients have developed trust in the therapist and comfort in the relationship, they will divulge this experience on their own. Sexual torture and/or rape is more traumatizing than other forms of torture because of the special nature of sexual violation as perceived by torturer and victim alike, and because of the consequences of divulging this information to family and friends. Raped women are treated as damaged goods in some societies, divorced by their husbands, ostracized by their families, and in some cases even killed or forced into suicide. Some raped women commit suicide on their own. Consequently, these revelations are subject to stringent confidentiality; otherwise, the structure of an entire family could be destroyed.

9.24.4.8 Treatment Guidelines The adverse effects of torture do not disappear with time. The prevalence of PTSDrelated symptoms as well as generalized anxiety and depression remain well above the control baseline. The willingness of torture victims to divulge their torture experiences to professional mental health workers varies widely. Many do not seek professional help because they do not believe they can be helped. Others are too ashamed of what was done to them or what they did under duress (e.g., implicated others, signed false confessions) to confide in others. Still

9.24.4.9 Treatment Centers Vesti and Kastrup (1995b) describe a multimodal treatment program for torture victims that involves concurrent physical and psychological therapy, involvement of the victim's family, and establishing a therapeutic milieu that contains few of the physical cues and situations that might remind victims of their torture experiences (e.g., lengthy waiting time, abrupt noise, sharp light shining directly in one's face). Physiotherapy and orthopedic

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rehabilitation are mandatory for injured limbs, medication is prescribed for reduction of anxiety or depression, and psychotherapy for psychic injury and behavioral dysfunction. Vesti and Kastrup cited numerous contraindications to insight-oriented psychotherapy (the presence of a paranoid or antisocial personality disorder, weak ego boundaries and poor reality testing, severe substance abuse). The treatment of torture victims is so new and the range of treatment modalities required by these people is so broad that professional treatment should only be done in or in conjunction with a recognized center. Clinical psychologists who work with refugees, but have little or no clinical experience in treating torture victims, should be prepared to raise the question of referral tactfully with refugees whose symptoms are not consistent with the account they gave of their preimmigration experiences. Clients who acknowledge having been tortured should be encouraged, but not pressured, to seek help in a treatment center. Inexperienced therapists may harm their clients by applying inappropriate treatment principles (e.g., pressuring the torture victim to tell all). Inexperienced therapists are also likely to develop strong countertransference reactions to torture victims. Therapists who react with horror on the one hand and pity on the other can offer little to the rehabilitation of torture victims. Therapists who are uncomfortable with the topic and discourage clients from talking about it are no more helpful than therapists who display a morbid interest in the details per se, hence the importance of referring these clients to people trained in this complex problem. 9.24.5 THE EFFECT OF WAR ON CIVILIAN POPULATIONS IN INTACT SOCIETIES 9.24.5.1 The USA and the Gulf War How American society was affected by the mobilization and movement of half a million military service men and women in Operation Desert Storm (1990±1991) is a question that is being evaluated and will continue to be evaluated for many years. The USA was not bombed or invaded, but the lives of the families and friends of the men and women who liberated Kuwait and forced the withdrawal of the Iraqi army were undoubtedly affected by the absence of their loved ones, concern for their safety, and the changed behavior of some military service personnel on their return. Tens of thousands complained in recent years about frequent headaches, stiffness of joints, nausea, and mood

changes. Evidence is now emerging that these soldiers may have been exposed to injurious chemicals due to the allied bombing of an Iraqi ammunition storage depot (NIH Technology Assessment Workshop Panel, 1994; Persian Gulf Veterans Coordinating Board, 1995). A task force on war-related stress was convened immediately after the cessation of hostilities, to develop strategies for the prevention and treatment of psychological, psychosocial, and psychosomatic disorders in the military and in the civilian population 6000 miles away from the hostilities (Hobfoll et al., 1991). Their report highlighted the major assumptions held by researchers and interventionists on warrelated stress in well-functioning societies that were not devastated by war. Their list of groups at risk for war-related distress and behavioral impairment contained some surprising choices: adults with prior histories of traumatic experiences, adults with prior histories of prewar psychopathology, and children in general. Several implications follow from these inclusions. (i) Media coverage of the Gulf war and contact with people directly affected by the Gulf war may have been upsetting to vulnerable groups. (ii) Vulnerable groups can be inoculated against stressful encounters by means of primary and secondary intervention directed toward the general public and toward professional workers (e.g., primary care physicians, psychiatrists, clergy, police) who come in contact with vulnerable people. (iii) Children may be especially vulnerable because, like adults, they are exposed to frightening images and accounts in the media but, unlike adults, they lack the cognitive ability and background information to place what they see and hear in a nonthreatening context. For these reasons, the task force made a number of recommendations to meet the special needs of children. Children should be given accurate information about the war that is appropriate to their developmental level. They should not be protected from potentially upsetting information, nor should they be asked to shoulder their parents' burden during family crises pertaining to the war. Children merit an attentive, nonjudgmental adult ear if they elect to talk about their war-related concerns. Children's reactions in war as in any other stressful situation tend to mirror the reactions of their parents and other significant adults. The best thing adults can do to help children cope with a stressful situation is to behave themselves in a responsible, reassuring manner, despite their own apprehensions. Children, like adults, should be provided with positive expectancies,

Long-term Adjustment of Traumatized Hostages that they will be able to cope effectively with whatever is bothering them. Children in general, but especially older children, should be recruited to perform useful tasks that are relevant to the war. 9.24.5.2 Israel and the Gulf War Israel was far more strongly affected by the Gulf war than the USA. If the casualties and damage incurred by 39 missiles launched from Iraq against Israel are translated into American terms (the ratio of population in the two countries is 50:1), the comparable losses in American terms would be 450 dead from direct causes and 3000 dead from indirect causes, over 11 000 injured, and 16 000 with severe stress reactions, and half a million dwellings damaged or destroyed (Bleich, Dycian, Koslowsky, Solomon, & Wiener, 1992). Over 14 000 people left the country just before the war broke out and over 100 000 left their homes in the targeted metropolitan areas for safer havens in the countryside. Studies of public morale and anxiety were consistent. There was high anxiety and even panic after the first few missiles, a leveling off thereafter, and a gradual decline as the war drew to a close. Citizens living in the vicinity of direct hits were far more apprehensive than those living elsewhere. There was a maximal use of hot-lines for many purposes, including how to don the gas mask, what to tell the children, how to handle one's own anxiety. The media recruited large numbers of psychologists to provide answers to practical questions, and subsequent polls of public satisfaction with these talk shows showed that it was high (Milgram, 1994). Many mental health workers spoke to teachers and members of other professional groups that came in contact with the general public. There was professional criticism about the exaggerated emphasis of many psychologists on ventilation and on maintaining emotional control and an insufficient emphasis on problem-solving behaviors during stressful periods (Milgram, 1993). Some unique features of this war induced a collective sense of learned helpless that affected individuals during the war and the national outlook after the war. Death, injury, and damage to property were all confined to the civilian sector. The Israel defense forces were not mobilized and the protection of the citizens was placed in the hands of American crews unsuccessfully trying to shoot Scud missiles out the sky with Patriot missiles. Adults in general and men in particular were unable to play their customary protective wartime roles and were correspondingly upset. All family members sat

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in sealed rooms during air raids wearing their gas masks, but were unable to do anything about the air raids themselves. The end of the war did not dispel uncertainty about future missile attacks and their potential payload (chemical or biological agents) and uncertainty about the ability of the Israeli defense force to predict and avert such attacks in the future. This uncertainty affected people's sense of well being, their attitudes toward their collective and personal security, and their willingness to make farreaching concessions to their Arab neighbors in the hope of achieving peace (Milgram, 1994).

9.24.6 LONG-TERM ADJUSTMENT OF TRAUMATIZED HOSTAGES The taking of hostages by ideologically driven terrorists has escalated in the latter half of the twentieth century. Ordinary citizens are seized without warning by terrorists who agree to release them unharmed if their government meets the demands of the terrorists (e.g., release their fellow terrorists in prison and grant them safe passage out of the country). Hostages are typically taken in Western countries that place a high value on human life and may be responsive to terrorists' demands. When hostages are released, they return home after a perfunctory debriefing to resume their normal undertakings. Whether they are able to resume their normal routines without suffering the chronic effects of PTSD symptoms and related interpersonal and intrapersonal difficulties is questionable (Ochberg & Soskis, 1982). The extent of their subsequent psychopathology depends on the stressful parameters of the hostage experience. When the experience involves long periods of deprivation, threats to and the injury and death of hostages, it may change a person's perceptions, feelings, cognitions, motivations, and corresponding behaviors permanently. Consider the consequences of the comparatively brief hostage situation described below. The account of the most famous hostagetaking episode in Israel provides a perspective on the long-term effects of a brief, terrifying hostage episode and the consequences of not providing comprehensive, long-term, multimodal treatment to liberated hostages. Over 100 Israeli high school students on a school outing away from home were seized and held hostage by three Palestinian terrorists in western Galilee in May, 1974. The terrorists had already killed a man, his pregnant wife, and their four-yearold child before coming upon the students. When the terrorists first entered the school building where the students were staying, nearly 20 escaped, including all of the responsible

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supervising adults. The remaining students found themselves abandoned by adult authority figures and threatened repeatedly by the terrorists for the next 16 hours. The terrorists mined the building with explosives and fired live ammunition between the legs of the hostages. During the rescue operation the terrorists killed 22 and injured more than 50 hostages. Seventeen years later, 59 survivors participated in a comprehensive follow-up study, along with a carefully selected control group (Gal, SynaDesivilya, & Ayalon, 1994). The vast majority had married, were raising families, and were gainfully employed. Their parenting skills and family adjustment were comparable to the levels of the control group. All of the physically capable men served in the Israel defense forces. Many survivors stated that the experience made them appreciate life more, enhanced their ability to cope with subsequent adversity, and their desire to help other people. However, there was evidence of nonspecific maladjustment as well as situation-specific chronic symptoms. Nearly half said that the tragedy had disrupted their lives, caused them great mental distress, and impeded their academic and career development. They reported more psychiatric symptoms than controls. They also reported a high frequency of PTSD symptoms reflecting features of the original traumatic experience. Those who suffered the greatest degree of victimization (more severe physical injury and greater exposure to traumatic events) were the most disturbed. As might be expected, the survivors were more apprehensive about being abandoned and had less trust in people than controls. After all, they had been abandoned by others during the crisis and many felt abandoned during their long recovery when many well-meaning people came briefly and then disappeared. This lack of trust in people may also account for their lower level of intimacy in marriage. That most of the men avoided doing their military service in combat units may be attributed to their heightened sensitivity to weapons and the sounds of weapons, a sensitivity acquired during the hostage episode. Most reported anxiety and fear reactions during the Gulf war because of the uncomfortable associations that the war elicited. Analysis of the kind and number of psychotherapy sessions given to the survivors indicated that there was no sustained effort by the mental health profession to provide systematic, long-term therapeutic intervention for them. Less than half received any psychotherapy immediately after the episode and, in most cases, it amounted to one or two sessions. Those who did receive psychotherapy indicated that it was ineffective.

Looking back today at their needs then, it is certain that had these people been given a broad range of learning and behavior modification treatments soon after their harrowing experiencesÐtreatments not available in 1974 Ðthey would be suffering fewer and less intense PTSD symptoms and related adjustment problems today. People who have been exposed to life-threatening situations, such as being taken hostage, and were fortunate enough to survive have suffered psychic injuries that justify their being offered a wide range of treatmentsÐ pharmacological, educational, behavioral, and psychotherapeutic. A group debriefing experience shortly after being freed from the hostage episode is a quick, but insufficient, fix. 9.24.7 PROFESSIONAL RESPONSIBILITIES OF CLINICAL PSYCHOLOGISTS 9.24.7.1 Ten Precautions Working with war victims, at any intervention level, is a highly complex and demanding professional endeavor. In undertaking to work with war victims, one should be mindful of Hippocrates's admonition: First, do no harm. There are many reasons why psychologists with the best of intentions may not help and even cause harm to these kinds of clients. 9.24.7.1.1 Problem of empathy with victims of human malevolence Most psychologists living in Western countries have encountered the kinds of war-time suffering experienced by Asians and Africans only in books and in the cinema. They are no more equipped to believe or to empathize with the litany of malevolence and degradation told by a solitary refugee than they are to deal with the sight of 30 000 injured, traumatized, and terrified survivors of the Rwanda massacres, mostly women and children, living in a crowded refugee camp on the border of an indifferent or hostile country. The mental health professional's initial reaction to the tales of the Holocaust survivors was denial of the message and rejection of the messenger. To overcome these understandable but antitherapeutic reactions it was necessary not only to acquire knowledge about the Holocaust but also to seek supervision from and collaboration with more experienced colleagues, if one hoped to conduct effective psychotherapy with Holocaust survivors (Danieli, 1981). The same cautions apply to war victims today.

Professional Responsibilities of Clinical Psychologists 9.24.7.1.2 Lack of concern for the client's cultural background Many psychologists are ignorant of or indifferent to the cultural background of many clients. Some psychologists may simply disregard or reject it out of hand. Cultural imperialism has its adherents and champions in many Western countries and in many walks of life. Clinical psychologists who hope to do effective work with war victims from other cultures must learn and listen first. 9.24.7.1.3 Misapplication of the psychodynamic orientation to traumatized clients Many clinical psychologists are wedded to a psychodynamic orientation to psychopathology and regard all current symptomatology as stemming from unresolved intrapsychic conflicts associated with the circumstances of their home and upbringing. War victims also carry with them the unresolved conflicts and vulnerabilities of childhood. They have been exposed, however, to extraordinary stressors in war that adversely affect all prior acquisitions, however successful. 9.24.7.1.4 Nonmatching and inappropriate attributions When clients enter therapy they may attribute their personal difficulties and distress to their own failings and mistakes (an internal orientation) or attribute them to the failings, mistakes, and malevolence of others or to fate (an external orientation). They may also attribute responsibility for resolving their difficulties and achieving mental health to their own efforts (internal) or to the efforts of the therapist or changes in the behavior of significant others (external). The combinations of internal vs. external attributional proclivity for problems and their resolution introduce complex considerations in psychotherapy (Brickman et al., 1982). That therapists also bring their own assumptions about proper attributions to their therapeutic endeavors adds further complications. Many therapists foster an internal orientation in their clients for the circumstances that brought them into treatment and most foster an internal orientation for what must be done to bring about desired change. Milgram (1986) has shown that if the client possesses one attributional style and the therapist another, the lack of correspondence can be a serious obstacle to therapeutic progress. This already complex problem becomes more complex when Western therapists deal with refugees from non-Western countries.

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It is inappropriate in most instances for therapists to encourage their clients' adopting an internal orientation for symptomatology and personal problems that stem from war and emigration. It may even be inappropriate for therapists to encourage their refugee clients' adopting an internal orientation for solving their problems. Clients who have been reared in the Western tradition of individualism and personal responsibility for one's successes or failures are more willing to adopt an internal orientation for resolving their difficulties. People reared in a more fatalistic tradition and who may attribute what happens to them as a reward or punishment for their actions in earlier reincarnations (e.g., Buddhist tradition) require a different attributional approach. There is no easy answer here, but it is imperative that therapists ascertain what are the attributional orientations of their clients toward their personal difficulties and the resolutions of these difficulties as they plan their therapeutic approach. 9.24.7.1.5 Professional bias against war victims Clinical psychologists, like other citizens, have distinct ideological preferences. It follows that clinical psychologists may find themselves treating refugees with whom they do not necessarily empathize. The professional behavior required of the clinical psychologist is to put aside ideological issues and allegiances and treat the client to the best of one's ability. If this is not possible, the psychologist must make an appropriate referral (Milgram & Toubiana, 1988). 9.24.7.1.6 Discomfort with expressions of revenge Many therapists are uncomfortable about expressions of retribution, retaliation, or revenge voiced by clients who have suffered physical and psychological injury at the hands of others. One can easily understand that many victims of the human malevolence that characterizes war may talk about these desires. However, many therapists regard talk about revenge as unworthy of their clients and forcefully discourage such talk. They may even suggest that their clients forgive and forget. This discomfort with the desire for restitution, retaliation, or revenge runs counter to the prevailing view that any human impulse or thought can be bared in therapy without fear of censure. It also runs counter to the moral outrage experienced by people when guilty parties go unpunished and the moral satisfaction when they are punished. Therapists must

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carefully think through their attitude toward the revenge theme when it arises in war victims and use it as a channel for enhanced communication and personal growth.

9.24.7.1.7 Reluctance to use lay support groups in treatment Many clinical psychologists prefer to see their clients in individual or in group therapy, but discourage their involvement in self-help groups run by lay leaders or in other lay support groups. This preference has its roots in the desire to keep the client centered on the therapeutic relationship and to discourage competing encounters that might dilute the relationship or reduce symptomatic distress at the expense of acquiring insight into one's difficulties. Community interventionists, however, encourage clients to receive support from significant lay people (Nietzel, Guthrie, & Susman, 1991). They justify the use of family, friends, and selfhelp groups to enhance empowerment, to facilitate change in clients who live and work in an open system that must change to accommodate itself to changes in their clients. They assert that it is easier to instigate and maintain change in a client when there are environmental supports. Moreover, if significant others are not involved, they may derail treatment out of resentment, ideological conflict, or any other reason. A comprehensive presentation of the many issues inherent in primary and secondary intervention in disasters may be found in Hobfoll and deVries (1995).

9.24.7.1.8 Reluctance to accept the role of the outsider Clinical psychologists who elect to work with people living in war-devastated societies (e.g., in refugee camps, or in the countries of origin) are likely to feel that they are outsiders looking in. This is understandable and essentially correct. They are outsiders, but do have professional skills and knowledge to impart to the insider leadership. They serve as consultants with the local leadership, offer to train them in skills relevant to the needs of the local populations, and maintain a watchful brief (Caplan, 1974). Clinical psychologists do not become insiders when they work in their own country and treat refugees coming in for treatment. They are still outsiders to the culture, language system, and the experiences of these people. They should acknowledge and accept their outsider role in good grace on their own home turf as in overseas assignments.

9.24.7.1.9 Caution against professional burnout The potential for burnout or what Figley (1994) has termed compassion fatigue, is very great in psychologists who immerse themselves for long periods of time, without respite, in their work with victims of war. This is especially true when psychologists work in refugee camps in Third World countries, but it may also occur when they work in their own countries. It is imperative to adopt the various work and life strategies that mitigate against burnout. 9.24.7.1.10 Danger of being overly cautious Some therapists may become overly cautious in their work with war victims. They may take to heart the caveats summarized above and adopt a passive, waiting orientation towards their clients. Western clients often welcome this orientation as a clear indication that therapy is their responsibility to make of it what they may. This orientation would be unfortunate in working with many war victims from nonWestern cultures because such people expect their healers to take positive action. Therapists who have a caring and respectful attitude toward their clients can take small risks in therapy if they have made their clients their partners in the enterprise. It is their partner's responsibility to provide feedback about the therapists' overtures. 9.24.7.2 Responsibilities of Clinical Psychologists Western-trained clinical psychologists have important responsibilities to perform with war victims. The psychologist is the major source of knowledge about assessment. Clinical psychologists are expert in the construction, validation, administration, and interpretation of assessment scales and interviews. Space does not permit citing the many scales that assess affect, adjustment, general symptoms of maladjustment, and specific scales of symptoms associated with exposure to traumatic episodes. Clinical psychologists are responsible for selecting the appropriate assessment techniques to use with a given population in a given situation, for adapting existing scales to the requirements of special groups, for constructing new scales for new groups, new situations, or new features of known situations, and for validating these scales. Clinical psychology shares with other professions the responsibility to intervene therapeutically on behalf of clients traumatized or otherwise impaired by their war experiences. Clinical psychologists with a background in

References community psychology will find the transition to primary and secondary intervention easier than those trained exclusively in one-to-one or group therapy. If clinical psychologists have cultivated a strong critical faculty about their work, they may be able to assess more quickly and correctly what is right and what is not in their work with these clients. Psychologists are involved in the training of professional and lay groups. These groups need to deepen their understanding of the many experiences, problems, and needs of war victims. Psychologists can make a major contribution by writing, conducting workshops, and consulting with these interventionist groups. The training of clinical psychologists in empirical research makes them critical consumers of research findings and of authoritative conclusions promulgated by experts in the field. It also qualifies them to engage in correlational clinical research as well as in conducting clinical trials on the efficacy of interventions. Clinical psychology accepts an advocacy function. War victims are at high risk for chronic psychopathology if needed interventions are not provided. Many of the necessary interventions are dependent on political decisions and support. Politicians with the best of intentions and with generous sums of money may accomplish little good and do much harm, if not given objective information about given problems and feedback about the efficacy of treatments to solve these problems. The training and talents of many clinical psychologists qualify them to analyze organizational endeavors in an effort to diagnose those variables that contribute to achieving the professed goals of the organizations and the variables that detract from achieving these goals, and to convey their findings and conclusions to others. The numbers and needs of war victims are staggering. To meet big needs, it is necessary to launch big programs. By their nature big programs can make big mistakes. Trouble shooting and whistle blowing are heavy responsibilities and fraught with risks for shooters and blowers. No one person can get the job done right, but no one should be exempt from trying. 9.24.8 REFERENCES American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Antonovsky, A. (1979). Health, stress, and coping. San Francisco: Jossey-Bass. Arieli, A., & Aycheh, S. (1992). Psychopathology among Jewish Ethiopian immigrants to Israel. Journal of Nervous and Mental Disease, 180, 465±466.

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Bleich, A., Dycian, A., Koslowsky, M., Solomon, Z., & Wiener, M. (1992). Psychiatric implications of missile attacks on a civilian population. Journal of the American Medical Association, 268, 613±615. Brickman, P., Rabinowitz, V. C., Karuza, J., Coates, D., Cohn, E., & Kidder, L. (1982). Models of helping and coping. American Psychologist, 37, 368±384. Caplan, G. (1974). Support systems and community mental health. New York: Human Sciences. Danieli, Y. (1981). Families of survivors of the Nazi Holocaust: Short and long-term effects. In C. S. Spielberger, I. W. Sarason, & N. A. Milgram (Eds.), Stress and anxiety (Vol. 8, pp. 405±421). Washington, DC: Hemisphere. Danieli, Y. (1993). Diagnostic and therapeutic use of the multigenerational family tree in working with survivors and children of survivors of the Nazi Holocaust. In J. P. Wilson & B. Raphael (Eds.), The international handbook of traumatic stress syndromes (pp. 889±898). New York: Plenum. Dattilio, F. M., & Freeman, A. (1994). Cognitive-behavioral strategies in crisis intervention. New York: Guilford. de Jong, J. T. V. M. (1995). Prevention of the consequences of manmade or natural disaster at the inter(national), the community, the family, and the individual level. In S. E. Hobfoll & M. W. deVries (Eds.), Extreme stress and communities: Impact and intervention (pp. 207±228). Dordrecht, The Netherlands: Kluwer. Duncan, J., & Kang, S. (1985). Using Buddhist ritual activities as foundation for a mental health program for Cambodian children in foster care. Unpublished manuscript. Mountainlake Terrace, WA: Lutheran Social Services. Eisenbruch, M. (1992). Toward a culturally sensitive DSM: Cultural bereavement in Cambodian refugees and the traditional healer as taxonomist. Journal of Nervous and Mental Disease, 180, 8±10. Figley, C. R. (Ed.) (1994). Compassion fatigue: Secondary traumatic stress from treating the traumatized. New York: Brunner/Mazel. Gal, R., Syna-Desivilya, H., & Ayalon, O. (1994). Coping and long-term adjustment: The case of the Ma'alot Survivors. Zichron Ya'akov, Israel: The Carmel Institute for Social Studies, Goldson, E. (1993). War is not good for children. In L. A. Leavitt & N. A. Fox (Eds.), The psychological effects of war and violence on children (pp. 3±22). Hillsdale, NJ: Erlbaum. Harel, Z., Kahana, B., & Kahana, E. (1993). Social resources and the mental health of aging Nazi Holocaust survivors and immigrants. In J. P. Wilson & B. Raphael (Eds.), The international handbook of traumatic stress syndromes (pp. 241±252). New York: Plenum. Hauff, E., & Vaglum, P. (1995). Organized violence and the stress of exile: Predictors of mental health in a community cohort of Vietnamese refugees three years after resettlement. British Journal of Psychiatry, 166, 360±367. Herman, J. L. (1992). Trauma and recovery. New York: Basic Books. Hobfoll, S. E. (1989). Conservation of resources: A new attempt at conceptualizing stress. American Psychologist, 44, 513±524. Hobfoll, S. E., & de Vries, M. W. (Eds.) (1995). Extreme stress and communities: Impact and intervention. Dordrecht, The Netherlands: Kluwer. Hobfoll, S. S., Spielberger, C. D., Breznitz, B., Figley, C., Folkman, S., Lepper-Green, B., Meichenbaum, D., Milgram, N. A., Sandler, I., & van der Kolk, B. (1991). War-related stress: Addressing the stress of war and other traumatic events. American Psychologist, 46, 848±855. International Federation of Red Cross and Red Crescent

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Societies (1995). World Disaster Report 1995. Geneva, Switzerland: Author. Janoff-Bulman, R. (1988). Victims of violence. In S. Fisher & J. Reason (Eds.), Handbook of life stress, cognition and health (pp. 101±113). New York: Wiley. Jerusalem, M., Kaniasty, K., Lehman, D. R., Ritter, C. & Turnbull, G. (1995). Individual and community stress: Integration of approaches at different levels. In S. E. Hobfoll & M. W. deVries (Eds.), Extreme stress and communities: Impact and intervention (pp. 105±130). Dordrecht, The Netherlands: Kluwer. Kaplan, H. I., & Sadock, B. J. (1985). Comprehensive textbook of psychiatry (Vol. IV). Baltimore: Williams and Wilkins. Kanfer, F. H., & Goldstein, A. P. (1991). Helping people change: A textbook of methods (2nd ed.). Boston: Allyn and Bacon. Kinzie, J. D. (1993). Posttraumatic effects and their treatment among Southeast Asian refugees. In J. P. Wilson & B. Raphael (Eds.), The international handbook of traumatic stress syndromes (pp. 311±319). New York: Plenum. Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer. Lomranz, J. (1995). Endurance and living: Long-terms effects of the Halocaust. In S. E. Hobfoll & M. W. deVries (Eds.), Extreme stress and communities: Impact and intervention (pp. 325±352). Dordrecht, The Netherlands: Kluwer. Marsella, A. J., Bornemann, T., Ekblad, S., & Orley, J. (1994). Amidst peril and pain: The mental health and well being of the world's refugees. Washington, DC: American Psychological Association. McIntyre, T. M., & Ventura, M. (1996). Civil war haunts Angola children. Psychology International, 7, 1±4. Meichenbaum, D. (1994). A clinical handbook of PTSD: Practical therapist manual for assessing and treating adults with PTSD. Watertown, Canada: Institute Press. Milgram, N. A. (1986). Attributional analysis of warrelated stress: Modes of coping and helping. In N. A. Milgram (Ed.), Stress and coping in time of war: Generalizations from the Israeli experience (pp. 9±25). New York: Brunner/Mazel. Milgram, N. (1993). Stress and coping in Israel during the Gulf War. Journal of Social Issues, 49, 103±123. Milgram, N. (1994). Israel and the Gulf War: The major events and selected studies. Anxiety, Stress, and Coping, 7, 205±215. Milgram, N. A. (1998). Children under stress. In T. H. Ollendick & M. Hersen (Eds.), Handbook of child psychopathology (pp. 505±536). New York: Plenum. Milgram, N. A., & Hobfoll, S. E. (1986). Generalizations from theory and practice to war-related stress. In N. A. Milgram (Ed.), Stress and coping in time of war: Generalizations from the Israeli experience (pp. 316±352). New York: Brunner/Mazel. Milgram, N. A., Sarason, B., Schonplug, U., Jackson, A., & Schwarzer, C. (1995). Catalyzing social support. In S. E. Hobfoll & M. W. deVries (Eds.), Extreme stress and communities: Impact and intervention (pp. 473±488). Dordrecht, The Netherlands: Kluwer. Milgram, N. A., & Toubiana, Y. H. (1988). Bias in identifying and treating high-risk groups. Professional Psychology: Research and Practice, 19, 21±25. Mollica, R. F. (1988). The trauma story: The psychiatric care of refugee survivors of violence and torture. In F.

M. Ochberg (Ed.), Post-traumatic therapy and victims of violence (pp. 295±314). New York: Brunner/Mazel. Nietzel, M. T., Guthrie, P. R., & Susman, D. T. (1991). Utilization of Community and Social Support Resources. In F. H. Kanfer & A. P. Goldstein (Eds.), Helping people change: A textbook of methods. (2nd ed., pp. 396±421). Boston: Allyn & Bacon. NIH Technology Assessment Workshop Panel (1994). The Persian Gulf experience and health. Journal of the American Medical Association, 272, 391±396. Ochberg, F. M., & Soskis, D. A. (1982). Victims of terrorism. Boulder, CO: Westview. Ong, A. (1995). Making the biopolitical subject: Cambodian immigrants, refugee medicine, and cultural leadership in California. Social Science and Medicine, 40, 1243±1257. Persian Gulf Veterans Coordinating Board (1995). Unexplained illnesses among Desert Storm veterans: A search for causes, treatment, and cooperation. Archives of Internal Medicine, 155, 262±268. Richman, N. (1993). Children in situations of political violence. Journal of Child Psychology and Psychiatry, 34, 1286±1302. Rousseau, C. (1995). The mental health of refugee children. Transcultural Psychiatric Research Review, 32, 299±332. Seligman, M. E. P. (1975). Helplessness: On depression, development and death. San Francisco: Freeman. Somasundaram, F. J. (1993). Psychiatric morbidity due to war in Northern Sri Lanka. In J. P. Wilson & B. Raphael (Eds.), The international handbook of traumatic stress syndromes (pp. 333±348). New York: Plenum. Taylor, S. E., & Lobel, H. (1989). Social comparison activity under threat: Downward evaluations and upward contacts. Psychological Review, 96, 569±575. US Committee on Prevention of Mental Disorders (1994). Reducing risks for mental disorders: Frontiers for preventive intervention research. Washington, DC: National Academy Press. van der Kolk, B., Roth, S., Pelcovitz, D., & Mandel, F. (1993). Complex PTSD: Results of the DSM-IV Field Trial for PTSD. Unpublished paper. Cambridge, MA: Harvard Medical School. Vesti, P., & Kastrup, M. (1995a). Refugee status, torture, and adjustment. In J. R. Freedy & S. E. Hobfoll (Eds.), Traumatic stress: From theory to practice (pp. 213±235). New York: Plenum. Vesti, P., & Kastrup, M. (1995b). Treatment of torture survivors: Psychosocial and somatic aspects. In J. R. Freedy & S. E. Hobfoll (Eds.), Traumatic stress: From theory to practice (pp. 339±363). New York: Plenum. Wardak, A. W. H. (1993). The psychiatric effects of war stress on Afghanistan society. In J. P. Wilson & B. Raphael (Eds.), The international handbook of traumatic stress syndromes (pp. 349±364). New York: Plenum. Weisath, L., & Eitinger, L. (1993). Posttraumatic stress phenomena: Common themes across wars, disasters, and traumatic events. In J. P. Wilson & B. Raphael (Eds.), The international handbook of traumatic stress syndromes (pp. 69±77). New York: Plenum. Westermeyer, J. (1989). Cross-cultural care for PTSD: Research, training and service needs for the future. Journal of Traumatic Stress, 2, 515±536. Zarowsky, C. (1995). Resources for a critical synthetic approach to refugee mental health. Transcultural Psychiatric Research Review, 32, 333±338.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

9.25 Adult Sexual Offenders WILLIAM L. MARSHALL Queen's University, Kingston, ON, Canada 9.25.1 INTRODUCTION

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9.25.2 NATURE AND PREVALENCE OF THE OFFENSES

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9.25.2.1 9.25.2.2 9.25.2.3 9.25.2.4 9.25.2.5 9.25.2.6

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Exhibitionism Voyeurism Frotteurism Child Molestation Sexual Assaults Summary of Prevalence

9.25.3 DIAGNOSIS AND ASSESSMENT

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9.25.3.1 Diagnosis 9.25.3.2 Assessment 9.25.3.2.1 Sexual interests/history 9.25.3.2.2 Social functioning 9.25.3.2.3 Cognitive processes 9.25.3.2.4 Personality 9.25.3.2.5 Substance abuse

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9.25.4 TREATMENT

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9.25.4.1 Cognitive-behavioral Programs 9.25.4.1.1 Acceptance of responsibility 9.25.4.1.2 Cognitive distortions 9.25.4.1.3 Empathy 9.25.4.1.4 Social functioning 9.25.4.1.5 Deviant fantasies 9.25.4.1.6 Relapse prevention 9.25.4.2 Overall Value of Treatment 9.25.5 FUTURE DIRECTIONS

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9.25.5.1 Research 9.25.5.2 Practice 9.25.6 SUMMARY

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9.25.7 REFERENCES

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are legally proscribed (i.e., exhibitionism, voyeurism, frotteurism, and pedophilia). DSM-IV also lists under ªSexual disorders not otherwise specifiedº additional behaviors that are illegal: necrophilia (sex with a corpse), bestiality (sex with animals), and scatologia (obscene phone calls). In addition, the category of sadism may involve behaviors that break the law (where the putative masochistic partner is

9.25.1 INTRODUCTION The legal and diagnostic systems differ in their identification of sexual offenders, with the legal system being far more inclusive. The American Psychiatric Association's (1994) Diagnostic and statistical manual of mental disorders (DSM-IV) lists under the category of ªParaphiliasº a limited set of behaviors that 407

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an unwilling participant). Unfortunately, many sexual offenders do not meet the diagnostic criteria for paraphilia and this presents a dilemma for clinicians who typically see a need to treat all sexual offenders whether or not they can be given a diagnosis. Worse than that, this conflict between legal proscriptions and diagnostic criteria presents serious problems for researchers, and particularly for reviewers attempting to assimilate the literature, in identifying the population samples. In this chapter the behaviors considered are described in generic terms as follows: exhibitionism, voyeurism, frotteurism, child molestation, and sexual assault (i.e., sexual attacks on adults). In this respect, sexual offenses are construed as sexual (or partly sexually motivated) acts perpetrated on an unwilling victim or on a person who is considered unable to give consent (e.g., a child or a severely disabled person). 9.25.2 NATURE AND PREVALENCE OF THE OFFENSES There is so little known about some sexual offenses (e.g., obscene telephone calls, bestiality, and necrophilia) that it makes little sense to discuss them. Consequently, the focus is on only those for which there is sufficient available evidence. 9.25.2.1 Exhibitionism Exhibitionism involves the deliberate and unsolicited exposure of the genitals to an unwilling audience. It is the most common of all sexual offenses, accounting for over onethird of all convictions for sexual crimes in the USA, Canada, England, Germany, and Hong Kong (Rooth, 1973). Abel et al. (1987) reported that exhibitionists attending their clinic admitted to an average of 514 acts per offender, and Marshall, Eccles, and Barbaree (1991) found that 57% of untreated exhibitionists reoffended within four years of being convicted. Up to 50% of adult women report having been the victim of an exhibitionist at least once in their life (Di Vasto et al., 1984). Exposing is obviously a very persistent and frequent behavior among these offenders. While there are some reports of female exhibitionists, almost all of those who are identified by the legal system, and who receive clinical attention, are males (Blair & Lanyon, 1981). Although some men may expose themselves to children, those who do so on a consistent basis are generally construed by clinicians as child molesters rather than exhibitionists. It appears that the majority of exhibitionists remain just that, although the boldness

of their acts typically increases over time as a result of desensitization to the risk of being caught (victims rarely report them). Some exhibitionists, however, do engage in other offensive behaviors. Freund (1990), for example, found that exhibitionists are also quite commonly voyeurs and that 12% had also raped a woman. 9.25.2.2 Voyeurism Voyeurism is the act of peeping in windows for the purpose of watching unsuspecting persons (usually women) who are undressing, already naked, or who are engaging in sexual acts. Again, it is mostly males who are identified as voyeurs. Abel, Becker, Cunningham-Rathner, Mittelman, and Rouleau (1988) found that voyeurs often display other sexually offensive behaviors, and Langevin, Paitich, and Russon (1985) found that every one of their sample of over 600 voyeurs had engaged in other sexual offenses, including rape. The actual frequency of voyeurism, however, is not well documented. 9.25.2.3 Frotteurism Frotteurism refers to touching or rubbing against an unwilling person in order to generate sexual excitement. The frotteur typically frequents crowded places so that he can engage in his offensive behavior. Some attempt to make their frotteurism appear accidental, while others are so emboldened that they do not appear to care what an observer might think. These latter frotteurs engage in such aggressive and intrusive behaviors that Langevin (1983) has considered them to belong to the same category as rapists. Again, the frequency of these behaviors is not well documented as frotteurs have rarely been identified in sufficient numbers to provide a basis for research. 9.25.2.4 Child Molestation Child molestation is a generic term used to describe all types of sexual acts perpetrated by an adult on a child regardless of the gender of the child or the relationship between victim and offender. There are, not surprisingly, important differences between those men who molest their own children (incest offenders) and those who molest unrelated children (nonfamilial offenders), and between those who abuse boys and those who assault girls, but these issues are left until Section 9.25.3. The majority of child molesters are males, but in the past decade there have been increasing reports of female child molesters (Allen, 1991; Elliot, 1993). Never-

Diagnosis and Assessment theless, male offenders very considerably outnumber females. The sexual molestation of children involves a range of behaviors from fondling to vaginal or anal intercourse. In our research, we found that 36% of child molesters had intercourse with their child victims and, although this was more likely to occur when the victims were aged 10 years or older, many younger victims (as young as nine months in one case) were forced to submit to vaginal or anal intercourse (Christie, Marshall, & Lanthier, 1979; Marshall & Christie, 1981). Further, over 50% of incarcerated child molesters and 23% of child molesters attending an outpatient clinic had used unnecessary force when sexually assaulting a child. Obviously, child molestation is a far more dangerous and damaging behavior than was once thought to be the case. Sexual assaults on children also occur with far greater frequency than most people wish to admit. Finkelhor and Lewis (1988), for example, asked a national sample of US adult males whether they had ever molested a child: 17% said yes. If we take this to provide an estimate of how many adult males have molested at least one child, then there are several million children in the USA who have been sexually assaulted. The Committee on Sexual Offenses against Children and Youths (1984) conducted national surveys in Canada to determine the frequency of child molestation. That committee concluded that one-half of Canadian females and onethird of Canadian males had been sexually victimized, and that over four-fifths of these assaults happened before the victim was aged 18 years. Seventy percent of the males and 62% of the females were prepubescent when the assaults occurred. Similar surveys in other countries have revealed similar figures and the effects on the victims are extensive and devastating (see Chapter 18, this volume).

0

9.25.2.5 Sexual Assaults In this chapter, the term sexual assaults is used interchangeably with rapes and the offenders are referred to as rapists. Sexual assaults on adults are almost exclusively enacted by males, and by far the majority of the victims are female, although there have been reports of male victims (Stermac, Sheridan, Davidson, & Dunn, 1996). Those assaults that lead to a conviction are typically quite aggressive and involve humiliating and degrading features. Christie et al. (1979) found that over 70% of rapists engaged in gratuitous violence against their victims, and Darke (1990) reported that 60% of rapists engage in behaviors that are

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intended to degrade their victims. Not surprisingly, the effects on the victims of sexual assault are profoundly damaging (Koss & Harvey, 1991). The Federal Bureau of Investigation's Uniform Crime Reports revealed dramatic increases in rape up to 1980, at which time 71 out of every 100 000 females at risk were assaulted. From 1980 on, there was a consistent slight decrease until 1989 when the rate returned to 1980 levels. Estimating rates of sexual assault from large-scale surveys reveals far higher frequencies, with the rates typically being four or more times greater than those derived from official figures (Ennis, (1967). Russell (1984), for example, found that 44% of the 930 women she surveyed reported having been sexually assaulted, but only 8% had reported the incident. Other surveys have produced similar findings (e.g., Koss, Gidcyz, & Wisniewski, 1987). 9.25.2.6 Summary of Prevalence From a consideration of all these data on the various types of sexual offenses, it is clear that these behaviors occur at an alarmingly high rate and cause considerable damage, not only directly to the victims, but also to their families and to the innocent members of the offenders' families.

9.25.3 DIAGNOSIS AND ASSESSMENT 9.25.3.1 Diagnosis In DSM-IV, the paraphilias are said to be characterized by ªrecurrent, intense, sexually arousing fantasies, sexual urges, or behaviorsº (American Psychiatric Association, 1994, p. 522), having to do with the specific interests of the paraphiliac. These fantasies, urges, or behaviors must also ªcause clinically significant distress, or impairment in social, occupational, or other important areas of functioningº (p. 523). Thus, a person may be diagnosed as having a paraphilia even if they have never acted on it. On the other hand, if they have enacted the behavior but it has not caused distress or impairment, then they should not be diagnosed as paraphilic. For pedophilia the diagnostic criteria include ªsexual activity with a prepubescent child or childrenº (American Psychiatric Association, 1994, p. 528), where the child is aged 13 years or younger. Just why this age limit was chosen is not clear. This criterion implies that a person who repeatedly molests postpubescent children should not be diagnosed as a pedophile. There

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is, unfortunately, no diagnostic category for what some clinicians have called ephebophilia (i.e., the molestation of young teenagers). Accordingly, those who sexually abuse children over age 14 years, even if they do so in a persistent and apparently preferential way, would not meet the diagnostic criteria for any paraphilia and yet they just as certainly would be considered sufficiently disordered by most clinicians to require treatment. As a result, clinicians and researchers do not always use the term ªpedophiliaº in strict accordance with the diagnostic guidelines. Very few rapists meet diagnostic criteria for a paraphilia, primarily because there is no specific category in DSM-IV for this behavior. Those few rapists who are said to be sadistic would qualify for a DSM-IV diagnosis, but there are problems in arriving at such a diagnosis for sexual offenders. According to the diagnostic criteria, a sadist is a person who is sexually excited by the psychological or physical suffering of another person, where the psychological suffering includes humiliation. In our examination of the motives of rapists (Darke, 1990; Marshall & Darke, 1982), we selected only those behaviors displayed by rapists during their assaults that were rated by independent judges to be unequivocal signs of intended humiliation. We found that in 60% of rapes there were clear indications of attempts to humiliate the victim and that 60% of rapists declared that it was their intention to humiliate their victims. If sexual excitement was produced by humiliation in these men, then as many as 60% of rapists would meet the diagnostic criteria for sadism. This seems to contradict current diagnostic practices where far fewer rapists are identified as sadistic. There are, then, problems in relating diagnostic criteria as defined by DSM-IV, to both clinical and research practice. Clinicians typically take the position that anyone who has committed a sexual offense is in need of assessment and treatment. Thus, clinicians tend to be guided by legal rather than by diagnostic criteria. Similarly, researchers generally have access only to adjudicated sexual offenders. Unfortunately, however, researchers have tended to use the terms child molester and pedophile rather loosely, so it is at times difficult to tell whether a study is examining all available child molesters or only those who meet the DSM criteria. Future revisions to the diagnostic manual should consider expanding the categories of paraphilia to approximate a closer match to clinical practice. Child molesters, with and without deviant preferences, and rapists with and without sadism, might be more useful categories.

9.25.3.2 Assessment The assessment of sexual offenders has typically been aimed not at arriving at a diagnosis but rather at determining the man's risk to reoffend, his treatment needs, and whether or not treatment produced the hopedfor result. In pursuit of these aims, an almost unlimited array of evaluation procedures have been adopted. While the assessment measures may differ, the content areas evaluated reveal some consistencies, with the targets identified in Table 1 being the most common. Table 1 also indicates some of the measures that have been used. Projective tests are not listed in this table, although a number of clinics routinely employ them, because the limited evidence available does not encourage confidence in their value with sexual offenders (Levin & Stava, 1987) and because there are more general questions concerning the psychometric properties of projective tests (Kline, 1993). Other alternatives that have been used to assess the accuracy of the self-reports of sexual offenders include conducting interviews assisted by polygraphy (Abrams, 1991; Emrick & Dutton, 1993), using tests that have built-in indicators of faking (e.g., the Minnesota Multiphasic Personality Inventory [MMPI], Graham, 1990; and the Multiphasic Sex Inventory, Nichols & Molinder, 1984), or adding a measure of the propensity to present in a socially desirable manner (e.g., the Marlowe±Crowne Social Desirability Scale, Crowne & Marlowe, 1980). Unfortunately, there are limits to the value of each of these assessment measures. Although the use of polygraphy in the evaluation of sexual offenders appears to be widespread, its value has been challenged (LalumieÁre & Quinsey, 1991) and there is evidence that sexual offenders can dissimulate on the MMPI without the faking measures detecting this (Langevin, Wright, & Handy, 1990). Also, there are some serious doubts about whether measures of social desirability do in fact evaluate this proclivity (Holden & Fekken, 1989). There is not room here to evaluate all the approaches to assessment, but comment is made on some because the areas they examine represent topical issues with sexual offenders. 9.25.3.2.1 Sexual interests/history It is clear that most offenders can fake their phallometric responses so as to appear to have normal preferences and while some of the more obvious attempts at faking can be detected, cognitive strategies cannot (Murphy & Barbaree, 1994). While some assessors have developed ways to circumvent faking (Malcolm, Davidson,

Diagnosis and Assessment

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Table 1 Assessment targets and some typical measures. Target

Typical measures

Sexual interests/history

Phallometric testing (Murphy & Barbaree, 1994) Sexual Interest Card Sort (Abel & Becker, 985) Clarke Sexual History Questionnaire (Langevin, 1983) Multiphasic Sex Inventory (Nichols & Molinder, 1984) Anxiety (Watson & Friend, 1969) Assertiveness (Rathus, 1973) State-Trait Anger Expression Inventory (Speilberger, 1988) Child Molester Empathy Measure (Fernandez, Marshall, Lightbody, & O'Sullivan, 1997) Social self-esteem (Lawson, Marshall, & McGrath, 1979) Social intimacy (Miller & Lefcourt, 1982) Abel's Cognitive Distortions Measure (Abel et al., 1989) Rape Myth Acceptance Scale (Burt, 1980) Attitudes toward women (Spence, Helmreich, & Stapp, 1973) Hostility toward women (Check, 1984) Hare's Psychopathy Checklist±±Revised (Hare, 1991) Minnesota Multiphasic Personality Inventory (Graham, 1990) Michigan Alcoholism Screening Test (Selzer, 1971) Drug Abuse Screening Test (Skinner, 1982)

Social functioning

Cognitive processes and attitudes and beliefs Personality Substance abuse

& Marshall, 1985; Quinsey & Chaplin, 1988), others have not consistently found these approaches to be effective (Proulx, CoteÂ, & Achille, 1993). Evidence on the reliability of phallometric assessments is quite limited and at least one study reported very poor test±retest reliability (Barbaree, Baxter, & Marshall, 1989). There are also other problems with the use of phallometry. For example, while the evidence suggests that phallometric measures can distinguish nonfamilial child molesters from other men, these evaluations have not proved so successful in identifying incest offenders, rapists, or exhibitionists (Murphy & Barbaree, 1994). Nevertheless, alternative assessment procedures (e.g., self-reported preferences or card-sort tests) seem even more vulnerable to dissimulation and even less reliably distinguish sexual offenders from other males (Marshall, 1996a). For the foreseeable future, then, phallometric measures will continue to represent the best approach to identifying deviant sexual interests. It is also essential to determine the sexual history of these men, partly to identify the range and persistence of their deviant practices, but also to determine their experience with appropriate sexual behaviors. Both the Clarke Sexual History Questionnaire (Langevin, 1983) and the Multiphasic Sex Inventory (Nichols & Molinder, 1984) are useful measures in this regard but so also is the clinical interview.

9.25.3.2.2 Social functioning The primary areas of interest here appear to be the offender's self-confidence, his capacity for empathy, his ability to form intimate relationships, and his more general social skills. There is clear evidence that sexual offenders lack self-esteem (Marshall, Anderson, & Champagne, 1996), have a limited capacity for empathy (Marshall, Hudson, Jones, & Fernandez, 1995), are deficient in intimacy (Marshall, 1993), and are socially deficient (McFall, 1990). Clearly, these aspects of their functioning need to be assessed in order to make clinical decisions about sexual offenders. Most measures of self-esteem treat the concept as a trait manifest across situations and time, and yet there is clear evidence that self-confidence is significantly affected by general circumstantial features (Marshall, Anderson et al., 1996). For example, we have found that the self-esteem of individual sexual offenders varies according to whether we are asking them about confidence in social or sexual interactions, or about their appearance or their occupational functioning (Anderson & Marshall, 1996). Measures of self-esteem, then, need to be specific to the domain of functioning in which we are particularly interested. Hanson (1997) has reviewed empathy measures that have been used with sexual offenders. He notes that empathy is, in fact, a multicomponent process and as such we need to

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employ more than a simple general measure. Davis (1980, 1983) has developed such a measure and it has been usefully employed with sexual offenders. However, more specific measures have also been developed for child molesters (Fernandez, Marshall, Lightbody, & O'Sullivan, 1997) and rapists (Fernandez, 1996), and for the critical perspective-taking aspect of empathy (Hanson & Scott, 1995). Relevant measures of the capacity of sexual offenders to form adult romantic/sexual relationships have been adopted from other fields of research. For example, various measures of intimacy have been applied to the assessment of sexual offenders and they have revealed significant deficits in these men compared with other males (Bumby & Marshall, 1994; Seidman, Marshall, Hudson, & Robertson, 1994). An alternative and perhaps more productive approach to relationship issues has been developed by Ward, Hudson, and McCormack (1997). They assess attachment styles rather than the attainment of intimacy, since it is the style that maximizes or minimizes the possibility of developing effective relationships, whereas intimacy can be the chance outcome of various other influences as well. Ward et al.'s measure of attachment style relies on a categorization developed by Bartholomew and Horowitz (1991) which unfortunately is rather crude and seems not to fully capture the essence of the issue. However, this appears to be a very promising approach and Bartholomew's measure may be useful in combination with a thorough interview. Attempts to evaluate other aspects of social functioning include questionnaire assessments of assertiveness, social anxiety, and anger, as well as role-play measures of social skills (Bellack, 1983). 9.25.3.2.3 Cognitive processes Ward, Hudson, Johnston, and Marshall (1997) have shown that sexual offenders characteristically have inappropriate views of the sexuality of women and children, and distorted perceptions of both their own behavior during their offenses and the reactions of their victims. It has also been shown that child molesters construe children in more appealing ways than they do adults (Horley, Quinsey, & Jones, 1997; Howells, 1978). Abel et al.'s (1989) measure of cognitive distortions in child molesters evaluates their tendency to distort the world in a self-serving way, but is restricted to their view of children and sexuality. Until the early 1990s, the majority of assessments of rapists' perceptions concerned the evaluation of their attitudes

toward women. However, Bumby (1996) developed two excellent measures of cognitive distortions: one for child molesters and one for rapists. Unfortunately, all of these measures rely on self-report, and many offenders who score in the appropriate range later in therapy, or at interview, reveal quite inappropriate or distorted perceptions.

9.25.3.2.4 Personality Much has been made in the literature of the possibility that sexual offenders may have distinctive personalities. However, despite persistent attempts to discern a personality profile that characterizes these men, little in the way of consistent findings has been revealed. Among the measures that have been used, the two most popular have been the MMPI and Hare's (1991) Psychopathy Checklist-Revised (PCL-R). While there have been inconsistent results using the MMPI (Marshall & Hall, 1995), it may, nevertheless, be useful to determine whether or not a particular offender displays any other sign of psychopathology. Hare's measure has consistently revealed psychopathic tendencies in a reasonable number of sexual offenders, although the percentage of psychopaths tends to be higher among those held in psychiatric facilities (Quinsey, LalumieÁre, Rice, & Harris, 1995) than among imprisoned sexual offenders (Serin, Malcolm, Khanna, & Barbaree, 1994). There is no doubt that Hare's measure is a useful assessment tool, particularly for determining a sexual offender's risk to reoffend.

9.25.3.2.5 Substance abuse A substantial number of sexual offenders are chronic abusers of either alcohol or some other drug, or use one or another drug prior to or during their offensive behavior. Using the Michigan Alcoholism Screening Test (Selzer, 1971), Langevin and Lang (1990) found that 55.8% of sexual offenders scored within the alcoholic range. On the Drug Abuse Screening Test (Skinner, (1982), Langevin and Lang (1990) found that 17.8% had a serious problem in the abuse of other drugs. These two measures adequately evaluate problems with alcohol or drug use, but it is also important for clinicians to attempt to discern the relationship between nonproblematic substance use and offending behavior. Many sexual offenders are more likely to abuse when they are somewhat intoxicated even if they do not characteristically have a substance-use disorder.

Treatment 9.25.4 TREATMENT Prior to the 1970s, treatment for sexual offenders, when it was provided, was based on a variety of theoretical views and each program tended to be distinctly unique. Very few of these programs provided sufficient details to allow replication and even less offered estimates of the effectiveness of their program. In the late 1960s, reports began to appear of treatments that were guided by a behavioral view of sexual offending. These programs took the position that sexual offending was driven by acquired deviant sexual preferences and that all that was necessary in treatment was to change these preferences and the problem behaviors would disappear. It did not take long, however, for behavior therapists to recognize that this was a naive conceptualization and elements having to do with social skills were quickly added. These behavioral programs evolved into progressively more comprehensive cognitive behavioral programs targeting an expanded range of social skills and including cognitive distortions and relapse prevention procedures. Along with the expansion of the content of cognitive behavioral programs, the use of pharmacologic interventions increased. Antiandrogen and hormonal agents were shown to reduce overall drive levels or, if administered in appropriate dosages, they reduced only deviant responding. Since the mid-1980s, the serotonin reuptake inhibitors have been found to reduce the strength of urges sufficiently for the offender to be able to exercise control. The use of these pharmacologic agents, however, has typically been as complementary to psychological interventions used as adjuncts to comprehensive cognitive-behavioral programs (Greenberg & Bradford, 1997). 9.25.4.1 Cognitive-behavioral Programs Cognitive-behavioral programs (or relapse prevention programs) have become the most popular approaches in North America, as well as in other countries, for the treatment of sexual offenders (Marshall, Fernandez, Hudson, & Ward, in press). The focus of 98% of these programs in North America is group therapy, although individual therapy is often used as an adjunct (Cellini, 1995). Although the content of these programs varies somewhat across the different settings, the following targets appear to be addressed in all cognitive-behavioral approaches: acceptance of responsibility, cognitive distortions and pro-offending attitudes; empathy for victims; social functioning; deviant fantasies; and the development of relapse prevention plans. In addition, most programs

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address a variety of other features, such as substance abuse, sex education, the childhood abuse of the offender, and whatever other idiosyncratic problems seem to be related to the client's offense propensity. 9.25.4.1.1 Acceptance of responsibility Many treatment programs appear to expect offenders to accept some degree of responsibility for having offended, prior to entry into treatment. Accordingly, these programs refuse to accept those clients who deny having committed an offense. Other programs consider extensive minimization (e.g., claiming that other people and external circumstances were responsible for the offending, or minimizing the nature of the offense) as evidence of poor motivation and, therefore, exclude them from treatment. However, refusing deniers and minimizers means excluding not only a substantial number of clients who have been convicted of sexual offenses but also many of the most dangerous offenders. All clients should be accepted into treatment because it is the job of therapists to motivate clients and get them to accept responsibility. By challenging them in a firm but supportive manner, and by making clear the costs to them for maintaining denial or minimization and the benefits of changing their position, therapists should be able to shift the sexual offenders' views to an acceptance of responsibility (Barbaree, 1991; Marshall, 1994). 9.25.4.1.2 Cognitive distortions This term describes both the distorted way in which sexual offenders perceive the responses of their victims and their attitudes that are offense supportive. Many sexual offenders perceive their victims as cooperative and as not distressed or otherwise harmed by the abuse. Rapists and exhibitionists frequently hold negative views of women and as a consequence feel anger toward them. Child molesters typically see children as either more friendly and less threatening than adults, or as simply available for their use. Using variations on what has been called cognitive restructuring procedures (Murphy, 1990), these views are challenged and alternative views are encouraged. However, no evaluations of the specific effects of these interventions are available. 9.25.4.1.3 Empathy The aims are to sensitize the offender to the harm their abuse has caused and to enhance his feelings of concern for those he has harmed. While the focus in this component of treatment

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Adult Sexual Offenders

is on the harm to the victim and on the offender's remorse for having caused this harm, the distress experienced by the victim's family and by the offender's own family is also emphasized (Pithers, 1994, in press). Since empathy has been conceptualized as a four-stage, unfolding process (Marshall et al., 1995), treatment efforts focus on these stages in order. First attempts are made to train offenders in recognizing emotions in others. Next, assistance is given to the offender in identifying harm to the victim by having him adopt the victim's perspective. As part of this process, offenders repeatedly report how they are feeling when they think about the victim and, finally, the offender indicates what he should do to avoid causing harm or to terminate distress when it occurs. Throughout these procedures, all group members are required to evaluate the target offender's responses and indicate their own feelings while attending to the target offender's responses. Evaluation of this treatment component has shown substantial improvement in sexual offenders (Marshall, O'Sullivan, & Fernandez, 1996). 9.25.4.1.4 Social functioning A broad range of issues are typically addressed in this component. Conversational skills, anxiety, anger management, assertiveness, and problem solving are among the many social problems targeted here. Treatment programs have also included procedures for enhancing self-esteem and improving relationship skills. Research across a variety of human problems has demonstrated that low self-esteem impedes progress in treatment and increases the risk of post-treatment relapse (Marshall, Anderson et al., 1996). Accordingly, therapists attempt to establish a working environment and a therapeutic process that will facilitate the enhancement of self-esteem, as well as employing specific procedures to increase self-confidence. An evaluation of this approach has revealed marked improvements in self-esteem (Marshall, Champagne, Sturgeon, & Bryce, 1997) and strong relationships between these improvements and positive changes in other treatment targets, including reductions in deviant preferences (Marshall, 1997) and increases in empathy and intimacy skills (Marshall, Champagne et al., 1997). Attachment style refers to the characteristic way in which people engage in, or avoid, intimate relationships. Treatment programs that address this issue train clients to develop more effective attachment styles and related skills by addressing issues such as the benefits of

good attachments, developing an understanding of effective sexual functioning, improving reciprocity and communication in relationships, increasing conflict-resolution skills, learning how to deal with being alone, and, finally, focusing on the nature of jealousy and the problems it can cause. Again, it has been demonstrated that these procedures are effective in reducing feelings of loneliness and in enhancing intimacy in the lives of sexual offenders (Marshall, Bryce, Hudson, Ward, & Moth, 1996). 9.25.4.1.5 Deviant fantasies Procedures have long been available for reducing an attraction to deviant sexual acts and for increasing the attractiveness for appropriate sexual behaviors. Early treatment programs employed some variation on aversion-conditioning procedures using either mild electric shocks, nausea-inducing drugs, or foul odors as the aversive event. These procedures have, for the most part, been abandoned and replaced by one of several alternatives. Covert sensitization is a technique that associates imagined unpleasant consequences with imagining a presently preferred, but maladaptive, behavior. Abel, Blanchard, and Becker (1978) provided a detailed account of the application of this procedure to the treatment of a rapist, and Maletzky (1980) described its use with exhibitionists. Covert sensitization, in various forms, has enjoyed considerable popularity ever since. However, the research supporting its use is not substantial, and it has not been unequivocally shown to alter sexual preferences (Quinsey & Earls, 1990; Quinsey & Marshall, 1983). Masturbatory reconditioning combines two procedures: (i) masturbation to appropriate fantasies up to the point of orgasm (Maletzky, 1985) and (ii) satiation procedures which involve repeated verbalizations (aloud or subvocal) of deviant fantasies during the refractory period immediately after orgasm (Marshall, 1979). While there is reasonable empirical support for the effectiveness of satiation, the evidence bearing on the first part of the procedure (i.e., masturbating to appropriate fantasies) is quite limited (Laws & Marshall, 1991). Despite these limitations in the evidence supporting procedures that attempt to modify disordered sexual interests, they continue to be employed (Dougher, 1995), apparently for two primary reasons. In the first place, most practitioners appear to believe that deviant sexual fantasies play a significant role in motivating deviant sexual behavior and sec-

Future Directions ondly, it appears to be assumed that most sexual offenders have deviant sexual fantasies even if these are not evident at assessment. Acceptance of these views, of course, would direct treatment attention to changing sexual preferences. However, as noted earlier, Marshall (1997) has found that modifying other aspects of the offenders' functioning produces indirect and beneficial changes in sexual preferences, and Pithers (in press) has reported similar findings. It seems reasonable to assume then, that, except for those limited number of cases where deviant arousal is very strong, it may not be necessary to directly target sexual preferences in treatment. In those cases where deviant arousal does seem to overwhelm the offender's sense of control, it may be wiser to employ either antiandrogen medication (Bradford, 1990) or serotonin reuptake inhibitors (Fedoroff, 1993) as an interim step until the offender begins to develop a personal sense of control. In fact, a focus on strictly sexual fantasies may miss the fact that sexual offenders have numerous other offense-related fantasies that need to be addressed in treatment. For example, many rapists are preoccupied with fantasies of control and with fantasies involving the humiliation and degradation of women. These fantasies frequently occur in the absence of sexual arousal and yet they appear to play an important role in motivating and maintaining a persistent disposition to attack women. Similar nonsexual fantasies seem to characterize both child molesters and exhibitionists. 9.25.4.1.6 Relapse prevention This approach to treatment was adapted from Marlatt and Gordon's 1985) description of their way of enhancing post-treatment maintenance of behavior in addicts and alcoholics. Pithers (1990) has detailed the structure and content of this approach, and Laws (1989) has provided clinical descriptions of each of the elements in a relapse-prevention approach with sexual offenders. Essentially, clients are trained to identify the factors that put them at risk, including precipitating factors (e.g., low selfesteem, deviant fantasizing, intoxication, anger, etc.), circumstantial risks (e.g., being alone with a child, cruising aimlessly in a car), and grooming techniques or strategies for gaining access to a victim. These risk factors are then addressed by generating plans to either avoid such risks or to escape from them should they inadvertently arise. Pithers (1990) adds to these so-called ªinternal managementº components of treatment, an ªexternal supervisory dimensionº that requires extensive post-treatment involvement in a maintenance program. This

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maintenance program includes careful supervision by a person trained in relapse-prevention techniques, the provision of an informed support group of friends or family, and regular participation in a treatment maintenance group. Attempts were made to evaluate, on the basis of the very limited evidence available, whether or not either the internal management or the external supervision components of relapse prevention added any therapeutic efficacy to the already comprehensive cognitive/behavioral treatment programs (Marshall & Anderson, 1996). It appears that the internal management component does increase efficacy, but the evidence was not sufficient to determine the value of the extensive external management procedures.

9.25.4.2 Overall Value of Treatment Although there is a lack of satisfactorily controlled treatment outcome studies, some authors have been satisfied that there are grounds for optimism based on the available, albeit limited, evidence (e.g., Marshall, Jones, Ward, Johnston, & Barbaree, 1991). On the other hand, Quinsey and his colleagues (e.g., Quinsey, Harris, Rice, & LalumieÁre, 1993) have consistently expressed pessimism regarding the value of treatment. Two meta-analyses of the available evidence have taken a more conservative view, suggesting that there does appear to be an effect for treatment but that the effect size is rather small (Hall, 1995; Hanson & BussieÁre, 1996). In part, this difficulty in discerning clear effects for treatment is the result of the characteristically low base-rate of recidivism among untreated sexual offenders. However, the fact that programs clearly vary, in the content of treatment, the process of treatment delivery, and the length of treatment provided, will continue to make it problematic to compare different programs and, thereby, preclude any general statement about treatment efficacy. On a more positive note, it has been shown that even minimally effective treatment of sexual offenders can reduce the future abuse of innocent women and children, and can save taxpayers a substantial amount of money (Marshall, 1992; Prentky & Burgess, 1991).

9.25.5 FUTURE DIRECTIONS Despite the difficulties or impracticalities of distinguishing research from practice, this chapter tries to identify those future directions considered to be most important within each of these domains.

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9.25.5.1 Research A primary failing that has beset this area throughout its history remains a stumbling block to attempts at integrating findings from various studies. This failing concerns the lack of sufficient information provided in reported studies on the subjects, procedures, and settings in which the research was conducted. Presumably, no one would expect offenders with a chronic history of sexually abusing numerous victims in a vicious manner to display the same characteristics, and be as responsive to the same treatment, as would single-victim offenders who have engaged in only mildly intrusive, nonforceful acts. Freund and Watson (1991), for example, found that the phallometric test sensitively identified child molesters with multiple victims (80% accurate with nonfamilial offenders who molested female children, and 90% for those with male children victims) but did not do at all well with single-victim offenders (only 45% accuracy). Very few other reports of phallometric evaluations have made this distinction among their subjects, and yet it is obviously very important. On this issue of phallometric testing, far more research is needed on its psychometric properties, as the present data do not provide a satisfactory basis to defend the use of these procedures. For example, the reliability of phallometry is questionable with very few studies being available and the findings across studies are inconsistent (Marshall, 1996a). In various other respects, although there is an extensive body of literature on phallometric test results, the available data can only be integrated into a supportive argument if a whole range of important inconsistencies between studies are ignored. Related to this, there is very little support for the value of therapeutic procedures aimed at modifying deviant sexual preferences (Laws & Marshall, 1991; Quinsey & Earls, 1990; Quinsey & Marshall, 1983). In fact, some data suggest that these procedures may be unnecessary (Marshall, in press). Further research is clearly needed to either substantiate the value of these procedures (i.e., do they, in fact, modify deviant arousal) or, more importantly, to determine the necessity of targeting deviant preferences in treatment. The prediction of recidivism is a critical area that only began to receive the necessary empirical attention in the mid-1990s. While Quinsey et al. (1995) made an excellent start to this process, the research needs to be extended to broader populations of sexual offenders and, most importantly, needs to include more dynamic factors that are open to therapeutic

modification. One of the problems that obstructs such research concerns the identification of reoffending. In Canada, satisfactory systems are accessible to researchers that identify all charges, reconvictions, and parole lapses across the country. In the USA and other countries, researchers do not have access to such a complete set of data, making recidivism studies something of a hit-or-miss gamble. In order for effective research to proceed, a sound basis on which to estimate recidivism must be developed. If governments wish to develop a comprehensive understanding of sexual offenders, they must be willing to establish a national pool of information on reoffending that is available to researchers. Treatment evaluations have been limited in number and have rarely been able to provide an estimate of recidivism in the absence of treatment. This presents a very difficult problem because the opportunity to conduct an outcome study, where subjects are randomly allocated to treatment or no treatment, is rare. In most cases, researchers cannot get the cooperation of sexual offenders because their possible release on parole would be blocked if they remained untreated. Also, very few organizations would be willing to endorse such an endeavor because of the potential for extremely negative publicity that would result if a deliberately untreated sexual offender were to attack an innocent person after discharge. Unfortunately, in those rare cases where rigorous evaluations have been conducted, the funding agencies seem more concerned with imposing experimental rigor than they are with evaluating appropriate clinical applications of treatment. This, of course, represents an ever-present clash of ideologies about how to effectively evaluate clinical processes. While the absence of a concern for controlled evaluations has been most unfortunate, the overconcern for experimental rigor is not necessarily a step forward. On the issue of treatment evaluation, one of the features that needs examination is the value of the extensive, and expensive, aftercare procedures that are advocated by relapseprevention enthusiasts. Some degree of postrelease supervision and maintenance seems necessary, if only to convince the public that every precaution has been exercised. However, it has been simply assumed that the need for extensive aftercare is obvious. Sometimes what seems obvious is not supported by careful examination, and that needs to be done in this case, particularly considering the very expensive nature of maintenance programs being advocated. Finally, more work needs to be done on identifying features of sexual offenders that

Summary indicate the extent of their treatment needs. This ties in with the need to have available clear indices of reoffending. Limited treatment resources must be put where they are most needed. It is pointless offering extensive treatment to all sexual offenders when some of them are at quite low risk to reoffend, and have limited problems that need treatment attention. However, allocating offenders to one or another level of treatment involvement relies on guesswork based on limited evidence. This basis of evidence needs to be extended. However, generating typologies, as they have been created in the past, has not been particularly useful in solving the problem of the appropriate allocation of treatment resources. While Knight and Prentky's (1990, 1993) typology is a marked improvement over previous classificatory systems, it is, nevertheless, not designed to identify likely treatment responsiveness or needs, and has not, in the late 1990s, yet been evaluated for its utility in this regard. 9.25.5.2 Practice Parallel with attempts to discern those sexual offenders in need of extensive or less extensive treatment, intervention programs need to develop strategies for allocating resources to clients with different needs so that resources can be maximally utilized. We have outlined an approach for dealing with this problem within both our prison-based and community-based programs (Marshall, Eccles, & Barbaree, 1993). Essentially, we allocate offenders on the basis of assessment and risk determined needs, to one of three levels of extensive/intensive treatment. High risk/high needs offenders receive the maximum allocation of our resources, while the low risk/low needs clients get far less extensive treatment and a lower frequency of treatment sessions. So far, the results from this allocation of resources encourage confidence that our decisions are correct, although more sophisticated procedures for identifying needs based on long-term outcome studies must be developed. Other programs all too frequently do not make such practical use of their limited resources. In addition to this allocation of resources, it seems sensible to develop specific programs to deal with particular types of offenders, such as minority or culturally distinct groups, disabled offenders, psychiatrically disturbed offenders, professional or clergy offenders, etc. Work on these types of programs has been developed, but most modifications meant to fit these special populations have been based on the practitioners' assumptions of the unique problems facing these offender types rather than on an

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empirical evaluation of the need for specific approaches. There are, of course, many features of assessment and treatment that need further development. We are only at the beginning of determining the best way to address the issues of empathy, denial and minimization, attachment styles, and attitudes and belief systems. Conceptualizations of these problems have been inadequate and the consequent lack of clarity has meant that various practitioners use different assessment and treatment approaches to these problems. Not surprisingly, this has meant that, in the late 1990s, assessment procedures for each of these topics are rather inadequate and need improving, and the treatment of these problems has, to date, been either based on the good sense of the practitioner or simply adopted from other areas of treatment without modifications to meet the peculiar needs of sexual offenders. Clarification of, and some degree of agreement about, what constitutes empathy, intimacy, denial, minimization, and dysfunctional attitudes and beliefs, is essential, and practitioners cannot afford to be complacent about this problem. The final features suggested in this chapter which need a good deal more clinical attention and research are the processes of treatment and assessment. The advent of behavioral therapy, and its offspring cognitive/behavioral therapy, brought about a quite proper concern for specifying procedures, but unfortunately, it also brought with it the belief that procedures alone could produce satisfactory assessment and treatment. There is now a growing sentiment within cognitive/behavioral therapy that process variables, such as the assessor's or therapist's style and the nature of the relationship established between assessors/therapists and clients, are critical to effective evaluation and treatment (Miller & Rollnick, 1991; Schaap, Bennun, Schindler, & Hoogduin, 1993). An examination of these features in the context of work with sexual offenders is long overdue, but some possible avenues for developing clinical practice have been suggested (Marshall, 1996b). Far more work on these presumably critical variables is needed both in clinical practice and in research.

9.25.6 SUMMARY This chapter has described what appear to be the main issues concerning adult sexual offenders. The nature and extent of sexual abuse is of such significant magnitude, and damages so many innocent lives, that those who work in this field must apply themselves diligently to the task

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of addressing this serious social problem in the most effective and cost-beneficial way possible. Significant progress has already been made but there is a long way to go and researchers cannot afford to be complacent. Our research and clinical practice needs to be expanded so that the capacity to identify the highest-risk offenders can be increased and the likelihood that they will not reoffend maximized. Evidence available encourages optimism that we are on the right track, but we need to examine procedures more thoroughly and, most importantly, develop new ones as concepts are refined and the areas of evaluation and treatment are expanded. 9.25.7 REFERENCES Abel, G. G., & Becker, J. V. (1985). Sexual interest cardsort. Atlanta, GA: Behavioral Medicine Laboratory, Emory University. Abel, G. G., Becker, J. V., Cunningham-Rathner, J., Mittelman, M. S., & Rouleau, J. L. (1988). Multiple paraphilic diagnoses among sex offenders. Bulletin of the American Academy of Psychiatry and the Law, 16, 153±168. Abel, G. G., Becker, J. V., Mittelman, M. S., CunninghamRathner, J., Rouleau, J. L., & Murphy, W. D. (1987). Self-reported sex crimes of nonincarcerated paraphiliacs. Journal of Interpersonal Violence, 2, 3±25. Abel, G. G., Blanchard, E. B., & Becker, J. V. (1978). An integrated treatment program from rapists. In R. T. Rada (Ed.), Clinical aspects of the rapists (pp. 161±214). New York: Grune & Stratton. Abel, G. G., Gore, D. K., Holland, C. L., Camp, N., Becker, J. V., & Rathner, J. (1989). The measurement of the cognitive distortions of child molesters. Annals of Sex Research, 2, 135±152. Abrams, S. (1991). The use of polygraphy with sex offenders. Annals of Sex Research, 4, 239±263. Allen, C. (1991). Women and men who sexually abuse children: A comparative analysis. Brandon, VT: Safer Society Press. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Anderson, D., & Marshall, W. L. (1996). A multidimensional self-esteem inventory related to sexual offending. Paper presented at the 15th Annual Research and Treatment Conference of the Association for the Treatment of Sexual Abusers, Chicago. Barbaree, H. E. (1991). Denial and minimization among sex offenders: Assessment and treatment outcome. Forum on Corrections Research, 3, 300±333. Barbaree, H. E., Baxter, D. J., & Marshall, W. L. (1989). The reliability of the rape index in a sample of rapists and nonrapists. Violence and Victims, 4, 299±306. Bartholomew, K., & Horowitz, L. M. (1991). Attachment style among adults: A test of a four category model. Journal of Personality and Social Psychology, 61, 226±244. Bellack, A. S. (1983). Recurrent problems in the assessment of social skills. Behaviour Research and Therapy, 27, 29±42. Blair, D. C., & Lanyon, R. I. (1981). Exhibitionism: Etiology and treatment. Psychological Bulletin, 89, 439±463. Bradford, J. M. W. (1990). The antiandrogen and hormonal treatment of sex offenders. In W. L. Marshall, D. R. Laws, & H. E. Barbaree (Eds.), Handbook of

sexual assault: Issues, theories, and treatment of the offender (pp. 297±310). New York: Plenum. Bumby, K. M. (1996). Assessing the cognitive distortions of child molesters and rapists: Development and validation of the MOLEST and RAPE scales. Sexual Abuse: A Journal of Research and Treatment, 8, 37±54. Bumby, K., & Marshall, W. L. (1994). Loneliness and intimacy dysfunction among incarcerated rapists and child molesters. Paper presented at the 13th Annual Research and Treatment Conference of the Association for the Treatment of Sexual Abusers, San Francisco. Burt, M. (1980). Cultural myths and supports for rape. Journal of Personality and Social Psychology, 38, 217±230. Cellini, H. R. (1995). Assessment and treatment of the adolescent sexual offender. In B. K. Schwartz & H. R. Cellini (Eds.), The sexual offender: Corrections, treatment and legal practice (pp. 6.1±6.12). Kingston, NJ: Civic Research Institute. Check, J. V. (1984). The hostility towards women scale. Unpublished doctoral dissertation, University of Manitoba, Winnipeg, MB. Christie, M. M., Marshall, W. L., & Lanthier, R. D. (1979). A descriptive study of incarcerated rapists and pedophiles. Report to the Solicitor General of Canada, Ottawa, ON. Committee on Sexual Offenses against Children and Youths (1984). Report on the Committee on Sexual Offenses against Children and Youths, Vols. 1±11, and Summary (Badgley Report), Ottawa, ON: Department of Supply and Services. Crowne, D. P., & Marlow, D. (1980). A new scale of social desirability independent of psychopathology. Journal of Consulting Psychology, 24, 349±354. Darke, J. L. (1990). Sexual aggression: Achieving power through humiliation. In W. L. Marshall, D. R. Laws, & H. E. Barbaree (Eds.), Handbook of sexual assault: Issues, theories, and treatment of the offender (pp. 55±72). New York: Plenum. Davis, M. H. (1980). A multidimensional approach to individual differences in empathy. JSAS Catalog of Selected Documents in Psychology, 10, 85. Davis, M. H. (1983). Measuring individual differences in empathy: Evidence for a multidimensional approach. Journal of Personality and Social Psychology, 44, 113±126. Di Vasto, P. V., Kaufman, L. R., Jackson, R., Christy, J., Pearson, S., & Burgett, T. (1984). The prevalence of sexually stressful events among females in the general population. Archives of Sexual Behavior, 13, 59±67. Dougher, M. J. (1995). Behavioral techniques to alter sexual arousal. In B. K. Schwartz & H. R. Cellini (Eds), The sex offender: Corrections, treatment and legal practice (pp. 15.1±15.8). Kingston, NJ: Civic Research Institute. Elliot, M. (1993). Female sexual abuse of children. New York: Guilford Press. Emrick, R. L., & Dutton, W. A. (1993). The effect of polygraphy on the self report of adolescent sex offenders: Implications for risk assessment. Annals of Sex Research, 6, 83±103. Ennis, P. H. (1967). Criminal victimization in the United States: A report of a national survey. National Opinion Research Center (NORC), University of Chicago. Washington, DC: US Government Printing Office. Fedoroff, J. P. (1993). Serotonic drug treatment of deviant sexual interests. Annals of Sex Research, 6, 105±121. Fernandez, Y. M. (1996). The rapist empathy measure. Paper presented at the 15th Annual Research and Treatment Conference of the Association for the Treatment of Sexual Abusers, Chicago. Fernandez, Y. M., Marshall, W. L., Lightbody, S., & O'Sullivan, C. (1997). The child molester empathy measure. Manuscript submitted for publication.

References Finkelhor, D., & Lewis, I. (1988). An epidemiologic approach to the study of child molestation. The Annals of the New York Academy of Science, 528, 64±67. Freund, K. (1990). Courtship disorder. In W. L. Marshall, D. R. Laws, & H. E. Barbaree (Eds.), Handbook of sexual assault: Issues, theories, and treatment of the offender (pp. 195±207). New York: Plenum. Freund, K., & Watson, R. J. (1991). Assessment of the sensitivity and specificity of a phallometric test: An update of phallometric diagnosis of pedophilia. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 3, 254±260. Graham, J. R. (1990). MMPI-2: Assessing personality and psychopathology. New York: Oxford University Press. Greenberg, D. M. & Bradford, J. M. W. (1997). Treatment of the paraphilic disorders: A review of the role of the selective serotonin reuptake inhibitors. Sexual Abuse: A Journal of Research and Treatment, 9, 349±360 Hall, G. C. N. (1995). Sexual offender recidivism revisited: A meta-analysis of recent treatment studies. Journal of Consulting and Clinical Psychology, 63, 802±809. Hanson, R. K. (1997). Invoking sympathy: Assessment and treatment of empathy deficits among sexual offenders. In B. K. Schwartz & H. R. Cellini (Eds.), The sex offender: New insights, treatment innovations and legal developments (Vol. 11, pp. 1.1±1.12). Kingston, NJ: Civic Research Institute. Hanson, R. K., & BussieÁre, M. (1996). Predictors of sex offender recidivism: A meta-analysis. Report to the Solicitor General of Canada, Ottawa, ON. Hanson, R. K., & Scott, H. (1995). Assessing perspective taking among sexual offenders, nonsexual criminals and nonoffenders. Sexual Abuse: A Journal of Research and Treatment, 7, 259±277. Hare, R. D. (1991). Manual for the revised psychopathy checklist. Toronto, ON: Multi-Health Systems. Holden, R. R., & Fekken, G. C. (1989). Three common social desirability scales: Friends, acquaintances, or strangers? Journal of Research in Personality, 23, 180±191. Horley, J., Quinsey, V. L., & Jones, S. (1997). Incarcerated child molesters' perceptions of themselves and others. Sexual Abuse: A Journal of Research and Treatment, 9, 43±55. Howells, K. (1978). Some meanings of children for pedophiles. In M. Cook & G. Wilson (Eds.), Love and attraction (pp. 57±82). London: Pergamon. Kline, P. (1993). The handbook of psychological testing. New York: Routledge. Knight, R. A., & Prentky, R. A. (1990). Classifying sexual offenders: The development and corroboration of taxonomic models. In W. L. Marshall, D. R. Laws, & H. E. Barbaree (Eds.), Handbook of sexual assault: Issues, theories and treatment of the offender (pp. 23±52). New York: Plenum. Knight, R. A., & Prentky, R. A. (1993). Exploring characteristics for classifying juvenile sexual offenders. In H. E. Barbaree, W. L. Marshall, & S. M. Hudson (Eds.), The juvenile sex offender (pp. 45±83). New York: Guilford. Koss, M. P., Gidycz, C. A., & Wisniewski, N. (1987). The scope of rape: Incidence and prevalence of sexual aggression and victimization in a national sample of higher education students. Journal of Consulting and Clinical Psychology, 55, 162±170. Koss, M. P., & Harvey, M. R. (1991). The rape victim: Clinical and community interventions (2nd ed.). Newbury Park, CA: Sage. LalumieÁre, M. L., & Quinsey, V. L. (1991). Polygraph testing of child molesters: Are we ready? Violence Update, 1, 3±11. Langevin, R. (1983). Sexual stands: Understanding and treating sexual anomalies in men. Hillsdale, NJ: Erlbaum.

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Langevin, R., & Lang, R. A. (1990). Substance abuse among sex offenders. Annals of Sex Research, 3, 397±424. Langevin, R., Paitich, D., & Russon, A. E. (1985). Are rapists sexually anomalous, aggressive, or both? In R. Langevin (Ed.), Erotic preference, gender identity, and aggression in men: New research studies (pp. 130±138). Hillsdale, NJ: Erlbaum. Langevin, R., Wright, P., & Handy, L. (1990). Use of the MMPI and its derived scales with sex offenders: 1. Reliability and validity studies. Annals of Sex Research, 3, 245±291. Laws, D. R. (Ed.) (1989). Relapse prevention with sex offenders. New York: Guilford. Laws, D. R., & Marshall, W. L. (1991). Masturbatory reconditioning: An evaluative review. Advances in Behaviour Research and Therapy, 13, 13±25. Lawson, J. S., Marshall, W. L., & McGrath, P. (1979). The social self-esteem inventory. Educational and Psychological Measurement, 39, 803±811. Levin, S. M., & Stava, L. (1987). Personality characteristics of sex offenders: A review. Archives of Sexual Behavior, 16, 57±79. Malcolm, P. B., Davidson, P. R., & Marshall, W. L. (1985). Control of penile tumescence: The effects of arousal level and stimulus content. Behaviour Research and Therapy, 23, 273±280. Maletzky, B. M. (1980). Assisted covert sensitization. In D. J. Cox & R. J. Daitzman (Eds.), Exhibitionism: Description, assessment, and treatment (pp. 187±285). New York: Garland STPM Press. Maletzky, B. M. (1985). Orgasmic reconditioning. In A. S. Bellack & M. Hersen (Eds.), Dictionary of behavior therapy techniques (pp. 157±158). New York: Pergamon. Marlatt, G. A., & Gordon, J. R. (Eds.) (1985). Relapse prevention. New York: Guilford. Marshall, W. L. (1979). Satiation therapy: A procedure for reducing deviant sexual arousal. Journal of Applied Behavior Analysis, 12, 10±22. Marshall, W. L. (1992). The social value of treatment and sexual offenders. Canadian Journal of Human Sexuality, 1, 109±114. Marshall, W. L. (1993). The role of attachment, intimacy, and loneliness in the etiology and maintenance of sexual offending. Sexual and Marital Therapy, 8, 109±121. Marshall, W. L. (1994). Treatment effects on denial and minimization in incarcerated sex offenders. Behaviour Research and Therapy, 32, 559±564. Marshall, W. L. (1996a). Phallometric testing with sexual offenders: Limits to its value. Manuscript submitted for publication. Marshall, W. L. (1996b). The sexual offender: Monster, victim, or everyman? Sexual Abuse: A Journal of Research and Treatment, 8, 317±335. Marshall, W. L. (1997). The relationship between selfesteem and deviant sexual arousal in nonfamilial child molesters. Behavior Modification, 21, 86±96. Marshall, W. L. (in press). Sexual preferences: Are they useful in the assessment and treatment of sexual offenders? In D. Fisher, M. Cardgo, & B. Print (Eds.), Sex offenders: Toward improved practice. London: Whiting & Birch. Marshall, W. L., & Anderson, D. (1996). An evaluation of the benefits of relapse prevention programs with sexual offenders. Sexual abuse: A Journal of Research and Treatment, 8, 209±221. Marshall, W. L., Anderson, D., & Champagne, F. (1996). The importance of self-esteem in sexual offenders. Psychology, Crime and Law, 3, 81±106. Marshall, W. L., Bryce, P., Hudson, S. M., Ward, T., & Moth, B. (1996). The enhancement of intimacy and the reduction of loneliness among child molesters. Journal of Family Violence, 11, 219±235.

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Marshall, W. L., Champagne, F., Sturgeon, C., & Bryce, P. (1997). Increasing the self-esteem of child molesters. Sexual Abuse: A Journal of Research and Treatment, 9, 321±333. Marshall, W. L., & Christie, M. M. (1981). Pedophilia and aggression. Criminal Justice and Behavior, 8, 145±158. Marshall, W. L., & Darke, J. (1982). Inferring humiliation as motivation in sexual offenses. Treatment for Sexual Aggressives, 5, 1±3. Marshall, W. L., Eccles, A., & Barbaree, H. E. (1991). Treatment of exhibitionists: A focus on sexual deviance versus cognitive and relationship features. Behaviour Research and Therapy, 29, 129±135. Marshall, W. L., Eccles, A., & Barbaree, H. E. (1993). A three-tiered approach to the rehabilitation of incarcerated sex offenders. Behavioral Sciences and Law, 11, 441±445. Marshall, W. L., Fernandez, Y. M., Hudson, S. M., & Ward, T. (Eds.) (in press). Sourcebook of treatment programs for sexual offenders. New York: Plenum. Marshall, W. L., & Hall, G. C. N. (1995). The value of the MMPI in deciding forensic issues in accused sexual offenders. Sexual Abuse: A Journal of Research and Treatment, 7, 203±217. Marshall, W. L., Hudson, S. M., Jones, R. L., & Fernandez, Y. M. (1995). Empathy in sex offenders. Clinical Psychology Review, 15, 99±113. Marshall, W. L., Jones, R. L., Ward, T., Johnston, P., & Barbaree, H. E. (1991). Treatment outcome with sex offenders. Clinical Psychology Review, 11, 465±485. Marshall, W. L., O'Sullivan, C., & Fernandez, Y. M. (1996). The enhancement of victim empathy among incarcerated child molesters. Legal and Criminological Psychology, 1, 95±102. McFall, R. M. (1990). The enhancement of social skills: An information processing analysis. In W. L. Marshall, D. R. Laws, & H. E. Barbaree (Eds.), Handbook of sexual assault: Issues, theories, and treatment of the offender (pp. 311±330). New York: Plenum. Miller, R. S., & Lefcourt, H. M. (1982). The assessment of social intimacy. Journal of Personality Assessment, 46, 514±518. Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford. Murphy, W. D. (1990). Assessment and modification of cognitive distortions in sex offenders. In W. L. Marshall, D. R. Laws, & H. E. Barbaree (Eds.), Handbook of sexual assault: Issues, theories, and treatment of the offender (pp. 331±342). New York: Plenum. Murphy, W. D., & Barbaree, H. E. (1994). Assessments of sex offenders by measures of erectile response: Psychometric properties and decision making. Brandon, VT: Safer Society Press. Nichols, H. R., & Molinder, I. (1984). Multiphasic sex inventory manual. Tacoma, WA: Author. Pithers, W. D. (1990). Relapse prevention with sexual aggressors: A method for maintaining therapeutic gain and enhancing external supervision. In W. L. Marshall, D. R. Laws, & H. E. Barbaree (Eds.), Handbook of sexual assault: Issues, theories, and treatment of the offender (pp. 343±361). New York: Plenum. Pithers, W. D. (1994). Process evaluation of a group therapy component designed to enhance sex offenders' empathy for sexual abuse survivors. Behaviour Research and Therapy, 32, 565±570. Pithers, W. D. (in press). Empathy: Definition, enhancement, and relevance to the treatment of sexual abusers. In W. L. Marshall & J.Frenken (Eds.), North American and European approaches to research and treatment of sexual offenders. Newbury Park, CA: Sage Publications. Prentky, R. A., & Burgess, A. W. (1991). Rehabilitation of child molesters: A cost-benefit analysis. American

Journal of Orthopsychiatry, 60, 108±117. Proulx, J., CoteÂ, G., & Achille, P. A. (1993). Prevention of voluntary control of penile response in a homosexual pedophile during phallometric testing. Journal of Sex Research, 30, 140±147. Quinsey, V. L., & Chaplin, T. C. (1988). Penile responses of child molesters and normals to descriptions of encounters with children involving sex and violence. Journal of Interpersonal Violence, 3, 259±274. Quinsey, V. L., & Earls, C. M. (1990). The modification of sexual preferences. In W. L. Marshall, D. R. Laws, & H. E. Barbaree (Eds.), Handbook of sexual assault: Issues, theories, and treatment of the offender (pp. 279±295). New York: Plenum. Quinsey, V. L., Harris, G. T., Rice, M. E., & LalumieÁre, M. L. (1993). Assessing treatment efficacy in outcome studies of sex offenders. Journal of Interpersonal Violence, 8, 512±523. Quinsey, V. L., LalumieÁre, M. L., Rice, M. E., & Harris, G. T. (1995). Predicting sexual offenses. In J. C. Campbell (Ed.), Assessing dangerousness: Violence by sexual offenders, batterers, and child abusers (pp. 116±137). Thousand Oaks, CA: Sage. Quinsey, V. L., & Marshall, W. L. (1983). Procedures for reducing inappropriate sexual arousal: An evaluation review. In J. G. Greer & I. R. Stuart (Eds.), The sexual aggressor: Current perspectives on treatment (pp. 267±289). New York: Van Nostrand Reinhold. Rathus, S. A. (1973). A thirty-item schedule for assessing assertive behavior. Behavior Therapy, 4, 398±406. Rooth, F. G. (1973). Exhibitionism outside Europe and America. Archives of Sexual Behavior, 2, 351±363. Russell, D. E. H. (1984). Sexual exploitation: Rape, child sexual abuse, and workplace harassment. Newbury Park, CA: Sage. Schaap, C., Bennun, I., Schindler, L., & Hoogduin, K. (1993). The therapeutic relationship in behavioral psychotherapy. New York: Wiley. Seidman, B. T., Marshall, W. L., Hudson, S. M., & Robertson, P. J. (1994). An examination of intimacy and loneliness in sex offenders. Journal of Interpersonal Violence, 9, 518±534. Selzer, M. L. (1971). The Michigan Alcoholism Screening Test (MAST): The quest for a new diagnostic instrument. American Journal of Psychiatry, 127, 1653±1658. Serin, R. C., Malcolm, P. B., Khanna, A., & Barbaree, H. E. (1994). Psychopathy and deviant sexual arousal in incarcerated sexual offenders. Journal of Interpersonal Violence, 9, 3±11. Skinner, H. A. (1982). The drug abuse screening test. Addictive Behaviors, 7, 363±371. Speilberger, C. D. (1988). State-trait anger expression inventory: Professional manual, research edition. Odessa, FL: Psychological Assessment Resources. Spence, J. T., Helmreich, R., & Stapp, J. (1973). A short version of the Attitudes Towards Women scale (ATW). Bulletin of the Psychonomic Society, 2, 219±220. Stermac, L. E., Sheridan, P. M., Davidson, A., & Dunn, S. (1996). Sexual assault of adult males. Journal of Interpersonal Violence, 11, 52±64. Ward, T., Hudson, S. M., & McCormack, J. (1997). Attachment style, intimacy deficits, and sexual offending. In B. K. Schwartz & H. R. Cellini (Eds.), The sex offender: New insights, treatment innovations and legal developments (Vol. 11, pp. 2.1±2.14). Kingston, NJ: Civic Research Institute. Ward, T., Hudson, S. M., Johnston, L., & Marshall, W. L. (1997). Cognitive distortions in sex offenders: An integrative review. Clinical Psychology Review, 17, 479±507. Watson, D., & Friend, R. (1969). Measurement of social evaluation anxiety. Journal of Consulting and Clinical Psychology, 33, 448±457.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

9.26 Perpetrators of Physical Violence and Abuse ABRAM ROSENBLATT and JENNIFER A. ROSENBLATT University of California, San Francisco, CA, USA 9.26.1 INTRODUCTION 9.26.2 NATURE 9.26.2.1 Types of Violence 9.26.2.2 Predisposing Factors 9.26.2.2.1 Biological factors 9.26.2.2.2 Developmental factors 9.26.2.2.3 Environmental factors 9.26.3 PREVALENCE 9.26.3.1 Violence and Mental Disorder 9.26.3.2 Mental Disorder Among Violent Offenders 9.26.3.3 Violence and the Mentally Ill 9.26.3.4 Summary 9.26.4 ASSESSMENT 9.26.4.1 Offender Risk Assessments 9.26.4.1.1 Violence Risk Appraisal Guide 9.26.4.1.2 Hare Psychopathy Checklist-Revised 9.26.4.1.3 Statistical Information on Recidivism Scale 9.26.4.1.4 HCR-20 9.26.4.2 Child Abuse Assessment Instruments 9.26.4.2.1 Child Abuse Potential Inventory 9.26.4.2.2 Michigan Screening Profile of Parenting 9.26.4.2.3 Parenting Stress Index 9.26.4.3 Summary 9.26.5 TREATMENT 9.26.5.1 Characteristics of Effective Programs 9.26.5.2 Characteristics of Ineffective Programs 9.26.5.3 Programs for Treating Violence 9.26.5.3.1 Therapeutic community program 9.26.5.4 Medications 9.26.5.5 Psychotherapy for Violent Outpatients 9.26.5.6 Behavioral Techniques 9.26.5.7 Treatment of Child Abusers 9.26.5.8 Summary 9.26.6 FUTURE DIRECTIONS FOR RESEARCH AND PRACTICE 9.26.6.1 Research on the Nature of Violence 9.26.6.2 Research on the Prevalence of Violence 9.26.6.3 Research on the Assessment of Violence 9.26.6.4 Treatment of Violent Offenders 9.26.7 SUMMARY 9.26.8 REFERENCES

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9.26.1 INTRODUCTION Violence is a vexing problem that conjures a host of public perceptions, both real and imagined. A remarkable amount of the public debate concerning the delivery of human welfare services is driven by widespread fear of physical violence against both adults and children. The need to protect children from abuse clearly dominates the agenda of social welfare services. Parents, concerned about the safety of their children, may move from one community to the next in the hopes of finding a place where children can play without fear. For better or worse, it is the fear of potential violent behavior on the part of persons with mental disorders that mobilizes much of the public debate on mental health services. Current social policies regarding the incarceration of criminal offenders are largely driven by a desire to get violent criminals off the streets. The prevalence rates of different types of physical violence vary over time. In the USA, reported murder rates increased from 5.1% in 1965 to 9.8% in 1991 (Federal Bureau of Investigation, 1965±1991). This particular crime statistic is alarming to both policy makers and the general public (Lowenstein, 1991). More recently, however, data from the Federal Bureau of Investigation (1996) revealed a 9% decrease in murder rates and an overall decrease in violent crime of 6% in 1996. In spite of such potentially encouraging figures, the rate of violent crime in the USA remains high, relative to other industrialized countries. It remains to be seen whether decreasing rates of physical violence are actually decreasing as part of a longer-term trend. The perception on the part of the public of increasing violence is pushing lawmakers to enact new legislation designed to tackle the problem of violent crime. The most salient example of such legislation, the Violent Crime Control and Law Enforcement Act, was passed in 1994. This legislation allocated $22 billion to increase the number of police officers, augment prison budgets, increase the duration of prison sentences, and fund prevention programs. The prevention program dollars (US$5 billion), however, were shifted to law enforcement and prison expansion in a revision of the original act by the House of Representatives (Petersilia, 1995). Although these measures are certainly popular, and rates of violent crime appear to be dropping slightly, most criminal justice experts agree that these tough on crime efforts will do little to decrease crime in the long term. Even some professionals who might be expected to

support this legislation are skeptical. A national survey of prison wardens, for example, revealed that 85% of participants agreed that the new crime policy would not be effective (Petersilia, 1995). One reason for the lack of optimism regarding such federal efforts to curb crime is the predominant focus on prisons as the primary mode of intervention. A majority of offenders are not imprisoned; they remain in the community under probation or parole supervision. Less than 20% of all offenders are imprisoned and the majority of violent offenders are not in jail (US Bureau of Justice Statistics, 1995). Approximately 372 000 individuals convicted of a violent offense in 1991 were incarcerated, whereas approximately 590 000 persons convicted of a violent crime resided in the community. Consequently, it is important to understand the problem of physical violence both because it is desirable to reduce the occurrence of such acts and because the fear of physical violence currently receives considerable attention in the creation of social policy. In the absence of empirical information, social policy is determined largely by public perceptions and the existing political climate. This chapter summarizes the empirical literature, the nature, prevalence, assessment, and treatment of persons who commit violent acts. The chapter focuses both on adults who commit violence toward other adults and on adults who commit violence towards children (commonly referred to as abuse). The problems of domestic violence and juvenile crime are addressed elsewhere in this volume. Finally, attention is focused on the special concerns posed by persons with mental disorders who commit violent acts because this is the group most likely to be seen by mental health professionals.

9.26.2 NATURE There are potentially many types of violence and factors that influence whether a person may become violent. Understanding the nature of violence requires an understanding of the types of violence and the factors that might predispose an individual to commit violence. Although the end result of violence is the harming of another person, the legal system certainly recognizes that violence committed under different circumstances may be justifiable. Premeditated murder, manslaughter, and self-defense may all result in the death of a person, but punishments for these different types of violence range from the death penalty to being absolved of any blame.

Nature 9.26.2.1 Types of Violence Much of the reason why an act of violence is considered justifiable can be traced to whether the violent act is reactive or instrumental in nature. Reactive aggression and violence are committed in response to a perceived threat or provocation, whereas instrumental acts of violence and aggression are goal directed (Dodge, 1991; Parke & Slaby, 1983). Studies suggest that individuals engaging in instrumental violence can be distinguished from those committing reactive violent crimes. Two studies examining violent offenders suggested that reactive offenders were more likely to harm familiar victims, be angry with their victims, and perceive their victims as provoking the violent act. Instrumental offenders tend to seek a clearly discernible goal (Cornell et al., 1996). Although offenders often engage in reactive and instrumental acts of violence, reactive incidents appear to be more pervasive. Cornell et al. (1996) suggested that individuals who engage in instrumental crime are more pathological than those who engage in reactive violence. These researchers contend that goal-directed acts of violence stem from a lack of concern and respect for others, and an absence of internalized social principles. Instrumental violence appears to be more associated with psychopathy than reactive violence.

9.26.2.2 Predisposing Factors Although different types of people may commit different types of violence, a considerable body of research examines the range of factors that influence the likelihood that an individual may engage in any type of violent act. Much of this research can be grouped into three classes of factors that may increase violence potential: (i) biological factors; (ii) developmental factors; and (iii) environmental factors. Although examined separately here, violence is generally thought to derive from some combination of all three of these factors. 9.26.2.2.1 Biological factors Biological factors, such as neurotransmitter levels, brain structure, and neurophysiology, may contribute to the potential for aggression and violence. Research on neurotransmitter levels indicates that increased levels of norepinephrine and dopamine (Eichelman, Elliot, & Barchas, 1981) and decreased levels of serotonin (Brown et al., 1982; Lidberg, Tuck, Asberg, Scalia-Tomba, & Bertilsson, 1985) are associated with aggression and impulsive violence.

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Abnormalities in brain structure, specifically in the temporal-frontal lobe, have been discovered in violent patients through the use of computer tomography and magnetic resonance imaging (Tonkonogy, 1991). Patients with extremely violent behavior also show metabolic abnormalities in the temporal lobes (Seidenwurm, Pounds, Globus, & Valk, 1997). Similarly, a study using brain single photon emission computerized tomography (SPECT) imaging found differences in brain structures in aggressive individuals as compared to individuals without reported violent behavior (Amen, Stubblefield, Carmicheal, & Thisted, 1996). Historically, neurophysiological factors, particularly the limbic system, were thought to be associated with violent behavior (Mark & Ervin, 1970). Some more recent controlled studies, however, failed to corroborate these findings by discovering no differences in the level of violence for persons with and without epilepsy (Hermann & Whitman, 1984). This conclusion is supported in a collaborative largescale study demonstrating that violent episodes were rare for epileptics during seizures (Delgado-Escueta et al., 1981). Although violence potential may be associated with biological factors, recent reviews of literature on genetic abnormalities suggested that violent behavior cannot be accounted for by chromosomal anomalies (Tardiff, 1996). 9.26.2.2.2 Developmental factors In addition to the biological antecedents of violence, developmental factors also appear to be associated with increased violence. A large body of research suggests a positive relationship between childhood abuse and becoming a physically abusive adult (Kempe & Helfer, 1980; Rivera & Widom, 1990; Widom, 1989b). For example, a study comparing individuals with an official record of neglect or abuse to a matched control group of individuals with no record of abuse found that individuals victimized as children were at increased risk for committing a violent offense (Widom, 1989a). The relationship, however, between abuse and violence may be mediated by other factors. Weiler and Widom (1996), for instance, examined the relationship between childhood victimization, psychopathy, and violence and found that although childhood victimization predicted violence, psychopathy appeared to mediate this relationship. Children witnessing domestic violence may also have an increased chance for becoming violent adults (Jaffe, Wolfe, Wilson, & Zak, 1986; Pelcovitz & Kaplan, 1994). Although many studies suggest the existence of an intergenerational transmission

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of violence, Widom (1989b) has stressed that understanding of long-term consequences of abusive home environments is circumscribed by a paucity of acceptable empirical evidence. 9.26.2.2.3 Environmental factors A range of environmental factors are associated with increased violence, including: low socioeconomic status and marital disruption (Messner & Tardiff, 1986); physical crowding and heat (Bell & Baron, 1981); and racial and economic inequality (Blau & Blau, 1982). Longitudinal research suggests that a range of individual, family, school, and peer factors may constitute antecedents of violent behavior. These factors include: (i) history of violence, threatening behavior, and the use of weapons; (ii) exposure to violence as a child; (iii) previous history of alcohol or drug abuse; (iv) history of psychological disorders (e.g., anxiety and depression); (v) antisocial behavior problems; (vi) low self-esteem and feelings of helplessness; (vii) social withdrawal, isolation and lack of social support; (viii) jealousy; (ix) recent aversive life event (e.g., death of a spouse, child, or parent); (x) financial difficulties (e.g., unemployment); and (xi) job dissatisfaction and stress (Browne & Herbert, 1996). More temporally remote antecedents of violent behavior may exist in the link between childhood aggression and adult violence. The literature suggests that antisocial and aggressive behaviors in childhood are strong predictors of aggression in adulthood (Caspi & Moffit, 1995; Sampson & Laub, 1993). Aggressive children tend to engage in more violent acts as adults than do their nonaggressive counterparts (Jessor, Donovan, & Costa, 1991; Laub & Lauritsen, 1993; Reiss & Roth, 1994). Several factors associated with childhood aggression may, consequently, be associated with adult violence including: child temperament (White, Moffitt, Earls, Robins, & Silva, 1990); poor family functioning (Loeber & Stouthamer-Loeber, 1986); weak social bonds (Laub & Sampson, 1993); academic failure and truancy (Farrington, 1991); and peer rejection (Cairns & Cairns, 1992). Protective factors may mediate the impact of risk factors. For example, most antisocial youths do not become violent adults. It may be the case that a subgroup of boys with the most extreme behavior problems are those most likely to remain aggressive and antisocial in adulthood (Caspi & Moffitt, 1995). This general hypothesis was explored by Sampson and Laub (1993) who examined the incidence of violent crimes in adulthood for a group of delinquent youths and a group of nondelinquent youths.

They found that 33% of a sample of delinquent youths were arrested for a violent crime at ages 17±25, and 18% were arrested at ages 25±32. None of the nondelinquent controls were arrested for a violent crime as adults. Interestingly, these researchers also found that strong work and family connections in adulthood led to decreased crime in both the delinquent and control groups. Thus, social ties, such as marital attachment and job stability, may be mitigating factors in determining whether aggression and antisocial behavior in childhood leads to violent crime in adulthood (Sampson & Laub, 1993). These types of studies have led some researchers to suggest that prevention of antisocial behavior in childhood can reduce violent behavior in adulthood (Farrington, 1991; Laub & Lauritsen, 1993).

9.26.3 PREVALENCE An examination of the literature regarding the prevalence of violence reveals that although violent crime committed against adults receives considerable attention because of its frightening implications for personal safety, a relatively small proportion of adults engage in violent crimes against adult family members, strangers, and acquaintances. The homicide rate in the USA is 10 per 100 000 individuals. Homicide rates are substantially lower in other countries: 1.1 per 100 000 in Japan; 1.3 per 100 000 in the UK; and 2.3 per 100 000 in Australia (Browne & Howells, 1996). However, homicide is the least frequent type of violent offense. Arrest data from the US Department of Justice reveals that less than 3% of the arrests for violent crime in 1994 were for murder and manslaughter. The most common violent crime was burglary, followed by robbery and aggravated assault. Arrests for violent crimes as a whole represented only 5.4% of the offenses charged for that year (US Department of Justice, 1994). Sadly, violence against children in the form of abuse is relatively more common. According to a Gallup survey, three million of the approximately 77 million children in the USA (4%) were victims of physical abuse in 1995 (Moore, 1995). Reported rates of abuse do, however, vary considerably. A recent survey of 9953 individuals in Ontario, Canada, revealed that 31% of men and 21% of women self-reported physical abuse and 11% of those men and 9% of those women reported severe physical abuse by an adult during their childhood (MacMillan et al., 1997). Rates of violent offenses vary by demographic characteristics. Males have much higher rates of violent offending than females (Federal

Prevalence Bureau of Investigation, 1993). Of those arrested for violent crime in 1994, 84% were male (US Department of Justice, 1995). Over half of those arrested for violent crimes were Caucasian (54%) and virtually all of the rest were African-American (43%). Very few American-Indians or Asian/Pacific Islanders were arrested for violent crimes (less than 1% for both groups). Fewer Caucasians were arrested for robbery (38%) and murder (42%) than African-Americans (US Department of Justice, 1995). These figures must be considered in the context of the ethnic distribution in the USA as a whole, where 83% of the residents were Caucasian in 1994 and 12% were AfricanAmerican (US Bureau of the Census, 1994). 9.26.3.1 Violence and Mental Disorder The relationship between psychiatric disorders and violence is especially important to mental health professionals. There are considerable misperceptions about the violent nature of persons with psychiatric disorder. The psychopathic killer freshly escaped from the mental institution is a popular character in movies and television. Contrary to some popular portrayals, all people with mental disorders are not violent and all people who commit violent acts do not have a mental disorder. Fortunately, there is a growing knowledge base regarding the prevalence of mental disorders among violent offenders and the prevalence of violence among individuals with mental disorders. 9.26.3.2 Mental Disorder Among Violent Offenders The estimated prevalence rates of psychiatric disorders among criminals vary. Brodsky (1972), in a review of studies of prison and court samples from 1918 to 1970, found the rate of psychiatric disorder in criminals to range from 16% to 95%. Hodgins and Cote (1990) used the Diagnostic and statistical manual of mental disorders, third edition (DSM-III; American Psychiatric Association, 1980) and found the prevalence of schizophrenia in penitentiary inmates to be seven times higher than individuals in the general population. However, in a review of 18 studies of mental disorders among jail inmates, Teplin (1990) found rates of psychotic mental disorders to range from 5% to 16%. Steadman, Fabisiak, Dvoskin, and Holohean (1987) determined that 8% of 3000 prisoners had severe mental illness and another 16% of inmates had significant mental disabilities.

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Variation in rates of mental disorders in these prison samples are due, in part, to unstandardized methods of diagnosis (Monahan, 1992). More recent studies utilize structured diagnostic interviews such as the Diagnostic Interview Schedule (DIS). Teplin (1990) compared results from the DIS of 728 men from a county jail and 362 male prison inmates (Hodgins & Cote, 1990) to data from the National Institute of Mental Health's epidemiological catchment area (ECA) study (Robins & Regier, 1991). Results indicated that the prevalence of a severe disorder was 3±4 times greater in the prison and jail samples than in the general population. Specifically, the prevalence of major depression was 3±4 times higher, mania or bipolar disorder was 7±14 times higher, and schizophrenia was three times higher in inmates than in individuals from the general population. Although these findings indicate a high prevalence of mental disorder among males in jails and prisons, sampling biases exist. Violent offenders with mental illness are more likely to be arrested and imprisoned than offenders without mental illness. Robertson (1988), for example, found that perpetrators with schizophrenia had increased likelihood for arrest at a crime scene than individuals without disorders. Inmates may be a subset of perpetrators and, thus, are not necessarily representative of the population of violent offenders.

9.26.3.3 Violence and the Mentally Ill Findings from 11 studies of violence among individuals with mental disorders suggest that 10±40% of individuals sampled committed a violent act against another individual two weeks prior to hospitalization (Otto, 1992; Wessely & Taylor, 1991). In addition, Klassen and O'Connor (1990) found that 25±30% of male psychiatric subjects with at least one past incident of violence committed a violent act within a year of discharge from a hospital. The MacArthur Risk Assessment Study, an ongoing longitudinal project analyzing 1000 individuals admitted to psychiatric hospitals, reported that 33% of patients reported one or more violent incidents within a period of six months after hospital discharge (Steadman et al., 1994). Lidz, Mulvey, and Gardner (1993) found 45% of 712 patients engaged in violence within six months of a psychiatric emergency room visit. Although these studies suggest a positive relationship between violence and mental illness, fundamental methodological problems exist. For instance, very few studies assess rates of violence in comparative samples of nonhospitalized individuals. Selection bias also

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exists in studies assessing violence in hospitalized samples in that these patients are only a subset of the population of mentally ill. Patients with violent behavior are likely to be hospitalized due to the danger to others standard for civil commitment (Monahan, 1992). Violence may well be the primary reason why people with mental illness are hospitalized. There is some evidence that rates of violence among psychiatric patients may be rising, especially for females. Disturbingly, Tardiff, Marzuk, Leon, Portera, & Weiner (1997) found that, compared to a methodologically similar study conducted a decade earlier at the same clinic (Tardiff, 1984), the rate of violence among psychiatric patients increased 40% for males and 150% for females. The increase in the violence rates of psychiatric patients may be related to increased substance abuse (Tardiff et al., 1997). A study by Swanson, Holzer, Ganju, and Jono (1990) overcame several of the weaknesses found in prior studies by investigating the relationship between violence and mental illness in a community-based sample. Swanson et al. (1990) assessed psychiatric disorder and incidents of violence in 10 000 residents in three American cities using data from the National Institute of Mental Health's ECA study. DSMIII diagnoses were derived from a standardized interview and participants self-reported violent acts committed in the previous year. Higher rates of violence were positively associated with all psychiatric disorders. Specifically, 2.1% of individuals without a psychiatric diagnosis reported at least one violent incident. The percentage of individuals with a psychiatric diagnosis who reported at least one violent episode in the prior year was much higher, ranging from 11% to 35% depending on the type of diagnosis. Persons receiving a diagnosis of drug or alcohol abuse or dependence had the highest incidence of self-reported violence (35% for drug and 24.6% for alcohol). Rates of selfreported violence in other diagnostic groups were much lower and fairly consistent, including the diagnoses of schizophrenia (12.7%), panic disorder (11.6%), major depression (11.7%), and mania or bipolar disorder (11.0%). A study by Link, Andrews, and Cullen (1992) corroborated the findings of Swanson et al. (1990). Link et al. (1992) compared arrest rates and self-reported violence in individuals formerly hospitalized and treated, with arrest and violence data from a sample of 400 adults who had never been treated for a mental illness. After controlling for age, gender, ethnicity, socioeconomic status, educational level, homicide rate where the participant lived, and social desirability, researchers found that the treated

sample were 2±3 times more violent than the never-treated group. Link et al. (1992) also controlled for psychotic symptoms using the psychotic symptomatology scale. They found that almost all of the differences in rates of violence were accounted for by active psychotic symptoms: the rates of violence in treated patients were similar to untreated individuals when they were not experiencing any psychotic symptoms. In addition, treated and untreated individuals who were actively experiencing psychotic symptoms had a higher rate of violence than those with no psychotic symptoms. These data suggest that individuals who are actively experiencing psychotic symptoms have a greater likelihood for engaging in violent behavior than those nondisordered individuals in the community. Other research findings also point to a link between mental illness and dangerousness, especially with reference to psychopaths (Kosson, Smith, & Newman, 1990; Serin, 1991, 1996). Psychopathy may be a marker for violence and violent reoffending. Although not every psychopath is a violent offender and, conversely, not every violent offender is a psychopath, research suggests that psychopathic violent offenders have higher rates of violent recidivism (Quinsey, 1995). The preponderance of violence among persons who abuse alcohol and other drugs has also been found for violence against children (Chaffin, Kelleher, & Hollenberg, 1996; Dinwiddie & Bucholz, 1993; Kelleher, Chaffin, Hollenberg, & Fischer, 1994; Murphy et al., 1991). Kelleher et al. (1994) using ECA data found that 43% of parents who physically abused their children met the criteria for a diagnosis of substance abuse disorder.

9.26.3.4 Summary Overall, rates of violent offenses are low relative to other crimes, although abuse appears more common. Violence does vary by gender and age, with men and African-Americans having higher rates of arrests for violent offenses. Research does indicate that mental disorder may be a significant risk factor for violent offenses (Mullen, 1997; Wessely & Taylor, 1991). It is important to note that a psychiatric diagnosis alone may not necessitate risk; existence of active psychotic symptoms may be the link to violence (Link et al., 1992). Further, the majority of people with psychiatric disorders are not violent: only 10% of individuals with psychiatric diagnoses self-reported a violent incident in the previous year in the ECA study (Robins & Regier, 1991). Monahan

Assessment (1992) provided an eloquent summary of the relationship between violence and mental disorder: Evidence now indicates that mental disorder may be a consistent, albeit modest, risk factor for the occurrence of violence. Dire implications for mental patient advocacy, for mental health law, and for the provision of mental health treatment need not follow from candidly acknowledging the possibility of a limited connection between disorder and violence. (p. 511)

9.26.4 ASSESSMENT Data regarding the prevalence of mental disorder does not, alone, predict the violence potential of any given individual, just as no single characteristic studied at the epidemiologic level can predict future violence. Nonetheless, mental health professionals may be asked by correctional and parole boards to assess the risk of violent reoffending for known violent perpetrators (Serin, 1996), or to assess the violence potential of persons receiving mental health care. There has been some hope that reliable and valid psychiatric and psychological assessments could accurately predict violent behavior. Historically, methods for predicting violent behavior have been poor (Lidz et al., 1993; Menzies, Webster, McMain, Staley, & Scaglione, 1994; Quinsey, 1995; Quinsey & Maguire, 1986). Recent research, however, shows more promise for accurate prediction of violent reoffending (Bonta, Harman, Hann, & Cormier, 1996; Harris, Rice & Quinsey, 1993). The following instruments aid in assessing an offender's propensity to commit a violent offense, including child physical abuse (Blackburn, 1993). 9.26.4.1 Offender Risk Assessments 9.26.4.1.1 Violence Risk Appraisal Guide The Violence Risk Appraisal Guide (VRAG; Harris et al., 1993) is an empirically derived instrument used for assessing risk of future violence. The 12 items include: psychopathy; separation from parents at age 16 or younger; victim injury in index offense; schizophrenia; marital status; elementary school maladjustment; female victim in index offense; failure on prior conditional release; property offense history; age at index offense; alcohol abuse history; and a diagnosis of personality disorder. The VRAG was developed on a sample of individuals with at least one documented serious violent offense (Borum, 1996). The VRAG classification accuracy rate is approximately 75% and Rice (1997) has argued that this

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actuarial instrument can fairly accurately predict long-term criminal violence. 9.26.4.1.2 Hare Psychopathy Checklist-Revised The Psychopathy Checklist-Revised (PCL-R) is frequently used to predict recidivism in criminals (Serin, Peterson, & Barbaree, 1990) and psychiatric patients (Harris et al., 1993; Quinsey, Rice, & Harris, 1995). Empirical analyses have yielded two correlated factors. The first factor encompasses personality characteristics including lack of remorse, pathological lying, conning, and callousness. The second factor includes lifestyle indicators such as criminal versatility, impulsiveness, and boredom (Hare et al., 1990). Serin (1996) found that the PCL-R predicted violent recidivism more accurately than prior history of violence and actuarial risk scales. Findings from several other studies attest to this instrument's predictive validity (e.g., Harris, Rice, & Cormier, 1991; Serin & Amos, 1995). The PCL-R does require more time, training in scoring, and clinical skills than many other prediction scales. 9.26.4.1.3 Statistical Information on Recidivism Scale The Statistical Information on Recidivism (SIR) Scale was developed to inform parole boards of the future violence potential of federally sentenced inmates in Canada (Nuffield, 1989). Fifteen variables were empirically derived and related to general recidivism in a sample of over 2500 inmates with a follow-up period of three years. The SIR scale yields five categories of risk, ranging from ªvery good riskº to ªpoor risk.º The SIR scale was recently revalidated using 3267 male offenders from federal penitentiaries (Bonta et al., 1996). The SIR scale was used to assess violent risk as well as risk of violence in general. Results indicated that 18.6% of the offenders committed a violent crime during the follow-up period. A statistically significant relationship between the risk categories and violent recidivism was detected. A univariate correlation of 0.20 was found for SIR scores and future violent behavior. Bonta et al. (1996) suggested that the SIR predicts violent behavior beyond levels of chance. 9.26.4.1.4 HCR-20 The HCR-20 is a three-level checklist designed to assess risk of future violent behavior among criminal and psychiatric individuals (Webster, Eaves, Douglas, & Wintrup, 1995). The first 10 items pertain to historical variables (H scale) including previous violence, age at first

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violent offense, relationship stability, employment stability, alcohol or drug abuse, mental disorder, psychopathy, early home and school maladjustment, personality disorder, and prior release or detention failure. The second five items are clinical in nature (C scale), including insight, attitude, symptomatology, stability, and treatability. The final five items pertain to risk variables (R scale) in the community or situations in which the individual may be involved: plan feasibility, access, support and supervision, compliance, and stress (Webster et al., 1995). Preliminary data investigating the psychometric properties of the HCR-20 appear promising (Harris et al., 1993). 9.26.4.2 Child Abuse Assessment Instruments 9.26.4.2.1 Child Abuse Potential Inventory The Child Abuse Potential Inventory (CAP) is a self-report questionnaire widely used for screening suspected physical child abusers (Milner, 1986, 1994). The 160 agree±disagree items comprise a physical abuse scale and six descriptive factor scales. The factor scales include the following: distress, rigidity, unhappiness, problems with child and self, problems with family, and problems from others. The CAP Inventory also contains three validity indexes: faking-good index, faking-bad index, and random response index. A significant relationship between elevated abuse scores on the CAP Inventory and later physical child abuse has been reported (Milner, Gold, Ayoub, & Jacewitz, 1984). In addition, overall abuse scale classification rates are reported to range from 80 to 90% (Caliso & Milner, 1994; Milner, 1989, 1991; Milner & Robertson, 1989). 9.26.4.2.2 Michigan Screening Profile of Parenting The Michigan Screening Profile of Parenting (MSPP; Helfer, Hoffmeister, & Schneider, 1978) was designed as a screening tool for child abuse and/or neglect. The MSPP consists of 77 items and four factors: emotional needs met, relationship with parents, expectations of children, and coping. The ªemotional needs metº factor is used to detect physically abusive parents. Convergence analysis classifies parents as abusive through measurement of inconsistent responding (Hefler et al., 1978). Although sensitivity rates for child physical abusers are adequate, Schneider (1982) reported high rates (20%) of false positive classifications. Hefler et al. (1978) suggested that the MSPP is more suited for identification of problems in parenting than a screen for child abuse.

9.26.4.2.3 Parenting Stress Index The Parenting Stress Index (PSI; Abidin, 1990) is used to measure child- and parentrelated stress in physically abusive parents and those parents at risk for physical abuse, although the measure was not specifically designed for this purpose (Milner & Murphy, 1995). The PSI consists of 120 items that assess parent-related stress, child-related stress, and general life stress. PSI scores, specifically the ªparent domain stressº scores, have been correlated with child abuse potential (Milner, 1986). Data suggest that parents at risk for physical abuse as well as parents who are physically abusive score higher on the PSI than comparison parents (Abidin, 1990; Mash, Johnston, & Kovitz, 1983). 9.26.4.3 Summary A wide range of instruments are available for assessing violence potential, some with impressive psychometric properties. Scales with classification rates above 75% exist for predicting both violence and abuse. One of the difficulties in utilizing such scales is that consequences for false negatives can be extremely high if a person is deemed to be at little risk for future violence and still commits a violent offense. Nonetheless, reasonable tools for the assessment of violence and violence potential do exist. 9.26.5 TREATMENT The literature on the treatment of violent offenders is not as encouraging as the literature on assessment. The existing literature on the treatment of violent offenders is relatively limited. More extensive literature exists regarding the treatment of criminal offenders in general. Consequently, many of the treatment principles and methodological problems that are discussed in this section derive at least in part from research stemming from a wide range of criminals. There is a prevailing belief that imprisonment is the only viable solution for criminals involved in certain types of crime. Yet, jail time is known to have deleterious effects, frequently increasing the likelihood that the individual will reoffend (Lipsey, 1992). In fact, even the penalty of death does not appear to dramatically reduce serious crime. A study involving states with and without the death penalty found no differences in terms of serious crime rates (Hollin, 1996). During the 1970s, researchers suggested that existing treatments were not effective on the recidivism of offenders (Brody, 1976; Greenberg, 1977; Martinson, 1974). Indeed, Lipton,

Treatment Martinson, and Wilks (1975) reviewed 231 studies of the treatments for offenders and concluded that interventions studied had no differential effects. This conclusion was substantiated by a rigorous article review commissioned by a National Academy of Sciences panel (Sechrest, White, & Brown, 1979). Recent research, however, points to more positive findings regarding the effectiveness of treatment for criminal offenders (Andrews et al., 1990; Gendreau, 1996; Gendreau & Ross, 1987). Treatments do exist that appear to reduce the risk of recidivism at higher rates than punishment alone (Bonta, 1996). These treatments are enhanced through the use of empirically based risk/need assessment instruments designed to aid in planning specific treatment programs that match the level of offender risk (Bonta, 1996). 9.26.5.1 Characteristics of Effective Programs Several recent reviews identify the characteristics of successful treatment programs. Lipsey (1992) reviewed 443 programs and found that 64% of the studies reported higher reductions in recidivism rates for the treatment group as compared to the control group. The average recidivism rate was 10%. A review of approximately 500 control group studies on treatment programs for offenders yielded several common characteristics for interventions that have reduced recidivism by 25±80% (Andrews et al., 1990). Gendreau and Paparozzi (1995) provided a summary of the principles of effective interventions for criminal offenders: (i) 3±9 months of intensive services based on cognitive and social learning theories; (ii) services target antisocial attitudes and values; (iii) treatment style and mode is matched to offender's learning style; (iv) positive reinforcement is used more frequently than punishment; (v) clinicians are appropriately trained and supervised to relate to offenders in a sensitive and constructive manner; (vi) offenders are exposed to prosocial activities that interrupt the criminal network. Gendreau (1996) has contended that effective interventions should include intensive behavioral services that account for 40±70% of an offender's time. Suggested behavioral programs include token economies, modeling, and cognitive behavioral therapy. Criminogenic needs of high-risk offenders should be targeted. Criminogenic needs are dynamic risk factors that are amenable to change and predict criminal behavior (Andrews & Bonta, 1994). If criminogenic factors can be changed, the

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probability of future criminal behavior can be reduced (Bonta, 1996). These needs include antisocial attitudes, peer associations, issues of self-control, chemical dependencies, and behavioral styles (Andrews & Bonta, 1994). 9.26.5.2 Characteristics of Ineffective Programs Gendreau and Paparozzi (1995) and Gendreau (1996) have summarized the characteristics of programs that failed to reduce recidivism: (i) treatment interventions based on Freudian psychodynamic and Rogerian nondirective theories; (ii) medical model approaches such as dietary alterations, plastic surgery, and pharmacological treatments; (iii) boot camps; (iv) services targeting noncriminological issues such as anxiety, self-esteem, and depression; (v) ªpunishing smarterº strategies, including intensive supervision programs (ISPs). ISPs typically include home confinement, drug testing, restitution, shock incarceration, boot camps, and electronic monitoring. 9.26.5.3 Programs for Treating Violence Although the characteristics of effective programs for criminal offenders can be applicable to violent offenders, there are several programs designed specifically for the subgroup of criminal offenders who are violent. Several of the most visible and well-researched programs for violent offenders are reviewed below. It is evident that the data on the effectiveness of these programs are mixed. 9.26.5.3.1 Therapeutic community program The Oak Ridge Division of the Mental Health Centre in Ontario, Canada began a treatment program in the 1960s and 1970s that attempted to reduce the incidence of violence of participants after release. This program treated psychotic and nonpsychotic patients with up to 80 hours of weekly structured therapeutic activity. The program was designed to increase cooperation, caring, empathy, responsibility, and insight (Rice, 1997). The evaluation study included 146 men treated in the therapeutic program for at least two years and 146 men matched on age, offense type, and criminal history who were in prison. Violent recidivism was examined after 10 years and, unfortunately, was 40% for both untreated and treated participants.

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A significant finding was discovered, however, when data from psychotic and nonpsychotic participants were analyzed. A large interaction effect indicated that the treated psychopaths had significantly higher recidivism rates than the untreated psychopaths, and the treated nonpsychopaths had significantly lower recidivism rates than the untreated nonpsychopaths (Harris, Rice, & Cormier, 1994). The program evaluators speculated that the treatment program taught psychopaths how to better manipulate and deceive others while increasing their self-esteem, leading to increased levels of aggression (Baumeister, Smart, & Boden, 1996). These findings suggest that therapeutic programs are less effective in decreasing violent behavior in psychopathic offenders than other criminals. 9.26.5.4 Medications Prescribed medication is frequently used for violent psychiatric patients. The type of medication prescribed is dependent on the etiology of the violent behavior (Tardiff, 1996). For example, antipsychotic medications (haloperidol, clozapine, and fluphenazine) are used to treat delusional thinking and aid in the management of violence stemming from organic disorders. Clozapine (Buchanan, 1995) and carbamazepine (an anticonvulsant; Neppe, 1983) have both been shown to reduce symptoms of violence and aggression in schizophrenics. Beta blockers have been effective in managing violent behavior in individuals with traumatic brain injury and psychosis (Barratt, 1993). Lithium has been found to be effective in reducing violence in patients with bipolar disorder or mental retardation (Tardiff, 1996). Data suggest that serotonergic medications (e.g., tryptophan and fluoxetine) may reduce violent episodes of patients with schizophrenia and personality disorders (Goldman & Janecek, 1990; Wilcock, 1987). 9.26.5.5 Psychotherapy for Violent Outpatients Family and group therapy are the most utilized forms of psychotherapy for violent patients. Family therapy is imperative because most violence occurs at home. Group therapy allows patients to discuss issues and interact with individuals experiencing similar violent and aggressive behaviors. Tardiff (1996) has delineated eight objectives of psychotherapy for violent patients: (i) evaluate the patients' motivations and reasons for participating in psychotherapy; (ii) facilitate expression of patients' problems

and issues in a nonjudgmental and empathetic manner; (iii) encourage patients' self-control; (iv) continual awareness of feelings of transference and countertransference; (v) develop patients' ability to recognize their own anger; (vi) increase awareness of dynamics of violence; (vii) increase awareness of consequences of behavior; (viii) aid in restructuring patients' environments to prevent violence. 9.26.5.6 Behavioral Techniques Behavior modification is known to be an effective tool in the management of mentally impaired violent patients. Effective behavioral programs include adequately trained staff, a specific treatment program, clear definitions of target behaviors and responses, positive reinforcement, improvement of social skills, withdrawal of positive reinforcement, sensory extinction, time-outs, and contingent restraint (Liberman & Wong, 1984; Tardiff, 1996). Social skills training programs, specifically, have been found to increase interpersonal and problem solving skills and social functioning (Liberman & Corrigan, 1993). Programs involving behavioral techniques coupled with prescribed medication appear promising for individuals with mental illness. An example is biobehavioral therapy (BBT) which combines behavioral assessment, social learning techniques, family participation, and social skills training with pharmacotherapy (Liberman, 1994; Liberman, Kopelowicz, & Young, 1994). 9.26.5.7 Treatment of Child Abusers There is a fairly extensive literature on the treatment of child abuse. A range of family therapies and other interventions are designed, at least in part, to prevent or remediate child abuse. In general, positive results have been achieved through parent-focused interventions (including behavioral and cognitive-behavioral programs) that focus on improving childrearing practices and management of stress (reviewed by Wolfe & Wekerle, 1993). Positive outcomes have also been found for physically abusive parents involved in individual behavior therapy and parenting classes, coupled with in-home behavioral coaching (Howing, Wodarski, Gaudin, & Kurtz, 1989). Family preservation services are frequently used as an intervention for families where child abuse exists. Although early research in this area supported the efficacy

Future Directions for Research and Practice of these services, more recent research questions the effectiveness, especially in the case of parents with psychopathology and substance use issues (Dore & Alexander, 1996).

9.26.5.8 Summary The literature on the effectiveness of treatment programs for criminal offenders, in general, and violent offenders, in particular, is plagued by a number of methodological and other problems. Research in the field of criminology does not always build from a strong empirical foundation (Andrews & Bonta, 1994). Andrews and Wormith (1989) stated that research findings not supportive of preferred theories of criminology have been frequently ignored, whereas weak findings supporting traditional theories have been well received. There is also a dearth of evaluation studies using robust experimental designs (Petersilia & Turner, 1993). Random assignment of offenders into treatment groups is difficult in that criminal justice professionals lose control of their decision-making regarding placement. This is especially problematic when the experimental condition is a less severe form of punishment (Petersilia & Turner, 1993). Another methodological issue that has plagued criminology research is the evaluation of program success. Outcomes are usually measured through perpetrator recidivism, typically assessed by arrest statistics and parole violations. These outcome variables are reliant on the capability and efficiency of law officials in apprehending offenders. Evaluation of community programs is especially problematic in that offenders are subjected to increased surveillance. Indeed, offenders may be arrested more frequently simply due to the increased chances of detection of transgressions (Cullen, Wright, & Applegate, 1996). Unfortunately, few studies have evaluated community-based programs for violent offenders due, in part, to the more serious nature of the crimes committed. Fortunately, some programs, such as home confinement and electronic monitoring, are beginning to admit more high-risk offenders, including individuals involved in crimes against persons (Cullen et al., 1996). Evaluation of these programs for violent offenders is still in its infancy, but preliminary data suggest that high-risk individuals may be adequately maintained in the community (Austin & Hardyman, 1991). It is generally agreed that community-based programs rather than incarceration hold the answer to reducing crime in the future (Reiss & Roth, 1994). However, considerable additional

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research is required before communities will feel confident of the potential of these programs to curb violent behavior. 9.26.6 FUTURE DIRECTIONS FOR RESEARCH AND PRACTICE Over the last decade, a range of research effort has shed light on many aspects of violence and abuse. Models regarding the nature and etiology of violence are increasingly demonstrating the interplay between environmental and biological factors to violent behavior. Epidemiological research suggests that there is a relationship between violence and mental disorder. Assessment tools exist that predict violence and abuse with relatively high levels of accuracy. Treatment programs for criminal offenders are appearing more promising than they were a decade ago. Nonetheless, much remains to be learned about violent behavior in each of the central areas elucidated in this chapter. 9.26.6.1 Research on the Nature of Violence Research on the nature of violence is characterized by advances in the understanding of biological and environmental risk factors for violent behavior. However, relatively limited research has examined the interactions between biological and environmental risk factors. Specifically, little is known about the relative contributions of biology and environment to violent behavior. Much more work is needed on the long-term consequences of abusive home environments for the development of violent behavior later in life (Widom, 1989b). Although risk factors for violent behavior are increasingly researched, protective factors are receiving relatively less attention. Understanding these protective factors is especially important for developing successful interventions for preventing violent behavior. Monahan and Steadman (1994) have contended that future violence prediction models should include the disaggregation of the violence predictor variables into (i) the risk factors, (ii) the amount and type of violence predicted, and (iii) the likelihood that a harmful event will occur. 9.26.6.2 Research on the Prevalence of Violence The epidemiological studies on violence that address the problem of violence and mental illness derive largely from one major epidemiological study conducted a decade ago (the National Institute of Mental Health's ECA study; Robins & Regier, 1991). That study did not extensively sample individuals in prisons or

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institutional care. Consequently, assessments of past and risk of future violence in large representative samples of individuals in the community, psychiatric hospitals, and prisons are needed to augment extant epidemiological studies. Although such studies can be costly, epidemiological research can be conducted across a range of special populations (e.g., the homeless mentally ill, prison inmates, psychiatric inpatients, incarcerated mentally disordered offenders). Findings can help to more fully develop the relationships between mental disorder, violence, and a range of risk and protective factors. With regard to child abuse, understanding of the actual prevalence rates of physical abuse remains relatively unknown. Rates currently vary depending on the sample and the manner in which questions regarding abuse are asked. 9.26.6.3 Research on the Assessment of Violence Adequate instruments exist for assessing violence potential. However, the utility of these tools largely rests on their sensitivity rather than their specificity. In general, it is better to intervene with an individual who is assessed as having a high potential for violence but does not actually commit a violent act, than to fail to intervene with an offender who commits an act of violence. Of course, false positives also have negative consequences with regard to social stigma for the person assessed as a high risk for violence, especially in the case of abuse. Nonetheless, more research on developing tests sensitive enough to merit confidence in their use remains a viable avenue for future investigation. 9.26.6.4 Treatment of Violent Offenders More research is needed on how to treat violent offenders. Existing literature focuses on criminal offenders, in general, with relatively less attention on violent offenders. Clearly, this lack of research is due in part to the desire to punish rather than to treat violent offenders. Furthermore, the consequences for ineffective treatment of violence are dire in that failure results in physical assault or abuse. Nonetheless, the large numbers of violent offenders who remain in the community, paired with high rates of recidivism among those who have been imprisoned, begs for more effective communitybased interventions. The only other alternative is longer-term incarceration, which is costly and appears ineffective. Finally, very little is known about the process of breaking the cycle of abuse and violence found in many families (Widom, 1989b). Rigorous, creative, controlled studies need to be conducted to examine how to

effectively treat the problem of violence for those living in the community as well as those who are incarcerated. Of all the areas discussed in this chapter, this topic requires the most thorough attention. 9.26.7 SUMMARY The facts regarding violent behavior appear to be clouded by misperceptions. Accurate data on violent criminals are particularly necessary in light of frequent public misconceptions. Partially due to the media's sensationalism of violence, the public tends to associate violence with the majority of offenders (Bonta & Hanson, 1994) and individuals with mental disorders. In reality, the base rate for violence is less than 10% in criminals (Bonta et al., 1996) and individuals with psychiatric disorders (Monahan, 1992). Nonetheless, the negative consequences of violent behavior exceed those of virtually any other type of behavior and extend beyond those who are actually harmed. Fear of violence and perceptions of the loss of safety intrude on the lives of those who have never been victimized by a violent act. In this type of environment, there is a strong desire to treat violence through punishment. However, there is little evidence that punishment will actually solve the problem of violence. Consequently, punishment should be combined with other interventions to reduce recidivism. Perhaps more important are the implications that derive from the assertion of Farrington (1990, p. 110) that ªproblem children tend to grow up into problem adults, and that problem adults tend to produce problem children.º The longer-term solutions to the problem of violence may constitute preventing violent behavior by identifying and intervening with those most at risk. Perpetrators of violence have heterogeneous characteristics. Interventions tailored to the characteristics of individual offenders could lead to more successful outcomes. As practitioners and researchers, understanding of the differences inherent in offenders, knowledge of risk assessment instruments, and awareness of the efficacy of interventions will aid in improving treatment and decreasing recidivism and incidence of violence. ACKNOWLEDGMENTS Preparation of this chapter was supported in part by Training and Center Grants from the National Institute of Mental Health (MH43694 and MH18261). The authors wish to acknowledge the assistance of Rachel DuPre and Karla Kruse.

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Schneider, C. J. (1982). The Michigan Screening Profile of Parenting. In R. H. Starr, Jr. (Ed.), Child abuse prevention: Policy implications (pp. 157±174). Cambridge, MA: Ballinger. Sechrest., L., White, S. O., & Brown, E. D. (1979). The rehabilitation of criminal offenders: Problems and prospects. Washington, DC: National Academy of Sciences. Seidenwurm, D., Pounds, T. R., Globus, A., & Valk, P. E. (1997). Abnormal temporal lobe metabolism in violent subjects: correlation of imaging and neuropsychiatric findings. American Journal of Neuroradiology, 18, 625±631. Serin, R. C. (1991). Psychopathy and violence in criminals. Journal of Interpersonal Violence, 6, 423±431. Serin, R. C. (1996). Violent recidivism in criminal psychopaths. Law and Human Behavior, 20, 207±217. Serin, R. C., & Amos, N. L. (1995). The role of psychopathy in the assessment of dangerousness. International Journal of Law and Psychiatry, 18, 231±238. Serin, R. C., Peterson, R. D., & Barbaree, H. E. (1990). Predictors of psychopathy and release outcome in a criminal population. Psychological Assessment, 2, 419±422. Steadman, H. J., Fabisiak, S., Dvoskin, J., & Holohean, E. (1987). A survey of mental disability among state prison inmates. Hospital and Community Psychiatry, 38, 1086±1090. Steadman, H. J., Monahan, J., Appelbaum, P. S., Grisso, T., Mulvey, E. P., Roth, L. H., Robbins, P. C., & Klassen, D. (1994). Designing a new generation of risk assessment research. In J. Monahan & H. Steadman (Eds.), Violence and mental disorder: Developments in risk assessment (pp. 297±318). Chicago: University of Chicago Press. Swanson, J. W., Holzer, C. E., Ganju, V. K., & Jono, R. (1990). Violence and psychiatric disorder in the community: Evidence from the epidemiologic catchment area surveys. Hospital and Community Psychiatry, 41, 761±770. Tardiff, K. (1984). Characteristics of assaultive patients in private hospitals. American Journal of Psychiatry, 141, 1232±1235. Tardiff, K. (1996). Concise guide to assessment and management of violent patients (2nd ed). Washington, DC: American Psychiatric Press. Tardiff, K., Marzuk, P. M., Leon, A. C., Portera, L., & Weiner, C. (1997). Violence by patients admitted to a private psychiatric hospital. American Journal of Psychiatry, 154, 88±93. Teplin, L. (1990). The prevalence of severe mental disorder among male urban jail detainees: Comparison with the epidemiologic catchment area program. American Journal of Public Health, 80, 663±669. Tonkonogy, J. M. (1991). Violence and temporal lobe lesion: Heat CT and MRI data. Journal of Neuropsychiatry and Clinical Neuroscience, 3, 189±196. US Bureau of the Census (1994). United States population estimates. Washington, DC: Author. US Bureau of Justice Statistics (1995). Correctional populations in the United States 1992. BJS Bulletin NCJ-146413. Washington, DC: Author. US Department of Justice (1994). Sourcebook of criminal justice statistics. Washington, DC: Author. US Department of Justice (1995). Crime in the US. Washington, DC: Author. Webster, C. D., Eaves, D., Douglas, K., & Wintrup, A. (1995). The HCR-20 Scheme: The assessment of dangerousness and risk. Burnaby, Canada: Simon Fraser University and Forensic Psychiatric Services Commission of British Columbia. Weiler, B. L., & Widom, C. S. (1996). Psychopathy and violent behavior in abused and neglected young adults.

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Copyright © 1998 Elsevier Science Ltd. All rights reserved.

9.27 Perpetrators of Domestic Violence ETIONY ALDARONDO Boston College, Chestnut Hill, MA, USA 9.27.1 INTRODUCTION

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9.27.1.1 Definitions 9.27.2 RESEARCH ON PERPETRATORS OF DOMESTIC VIOLENCE

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9.27.2.1 Incidence and Prevalence of Intimate Violence 9.27.2.1.1 Heterosexual relationships 9.27.2.1.2 Homosexual relationships 9.27.2.1.3 Continuity and cessation of wife assault 9.27.2.1.4 Intimate violence in clinical populations 9.27.3 CHARACTERISTICS OF PERPETRATORS OF DOMESTIC VIOLENCE

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9.27.3.1 Risk Markers for Wife Assault 9.27.3.2 Types of Men Who Batter 9.27.4 THE ASSESSMENT OF MALE BATTERERS

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9.27.4.1 Interview Assessment 9.27.4.2 Self-report Measures of Intimate Violence 9.27.4.3 Assessment of Dangerousness

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9.27.5 CLINICAL INTERVENTIONS WITH PERPETRATORS OF DOMESTIC VIOLENCE

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9.27.5.1 Treatment Programs for Male Batterers 9.27.5.1.1 Group therapy approaches 9.27.5.1.2 Couple therapy 9.27.6 SUMMARY AND FUTURE DIRECTIONS

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9.27.7 REFERENCES

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issue of diversity in national, community, and clinical samples of violent couples. The next two sections focus on assessment and treatment issues, and the final section discusses some implications of the heterogeneity perspective for research and practice.

9.27.1 INTRODUCTION Perpetrators of domestic violence are a heterogeneous group. Violent partners do not fit conventional molds of gender, deviancy, and psychopathology. An understanding of the variability within this group is essential to the development of viable theories, sound assessment instruments, assessment procedures, and effective treatments. Further, various forms of intimate violence, patterns of assault, and typologies of men who batter their female partners will require examination. Hence, the chapter has five sections. The first section examines the nature of research on perpetrators of violence. The second section examines the

9.27.1.1 Definitions Domestic violence may include intimidation, harassment and persecution, verbal aggression, denial of access to resources, sexual coercion and assault, physical assault, and torture (e.g., Walker, 1984). Although each form of violence can have devastating effects on the victim, the chapter will focus on physical aggression in 437

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adult intimate relationships. Terms such as abuse, violence, family violence, and intimate violence are used to connote acts of aggression with the potential to cause physical harm or death to a partner. When the issue being addressed is violence by men against female partners, it will be named wife assault. Violence in gay relationships will also be regarded as manto-man violence. Violence perpetrated by women against men will be called woman-to-man violence. Similarly, violence perpetrated by women in lesbian relationships will be called woman-to-woman violence. 9.27.2 RESEARCH ON PERPETRATORS OF DOMESTIC VIOLENCE Given the explosive growth of family violence research, one might assume that much is known about perpetrators of violence. However, research on domestic violence reveals a tenuous understanding of violent partners and many inconsistent findings on issues of theoretical and practical importance, such as sex role attitudes, alcohol use, recidivism following treatment, and psychopathology. While some of these inconsistencies are the result of methodological deficiencies, there is a growing consensus among family violence researchers that many discontinuities in the literature are also a consequence of the failure to recognize the heterogeneity among perpetrators of violence and to modify our understanding of intimate violence (Aldarondo & Sugarman, 1996; Holtzworth-Munroe & Stuart, 1994; Letellier, 1994; O'Leary, 1993). 9.27.2.1 Incidence and Prevalence of Intimate Violence 9.27.2.1.1 Heterosexual relationships Typically, intimate violence occurs under a veil of secrecy that makes it difficult to estimate its incidence and prevalence. National surveys, surveys of community samples, and homicide records suggest that violence against women by men is without doubt the most pervasive and consequential form of intimate violence. Male violence against women is a major social problem, a serious public health problem affecting the physical and mental health of women, and a serious obstacle to development and peace in the world (Goodman, Browne, Fitzgerald, Keita, & Russo, 1994; Russo, Koss, & Goodman, 1995). The available evidence for the USA indicates that: (i) an estimated two to three million women are severely assaulted by their husbands or boyfriends each year (Straus & Gelles, 1990); (ii) the rates of depression, suicide attempts, psychosomatic symptoms, and

stress are four times greater among female victims of severe violence than among women who are not victims of violence (Stets & Straus, 1990); (iii) most sexual assault of women is perpetrated by male intimates (Finkelhor & YlloÈ, 1985; Kilpatrick, Edmunds, & Seymour, 1992); and (iv) close to one third of all female homicides are perpetrated by male partners (Browne & Williams, 1993). The main sources of data on the incidence of intimate violence in the USA are three national surveys conducted in 1975 (Straus, Gelles, & Steinmetz, 1980), in 1985 (Straus & Gelles, 1990), and in 1992 (Kaufman, Jasinski & Aldarondo, 1994). Concerning severe violence only, wife assault rates on the three surveys were 3.8%, 3.0%, and 2.0%, respectively. Straus and Kaufman-Kantor (1994) reported continued significant decrease of severe violence from 1975 to 1992 regardless of the gender of the respondent. Moreover, these authors argued that the decrease in severe wife assaults ªis parallel to the 18% decrease in the rate of homicides of wives by husbands during this periodº (p. 8). In contrast, in 1992, the rate of minor violence against women as reported by women increased. Whether the decrease in severe violence by men reflects an actual reduction in wife assault or unwillingness to report is unknown, although reductions in the reports given by women suggest the former to be the case. Women in heterosexual relationships frequently report physical aggression against their male partners. Evaluations of national data have found comparable rates of physical violence by men and women (Brush, 1990; Morse, 1995; Straus, 1993; Straus & Gelles, 1990). Moreover, Browne and Williams' (1993) analysis of homicide records in the USA from 1976 to 1987 showed that over a third of all cases in which one partner killed another were men killed by female partners. The 1985 survey showed little change from the rates of womanto-man violence reported in 1975Ðsevere violence rates were 4.6% and 4.4%, respectively. The 1992 survey, however, found a significant increase in severe woman-to-man violence (5.9%), as reported by the wives themselves (Straus & Kaufman-Kantor, 1994). The national rates are much lower than those found in selected community samples (e.g., McLaughlin, Leonard, & Senchak, 1992; O'Leary et al., 1989). There is, however, substantial variability in the prevalence rates from community surveys (Fagan & Browne, 1994; Straus & Gelles, 1990). A review of family violence research concluded that ªthe larger samplesÐover 1000 women or couplesÐhave rates around 10 in 100 reporting some form of family violence as measured by the Straus and

Research on Perpetrators of Domestic Violence Gelles scaleº (Reiss & Roth, 1993, p. 227). Community samples have also found that rates of woman-to-man assaults are about the same as the rates of physical violence against women by men (Straus, 1993; Straus & Gelles, 1990). 9.27.2.1.2 Homosexual relationships In the 1990s, a growing number of studies of physical violence in lesbian and gay relationships (e.g., Kahuna, 1990; Margolies & Leeder, 1995) have challenged traditional feminist and sociocultural perspectives on intimate violence (Coleman, 1994; Letellier, 1994). These studies suggest that the prevalence of physical violence in homosexual relationships may be as high as or higher than in heterosexual couples. Lie and Gentlewarrior's (1991) survey of 1099 self-identified lesbian women showed that 52% had been victims of violence and 57% had been perpetrators of violence. In another study, Lie, Schilit, Bush, Montague, and Reyes (1991) evaluated the history of violence in the lives of 174 self-identified lesbian women. Forty-seven percent of the women had been victims of physical aggression and 38% had been perpetrators of violence in previous same-sex relationships. By comparison, relationships with current partners were considerably less aggressive; 10% of the women reported being victims and 9% reported being perpetrators of violence in their current relationships. Lockhart, White, Causby, and Isaac (1994) surveyed a self-selected sample of 284 women attending a women's music festival. The Conflict Tactics Scale (CTS) was used to measure acts of intimate violence directed towards the respondents during the past year. Almost a third of the women (31%) in same-sex relationships reported experiencing one or more incidents of physical abuse in the past year. Among the victimized women, 38% reported that they had experienced severe forms of violence. Concerning male homosexual relationships, Kelly and Washafsky (1987) found that 62% of the men reported some form of physical aggression in their relationships. Bologna, Waterman, and Dawson (1987) reported that 18% and 14% of gay men reported being victims or perpetrators of violence in their current or most recent relationship, respectively. 9.27.2.1.3 Continuity and cessation of wife assault Variability in patterns of violence over time is another important aspect of the incidence of violence in intimate relationships. Although there is some information about female perpetrators of violence and violent partners in homosexual relationships, most information

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about perpetrators of violence deals with men who abused their female partners. Therefore, unless otherwise specified, the discussions that follow will focus on male batterers. Many men assault their partner once in a period of several years, some men use physical aggression occasionally over time, and a smaller group of men persist in their use of violence over time (Aldarondo, 1996). Aldarondo (1996) evaluated patterns of cessation and persistence of wife assault over a three-year period, using data from the 1985 National Family Violence Survey as baseline. This analysis showed that over half of the men who assaulted their partners ceased or interrupted the use of physical violence for at least a year. After a year of cessation, these men were more likely to remain nonviolent than to resume the use of physical violence against their female partners. More than a third of the men recorded as violent in the first year of the study ceased the violence for the next two years. Data show that more than half of the violent men in the general population are involved in either persistent or intermittent patterns of wife assault (Aldarondo, 1996). This supports the common belief that once violence becomes scripted in many relationships, it is difficult to change (Bowker, 1983). Women who have ended abuse by a spouse and remained in the relationship have been found to have endured abuse for an average of 10 years (Horton & Johnson, 1993). Thus, although the relatively high rate of wife assault cessation brings hope for change in the lives of couples in which men are violent, the available evidence suggests that a considerable number of men who use physical violence against their female partners are likely to continue using violence in the future (Follingstad, Laughlin, Polek, Rutledge, & Hause, 1991; Woffordt, Mihalic & Menard, 1994). In regard to this issue, then, violent men in the general population resemble the clinical population of men who batter their female partners. 9.27.2.1.4 Intimate violence in clinical populations Although clinicians have been concerned about reports of physical aggression in mental health clinics for some time, the prevalence of intimate violence in the clinics and mental health centers has received scant attention. Gondolf, Mulvey, and Lidz (1989) assessed the prevalence of family violence in a psychiatric emergency room. Among 389 patients interviewed over a six-month period, 19% reported having perpetrated some act of physical aggression against their intimate partners. No

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information was offered about the gender of the perpetrators and the victims of violence. Tham, Ford and Wilkinson (1995) reported that 24% of people presenting acutely for psychiatric services at a clinic had been the victims of physical violence. Thirty-five percent of the women and 13% of the men reported suffering domestic violence at some point in their life. Among those with a history of domestic violence, 24% of the women and 16% of the men had suffered the violence within the last six months. In another study, Cascardi, Langhinrichsen, and Vivian (1992) found that 71% of couples seeking treatment at a marital therapy clinic reported acts of intimate violence in the year prior to coming to therapy. When reports by both men and woman were combined, 27% and 34% of the men were found to engage in minor and severe forms of violence, respectively. According to reports given by women, 54% of the men used physical aggression against them in the past year, and 62% of these violent men used severe forms of violence. Men's reports yielded comparable rates of overall wife assault (55%) but considerably less severe violence (40%) than their female partners reported. Considering woman-to-man violence, combined couple data indicated that 12% used minor violence, while 50% used severe forms of violence. Forty-five percent of the women described themselves as physically aggressive. Of these women, 79% reported having perpetrated severe acts of violence against their male partners in the past year. According to the men, 57% of the women had been physically aggressive in past year and, in 80% of these cases, women relied on severe violence. O'Leary, Vivian, and Malone (1992) evaluated the prevalence rates of wife assault in a sample of couples in treatment at the same marital therapy clinic mentioned above. Only 1.5% of the men and 6.0% of the women mentioned physical assaults in their written descriptions. Acts of physical aggression were mentioned by 46% of the men and 44% of the women during the interview. In contrast, 53% of the men, 53% of the women, and 67% of the couples reported wife assaults when assessed with the CTS. Severe forms of assault were reported by 17% of the men, 21% of the women, and 25% of the couples. 9.27.3 CHARACTERISTICS OF PERPETRATORS OF DOMESTIC VIOLENCE 9.27.3.1 Risk Markers for Wife Assault One way in which family violence researchers approach the study of perpetrators of domestic

violence is through the identification of risk markers. Risk markers are not conceived as causes of violence but their presence makes violence more likely under certain conditions. ªRisk factors are individual or group characteristics as well as social circumstances that are associated with the occurrence of family violence. Rarely does one factor alone determine overall risk; rather a few factors typically appear in combinationº (American Psychological Association, 1996, p. 18). Research on men who batter often relies on reports by female victims recruited from shelters for battered women, community samples, and mental health clinics. Typically, the women's input is obtained through self-report questionnaires and interviews designed to describe the men's use of violence, articulate the victims' experience, and generate a profile of the perpetrators. Research on men who batter is also done with men in court-mandated treatment programs for men who batter, couples in treatment, and with volunteer couples from the community. With such diversity in samples, it should not come as a surprise that an array of individual, social, and demographic variables have been submitted as potential risk factors for wife assault. Hotaling and Sugarman (1986) evaluated the consistency of 97 risk markers for wife assault across 52 studies of intimate violence. They found that witnessing parental violence during childhood or adolescence, sexual aggression towards the wife, use of violence towards children, high alcohol consumption, low income level, occupational status, low educational level, and lack of assertiveness were all consistent risk markers for men's use of physical aggression against their female partners. On the basis of this evaluation, Hotaling and Sugarman stated that, ªBatterers are exposed early in life to family violence, are less assertive, and possess fewer educational and occupational resources than nonviolent men. This review also finds that batterers are much more likely to engage in other forms of antisocial behavior than men who are not violent towards their wivesº (p. 114). Subsequently, Sugarman and Hotaling (1989) examined which risk markers best differentiated among nonviolent men, verbally aggressive men, men who engaged in minor forms of violence, and severely physically violent men in a national probability sample of 2143 families. They found that the higher the level of conflict in the relationship, the greater the probability that men would assault their female partners. Severely violent men were found to have lower socioeconomic status (SES) and greater frequency of witnessing violence in their family of

The Assessment of Male Batterers origin than all other groups of men. Aldarondo and Sugarman (1996) found that these conditions also increase the risk that men would continue to act violently against their female partners over time. 9.27.3.2 Types of Men Who Batter In addition to identifying risk markers for wife assault, family violence researchers are very interested in developing reliable and valid classification systems that would help differentiate between the various subtypes of men who batter. Such classifications are of potential theoretical and practical importance. Typologies of men who batter could help identify different processes leading to violenceÐwhat is important for the development of one type of batterer may be irrelevant for the development of other types. Such typologies could also support the development of specific treatment practices for different male batterers. As illustrated by research on the effects of arrest in cases of wife assault, interventions that are effective with some men have no effect on others, and, unfortunately, in some cases are followed by increased levels of violence against women (Buzawa & Buzawa, 1996; Sherman, 1992). In a review of the literature on typologies of male batterers, Holtzworth-Munroe and Stuart (1994) identified three dimensions that have been found consistently to differentiate among subtypes of batterers: severity of violence, generality of violence, and psychological functioning. On the basis of these dimensions they suggested that there are three main types of male batterers: family-only, dysphoric/borderline, and generally violent/antisocial. According to Holtzworth-Munroe and Stuart (1994), as many as 50% of men who batter their female partners may be classified as family-only batterers. These men engage in the least severe violence and are the least likely to engage in psychological and sexual abuse. Men in this group generally direct the violence to family members and are the least likely to perpetrate acts of violence outside the home and to have legal problems for this reason. The family-only batterer shows little evidence of psychopathology or personality disorder. Dysphoric/borderline batterers are estimated to constitute approximately 25% of batterer samples. These men engage in moderate to severe wife abuse, including psychological and sexual abuse. Like family-only batterers, dysphoric/borderline batterers direct their violence primarily to family members. However, unlike the family-only batterers, they may engage in violence outside the family and may engage in

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other criminal behavior. In terms of psychological functioning, these men are considered to be the most dysphoric, distressed, and emotionally volatile among male batterers. Their personality organization may include borderline and schizoid features. Alcohol and drug abuse may be common in this group of men. The dysphoric/borderline batterer is similar to what Dutton (1994) calls the abusive personality characterized by a cycle of fear and rage directed towards the women to whom they are emotionally connected. The remaining 25% of batterers are classified as generally violent/antisocial although the number of generally violent/antisocial batterers may be considerably higher in treatment programs with court-mandated batterers (Hart, Dutton, & Newlove, 1993). These men engage in moderate to severe violence, including psychological and sexual abuse. Frequently they engage in violence outside their intimate relationship and have extensive criminal records. In addition, they are likely to have substance abuse problems, antisocial personality disorder, or psychopathology. Research by Gottman et al. (1995) suggest that there may be a physiologically-based typology of male batterers that is consistent with the general distinction made above between male batterers who are abusive primarily at home and batterers who are also violent outside the marriage. They found that some male batterers (Type 1) lower their heart rate during arguments with their female partners, whereas other men (Type 2) increase their heart rate under similar conditions of conflict with their intimate partners. Although Type 1 men are not more violent against their female partners than Type 2 men, they are generally violent outside the family. They are also more likely to be assessed as antisocial, drugdependent, and aggressive±sadistic.

9.27.4 THE ASSESSMENT OF MALE BATTERERS Although there are no common guidelines for an integrated assessment of male batterers, family violence researchers and clinicians agree that women are more reliable sources of information about the violence they have experienced than the batterers. However, one of the major difficulties in the assessment of wife assault in clinical settings is that both perpetrators and victims of violence often fail to report the occurrence of violence (O'Leary et al., 1992). In order for clinicians to adequately evaluate perpetrators of wife assault, they need to be

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aware of several ªroadblocksº with the potential to divert and change the direction of the interview away from the issue of violence. A partial list of such roadblocks includes the following. (i) Some people believe that violence is tolerable provided it does not ªgo too far.º They may not be aware of the negative impact violence has in the quality of their life and in their personal health and tend to regard occasional instances of slapping or shoving as only a minor problem that is not important enough to bring up for discussion (O'Leary & Murphy, 1992). (ii) Millions of people grow up witnessing violence between their parents (Jaffe & Wolfe, 1990; Straus, 1992). This experience validates the use of physical violence as a means of resolving conflicts in the family when other alternatives do not achieve the desired end. (iii) Some people consider violent acts as merely symptomatic of more fundamental problems and therefore do not mention the violence. (iv) Often victims and perpetrators of intimate violence do not have the ability to report accurately about highly emotional and traumatic events (Walker, 1995). (v) Many people find it hard to disclose private aspects of their lives. Often, batterers are ashamed, embarrassed, and guilt-ridden regarding their violent behavior. They may choose to conceal or minimize the physical assaults to protect themselves or their loved ones from public condemnation and humiliation. (vi) Batterers are known to deny and minimize the violence to escape criminal responsibility (Sonkin, 1987). (vii) Denial and minimization of the violence by women are normal responses to abuse (Ferraro & Johnson, 1983). Female victims of violence may not trust therapists with knowledge of their victimization for fear their partner may learn about the disclosure and attack them, hurt the children, or take the children away. Women may also be reluctant to disclose acts of violence to avoid both potential retribution against their partners and the threat of separation.

9.27.4.1 Interview Assessment It is very important for clinicians to facilitate the development of a safe, structured, and supportive relationship that would reduce the need for self-protection and dissimulation on the part of perpetrators and victims of violence. There is no substitute for direct training and

supervision to develop these skills. Experts in the field suggest that interview assessment of male batterers should be informed by the following considerations. Many men who enter treatment are not familiar with the therapy process. They tend to enter treatment to appease their spouses or because they are being told to do so by the courts. Prior to the first meeting it is important to contact the referring person to learn about why the man is being referred for treatment and if there are any strings attached to his participation in therapy (e.g., separation from partner, incarceration). At the start of the assessment interview, it is important to explain the assessment process to the batterer and to discuss the limits of confidentiality. The latter issue is particularly important because, depending on the circumstances of the case and the philosophy of the treatment program, the need may arise for counselors to exchange information with probation departments, other therapists involved with the family, the female partners, shelters for battered women, and child protection agencies. It is also important for therapists to be mindful of the language they use to describe violent behavior. For many individuals there is a great difference between having pushed their intimate partner and having been violent. The latter is potentially an affront to their selfconcept and sense of self-worth and, for that reason, may not be perceived as applying to someone who ªonly shoved her.º Thus, although some therapists may regard using the term violence as more professional than pushing or shoving, only those clients who recognize their behavior as violent and who can tolerate defining themselves as such will respond, at least initially. Violence may not be revealed unless both partners are asked specifically (Szinovacz, 1983). Men in treatment for wife assault report less violence and less severe acts of wife assault than their partners report for them (Browning & Dutton, 1986). Moreover, questioning both partners reveals incidents that do not come to light when only one partner is questioned (Bohannon & Dosser, 1995). However, it is important to note that interviewing the partners together generates fewer reports of wife assault than separately obtained reports, especially from women (Cantos, Neidig, & O'Leary, 1994). Finally, many counselors working with men who batter agree that structured instruments should be used in conjunction with interview assessments (Saunders, 1995). The combined use of structured instruments and interview assessment yields additional acts of aggression

The Assessment of Male Batterers and intimidation and a better understanding of the context for the physical aggression and its consequences than either technique alone (O'Leary et al., 1992).

9.27.4.2 Self-report Measures of Intimate Violence Even therapists trained to do interview assessment of intimate violence obtain considerably less information about wife assault than can be obtained with the use of brief selfreport measures (O'Leary & Murphy, 1992; Rhodes, 1992). That is why most treatment programs for men who batter their female partners use some self-report measure of violence to assess the history and severity of the violence (Saunders, 1995). Several instruments have been developed to measure physical aggression and psychological abuse in intimate relationships. Most measures are designed to be used with female victims but some are used with both partners and still others with male batterers only. The following list is organized in alphabetical order. (i) The Abusive Behavior Inventory (ABI). Developed by Sheppard and Campbell (1992), this is a 30-item self-report measure of the frequency of abusive behaviors during a sixmonth period. The ABI includes 20 psychological abuse items concerning emotional abuse, intimidation, threats, use of male privilege, and economic abuse. It also includes 10 psychological abuse items, including forcing the woman to have sex. Initial evaluations of this measure show adequate reliability and validity (Sheppard & Campbell, 1992). (ii) The Aggression Scale (AGG). This is a self-report measure of physical and psychological aggression in intimate relationships (Snyder & Snow, 1995). It has 19 true±false items, including nine physical violence items and 10 psychological aggression items. In an initial evaluation, the AGG had a test±retest reliability of 0.81 and an alpha coefficient of internal consistency of 0.84 for the full scale. The physical violence and the psychological aggression subscales had reliability and internal consistency coefficients of 0.69 and 0.88 and of 0.82 and 0.94, respectively. Moreover, the scale was found to correlate moderately with the CTS verbal aggression and physical violence subscales and to discriminate between partners involved in intimate violence and violence-free couples (Snyder & Snow, 1995). (iii) The Conflict Tactics Scales (CTS). This is the most widely used measure of physical violence in intimate relationships. It is composed of 19 items that assess tactics used in

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interpersonal conflicts. The items are presented on a continuum from nonviolent to severely violent tactics. The scale has two stable factors, physical aggression and verbal aggression (Barling, O'Leary, Jouriles, Vivian, & MacEwen, 1987), and high internal reliability (Straus, 1979; 1990; 1996). In addition to the availability of normative tables, the CTS has several features that make it suitable for the practical needs of clinical psychologists and other mental health professionals. First, the CTS takes only a few minutes to administer, either within an interview or as a self-administered questionnaire. Thus, it can be added to standard intake procedures with relative ease. Second, the CTS targets specific behavior and thus minimizes the demand for respondents to recognize their behavior as violent in order to respond. Third, the CTS is a brief means of identifying the occurrence of violence as well as evaluating the severity and chronicity of that violence. Thus, the therapist is able to know whether acts of physical violence occurred prior to treatment and how many times those violent behaviors occurred over the course of the specified target date. The CTS also has some important limitations. The physical violence scale measures only the frequency and severity of physical attacks and does not indicate the extent of injury, if any, resulting from those attacks and it is unable to accurately measure sexual abuse within the relationship. (iv) The Danger Assessment Instrument (DA). This is a statistical risk factor assessment of homicide in couple relationships (Campbell, 1995). The scale has 20 items. First, women are asked to indicate on a calendar the approximate dates and the duration of five specific violent acts experienced by them. Then, they have to say (yes) or (no) to 15 questions covering issues such as increases in frequency of physical violence during the past year, availability of guns in the house, and threats of suicide. Initial evaluations of the DA using women victims of violence show an alpha reliability of 0.71 and test±retest reliability ranging from 0.89 to 0.94. Moreover, the scale reportedly has moderately strong correlations with the CTS and the Index of Spouse Abuse. Campbell (1995) has suggested that until appropriate tests of the DA's predictive validity support its utility, the measure could be used for informal prediction discussions with battered women and concerned professionals but should not be used for formal prediction of homicide in counseling and court sentencing situations. (v) The Index of Spouse Abuse (ISA). This was developed by Hudson and McIntosh (1981) to measure both physical and nonphysical abuse. The ISA consists of 30 items, three of

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which ask women about acts of physical violence, and one refers to sexual coercion that is not necessarily physical. The remaining items in the physical abuse subscale appear to measure physical intimidation and domination. Although the ISA provides useful information about the psychological maltreatment of women, the scale offers limited information about specific acts of physical violence. It also mixes physical violence with other forms of maltreatment. Thus, a subject could have a high score on the violence subscale without ever having been physically assaulted. In addition, the ISA contains no items on minor forms of physical violence and therefore is not sensitive to the most frequently occurring type of physical violence against women. (vi) The Measure of Wife Abuse (MWA). This is a 60-item questionnaire designed to measure different dimensions of wife abuse (Rodenburg & Fantuzzo, 1993). The MWA asks women to declare if during the past six months of their intimate relationship their male partners engaged in specific acts of violence and then asks them to indicate how much this experience hurt or upset them. Initial analysis of the MWA yields factors for physical abuse, sexual abuse, psychological abuse, and verbal abuse. Evaluations of the subscalesº internal consistency indicates reasonable reliability, with an average subscale alpha of 0.83 and a total alpha of 0.93. Moderate correlations with the CTS verbal and physical violence scales support the concurrent validity of the measure (Rodenburg & Fantuzzo, 1993). (vii) The Propensity for Abuse Scale (PAS). This is a self-report scale created to assess the propensity for men to abuse their female partners (Dutton, 1995a). It was constructed to circumvent the tendency by abusive or potentially abusive men to respond in socially desirable ways. The scale does not contain explicit reference to intimate violence. Instead, it includes 29 items on personality traits, anger, trauma symptoms, and recollections of parental treatment. Factor analysis of the PAS yield three factors: negative parental treatment, affective liability, and trauma symptoms. The PAS has good reliability (alpha=0.88). Moreover, the scale correlates significantly (0.30) with women's reports of physical assaults using the CTS and with women's reports of domination/isolation tactics (0.51) and emotional abuse (0.47) using the Psychological Maltreatment of Women Inventory. Dutton (1995a) cautions that ªprior to clinical use of the scale as a potential predictive instrument, more crossvalidation work is required, with clinical groups who do not present with an abuse problemº (p. 215).

(viii) The Psychological Maltreatment of Women Inventory (PMWI). This is a 58-item scale including both physical and psychological aggression against women (Tolman, 1989). The scale, which can be completed by both male batterers and female victims, asks respondents to report on the relative frequency of each behavior. It has two stable factors, dominance± isolation and verbal±emotional, with internal consistency reliability ranging from 0.91 to 0.95. Although the measure successfully discriminates between battered and nonbattered women, it remains to be determined if it discriminates between abusive and nonabusive men. Accordingly, Tolman (1989) has suggested that the PMWI ªcan be reliably used as a measure of psychological maltreatment women are experiencing in their relationshipsº (p. 175) but should be considered a reliable tool to use in the evaluation of programs for men who batter. (ix) The Relationship Conflict Inventory (RCI). This was developed by Bodin (1992) and consists of 114 items measuring levels of verbal and physical conflict among couples in treatment. Four items are used to measure physical violence. The psychometric properties of the RCI remain unknown. (x) The Revised Conflict Tactic Scales (CTS2). This is an enlarged version of the CTS which addresses some of the major criticisms of the original scale (Straus, Hamby, Boney-McCoy, & Sugarman, 1996). The CTS2 has 39 items. It includes a negotiation scale with six items, a psychological aggression scale including four items from the old verbal aggression scale and four new items, a 12-item physical assault scale with three new items, a sexual coercion scale with seven items, and a sixitem injury scale. An initial evaluation of the psychometric properties of the CTS2 indicates that the scales have good internal consistency reliability (range 0.79±0.95). There is also preliminary evidence of construct and discriminant validity. However, since these psychometric findings are based on administration to a sample of college students, additional analyses based on samples of the general population and relevant clinical populations are needed to determine the utility of the CTS2 for studying these populations (Straus et al., 1996). (xi) The Severity of Violence Against Women Scales (SVAWS). This is a 49-item instrument created to assess the severity of violence perpetrated by men on women (Marshall, 1992). Factor analysis of ratings made by college students and women in the community yielded nine factors (symbolic violence, mild threats, moderate threats, serious threats, minor violence, mild violence, moderate violence, sexual violence, and serious violence). There is

Clinical Interventions with Perpetrators of Domestic Violence no information on the validity and reliability of the SVAWS. (xii) The Spouse Specific Aggression Scale (SSA). This is a 29-item scale designed to measure psychological aspects of abuse in intimate relationships (O'Leary & Curley, 1986). The SSA has subscales for aggression and assertiveness. Respondents are asked to rate themselves on 12 items concerning passive aggressive and verbally aggressive behaviors. The SSA has been found to be associated with spouse abuse (Rosenbaum & O'Leary, 1981). In addition, the scale correlates highly with the verbal aggression subscale of the CTS. In terms of psychometric properties, the SSA has reliability coefficients for clinical samples of men and women of 0.74 and 0.85, respectively. (xiii) The Wife Abuse Inventory (WAI). A scale developed by Lewis (1985), it was designed to identify abused women or women at risk of being abused by their spouses. The scale asks women to rate their partners and themselves on a number of family management matters. As Saunders (1992b) pointed out, only two of these items measure physical violence and the rest focus not on abusive behaviors but on the causes and consequences of abuse. Thus, the WAI appears to measure the risk of abuse rather than detecting whether violence has occurred or is occurring (Sedlak, 1988). 9.27.4.3 Assessment of Dangerousness Data on the partners of battered women in shelters (Giles-Sims, 1983), on abusers who have been murdered by their victim (Browne, 1987), on court-mandated abusers (Saunders, 1992a), and on men who killed their spouses (Goetting, 1989, 1991) suggest that self-report measures of violence are not sufficient to identify the life-threatening and often lethal levels of violence that characterize these men. Previous evaluations of dangerousness in intimate relationships (Aldarondo & Straus; 1994; Campbell, 1995; Saunders, 1995; Sonkin, 1987) suggest paying attention to the following risk markers for life-threatening violence by men against women: (i) high frequency of violence; (ii) alcohol or drug abuse; (iii) history of dependency and/or jealousy; (iv) history of causing physical injuries on partner; (v) arrest history or violent behavior outside as well as inside the home; (vi) history of rape or of forcing partner to have sexual intercourse against her will; (vii) history of marital violence in the family of origin; (viii) possession or use of weapons; (ix) threats to hit and/or kill partner; (x) history of psychological maltreatment and coercive behaviors; and (xi) sociopathic and narcissistic features.

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It is important for therapists working with intimate violence to be familiar with the factors that increase the likelihood of such acts. However, it is also important to know that the prediction of homicides and potentially lethal violence always results in a high number of false-positive cases. Therapists should be mindful that ªthe prediction of dangerousness is not without its own dangersº (Saunders, 1995, p. 87). The high false-positive rate is inevitable because these are relatively rare events (Sedlak, 1988; Straus et al., 1980). Therefore, the presence of one or more of these risk markers does not necessarily mean impending lethal violence. It means that the situation must be monitored and that the possibility of lethal violence should be addressed specifically with the batterer, his female victim, and other concerned parties. Moreover, therapists should be prepared to deal with that possibility, including facilitating the connection with family and community resources, such as shelter services, she could use if necessary. In fact, clinical wisdom suggests that it is never too early to help a woman take responsibility to secure safety for herself and her children (Hamberger & Holtzworth-Munroe, 1994). As Rosenbaum and Maiuro (1990) state clearly. ªThere is, as yet, no scientific formula for determining when a client has crossed the threshold into the realm of dangerousness. It remains a matter of clinical judgment guided by experience and knowledge of the research literature on interpersonal violenceº (p. 292).

9.27.5 CLINICAL INTERVENTIONS WITH PERPETRATORS OF DOMESTIC VIOLENCE 9.27.5.1 Treatment Programs for Male Batterers Since the 1970s there has been a proliferation of treatment programs for men who abuse their female partners (Eddy & Meyers, 1984; Jennings, 1987). These programs vary in the duration of treatment, the number of sessions required of participants, the specialty and level of training of the counselors, the agency or agencies sponsoring the treatment program, the referral source, and the source of funding (Edleson & Tolman, 1992; Pirog-Good & Stets-Kealy, 1985). Many programs intervene only with perpetrators of violence, and some programs work with both men and their female victims (Jennings & Jennings, 1991). Accordingly, the two dominant treatment modalities are group therapy and couple therapy (Feldman & Ridley, 1995; Margolin & Burman, 1993).

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9.27.5.1.1 Group therapy approaches Most treatment programs for men who batter their female partners use some version of group therapy. The group format offers several practical and therapeutic advantages over other treatment formats. It is a cost-effective operation that allows a relatively small number of specialized professionals to serve a large number of clients needing intervention (Carden, 1994; Ganley, 1987). It is an affordable form of treatment, especially for poor or financially strapped clients (Rosenbaum & Maiuro, 1990). Moreover, group therapy is a viable sentencing option for judges, especially for first-offense cases of wife assault. In terms of therapeutic advantages, groups are presumed to: (i) reduce batterers' social isolation; (ii) provide a safe environment where they can deal with potentially volatile issues and challenge fellow group members who directly or indirectly engage in abusive behavior; and (iii) expose men to alternative coping models. Furthermore, group members offer the social support necessary for the batterer to stop minimizing his problems, address the shame he may feel about the abusive behavior, become accountable for his actions, and consider nonabusive ways of acting (Edleson & Tolman, 1992; Rosenbaum & Maiuro, 1990). In general, group treatment programs follow a cognitive-behavioral model informed by social learning theory. Many also have an underlying profeminist orientation to the issue. From a social learning perspective, wife assault is viewed as a pattern of behavior familiar to men in part because they have witnessed such behaviors in their families of origin (Hamberger & Lohr, 1989; O'Leary, 1988). Moreover, the men's use of violence against their female partners is presumed to have a functional significance for the men and becomes a regular part of their interpersonal relationships. In accordance with feminists' ideas about the social construction of gender and power in intimate relationships, many treatment programs for men who batter also understand violence against women as ªone of several forms of controlling behaviors men use against women. Such control is socialized early in a young boy's childhood and is maintained into adulthood through a continued societal message that legitimizes male violence against womenº (Eisikovits & Edleson, 1989, pp. 392±393). This conceptualization of men's violence against women as learned, functional, and maintained by interpersonal and social dynamics has favored the development of highly structured treatments focused on the cessation of violent behaviors over unstructured growth-

oriented approaches (see, e.g., Jennings, 1987; Wallace & Nosko, 1993). Most group treatment programs for wife assault try to: (i) educate men about the causes, dynamics, and consequences of violence; (ii) teach them how to recognize and deal with anger without resorting to violence; (iii) reduce their general level of arousal through relaxation and self-control techniques; (iv) teach them to use time-out techniques to avoid emotionally arousing situations and promote rational problem solving; (v) correct the distorted views and attitudes about intimate relationships that the men have used to justify the abusive behaviors; and (vi) teach them appropriate conflict resolution skills (Edleson & Tolman, 1992; Geffner & Rosenbaum, 1990; Rosenbaum & Maiuro, 1990; Saunders, 1989). Many treatment programs also focus on consciousness-raising and changing sexist attitudes (e.g., Gondolf & Russell, 1986; Pence & Paymar, 1993). These programs put a special premium on the integration of community resources to prevent and eradicate the maltreatment of women by men. They emphasize the men's accountability for the violent behaviors, explore sex roles, and advocate for an egalitarian ethic of intimate relationships (Pence & Paymar, 1993). Despite these multiple goals, the success of treatment programs for men who batter is judged typically by the reduction in the number of men who engage in violence against their female partners following treatment. However, accurate estimates of wife assault recidivism and cessation following treatment are difficult to obtain. Moral reproach for violent behavior and possible negative social and legal consequences of treatment failure can heighten people's tendency to underreport violence. Rosenfeld (1992) lists the following additional methodological difficulties in obtaining unbiased estimates of wife assault cessation: (i) most outcome studies report data only for men who completed treatment and were available at follow-up time; (ii) there is a low response rate to all follow-up data-gathering techniques; (iii) people who complete post-treatment assessments compare favorably with those who do not in important risk markers for wife assault such as economic resources, alcohol problems, violence in their family of origin, and severity of violence against women; and (iv) many treatment programs include different types of male batterers in the same treatment group while excluding difficult or inappropriate men from treatment. Considering these issues, it seems reasonable to assume that the available data may overestimate the rate of wife assault cessation and underestimate the rate of violence recidivism following treatment.

Clinical Interventions with Perpetrators of Domestic Violence Feazell, Mayers, and Deschner's (1984) survey of 90 treatment programs for male batterers revealed that between 66% and 75% of batterers ceased their violence for at least a year following treatment. Another survey of 16 group programs for men who batter (PirogGood & Stets-Kealy, 1985) found a four-month average cessation rate of 84%. However, as Edleson (1990) pointed out, neither of these studies indicates how the follow-up data were collected, who provided the information, and how the programs computed the cessation rates. Edleson and Tolman (1992) reviewed the results of 19 outcome studies on group treatment for male batterers, including 16 cognitive-behavioral programs. Most followup assessments relied on the CTS to measure violence. A small number of programs used police records and interviews. The follow-up time ranged from three months to three years, with two-thirds of programs completing the assessment at least six months following treatment. Wife assault cessation rates for men who completed treatment ranged from 59% to 87%. Lower violence cessation rates ªtended to occur in programs with lengthier follow-up and when success was based on women's reports rather than arrest or selfreportsº (Tolman & Bennett, 1990, p. 104). Moreover, approximately two-thirds of men continued their use of threats and emotionally abusive behavior following treatment. Other evaluations of treatment effectiveness have compared follow-up reports of violence among treatment dropouts and untreated men. As the name suggests, dropouts are men who abandoned treatment. Untreated men were referred for counseling but never started treatment because of practical issues or lack of motivation. At least two studies have found that men who complete treatment and men who do not have comparable rates of wife assault cessation at post-treatment (Edleson & Grunszki, 1988; Hamberger & Hastings, 1988). Rosenfeld's (1992) review of this literature reported overall wife assault cessation rates (based either on police or victim's reports) of 61% and 86% among treatment dropouts and untreated men, respectively. According to Rosenfeld (1992), the comparable rates of wife assault cessation among dropouts, untreated men, and treated men ªcast doubt on the specific effect of any spouse abuse treatment programº (p. 218). However, other researchers maintain that expectations for radical change in the behaviors of violent men may be unrealistic (Aldarondo, 1996; Jennings, 1990). As Dutton (1995b) has stated, ªIt seems overly optimistic to expect a 16-week treatment

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group to stop all abuse immediately after treatmentº (p. 220). 9.27.5.1.2 Couple therapy There is a growing literature in couple therapy on wife assault (e.g., Balcom, 1991; Gutsche & Murray, 1991; Hansen & Harway, 1993; Jenkins, 1990). Although many couple therapists differ in their theoretical and political orientation towards wife assault, most of them view violent behaviors not so much in terms of social and psychological determinants, as in terms of the interpersonal dynamics that promote and sustain the abuse of women by men. Mantooth, Geffner, Franks, and Patrick (1987) have argued that couple therapy offers a safe and structured environment in which partners can express their feelings, discuss emotionally charged issues, and learn about violence and how to deal with it together. In addition, Margolin and Burman (1993) have suggested that couple therapy: (i) gives partners the opportunity to identify and attempt to alter interactional patterns that promote and sustain the violence; (ii) helps men learn to monitor their emotions and to communicate to their female partners their desire for physical and emotional distance; and (iii) empowers women by teaching them to identify the cues that signal the man's escalation of anger and aggression. Unlike group therapy, which has been embraced uncritically by those committed to working with batterers, couple therapy for wife assault has been the focus of debate. Critics argue that interactional theories and interventions characteristic of couple therapy are illequipped to deal with issues of coercion and violence (Bograd, 1992), that abusive behaviors disappear in systemic formulations (Avis, 1992), and that couple therapy diffuses men's responsibility for their actions by implying that the women should be working on how to stop their victimization (Adams, 1988). Above all, critics argue that couple therapy can cause emotional and physical harm for women who are called to bring their partners' violence into the open (Bograd, 1984; Kaufman, 1992). Unfortunately, as Bograd (1994) has pointed out, although this is possibly one of the most controversial topics in the field, no study has explored the safety of the women when couple therapy is recommended or sought by the batterer. The apparent incongruity between couple therapy and group treatment for male batterers masks the fact that in practice couple therapy for wife assault relies heavily on short-term, cognitive-behavioral strategies akin to those

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used in group treatment. Some of these strategies include: (i) teaching the partners to identify cues of violence early on; (ii) teaching them when and how to use time-outs; (iii) using communication training and problem-solving techniques to help partners deal with anger and conflict; (iv) role playing nonviolent interactions, new communication skills, or particular disagreements; (v) teaching men to identify and change negative self-talk and other irrational beliefs that may be related to their use of violence; and (vi) training the couple to use relaxation techniques to reduce stress and promote problem-solving (Geffner, Mantooth, Franks, & Rao, 1989; Neidig & Friedman, 1984; Rosenbaum & O'Leary, 1986). In addition to traditional couple therapy, some programs use a couples' group format (Deschner, McNeil, & Moore, 1986; Mantooth et al., 1987; Neidig, Friedman, & Collins, 1985). Geffner et al. (1989) maintain that this format has an advantage over working with individual couples because it provides the opportunity for the partners to interact with others who have similar problems and to share information about what has helped them deal with similar issues. In addition, partners in couples' group counseling often establish friendships during the counseling process that may help reduce the partner's isolation and estrangement from others. In terms of outcome studies, there is a paucity of research on the effectiveness of couple therapy for wife assault. Lindquist, Telch, and Taylor (1985) found that 50% of the couples reported at least one incident of violence within six weeks following treatment. Moreover, all couples reported acts of violence after six months. Harris (1986) reported an undefined success rate of 73% among 30 couples assessed somewhere between two months and three years after treatment. Taylor (1984) reported a sixmonth wife assault cessation rate of 65% among 50 couples. However, Taylor failed to report both the source of data and the techniques used to obtain this information. Concerning outcome data on couples' group counseling, Neidig et al. (1985) reported that of 100 couples, 87% of all participants (men and women) were nonviolent four months following treatment. They also found that everyone evaluated reported positive changes in measures of locus of control and marital interaction. Unfortunately, the authors omitted the source of follow-up data, and the report is unclear about the criteria for inclusion in the follow-up. Similarly, Deschner et al. (1986) reported that couples who completed treatment reported significant increases in marital satisfaction and significant reductions in the frequency of

argument episodes of anger. Eight months after treatment, 8 out of 15 couples (53%) reported no violence.

9.27.6 SUMMARY AND FUTURE DIRECTIONS Intimate violence is an extensive and serious problem in both heterosexual and homosexual relationships. While wife assault often increases in frequency and severity over time, it is also characterized by the cessation or interruption of violence for prolonged periods of time. Moreover, different types of men who batter can be identified on the basis of both violent behavior and psychological characteristics. The heterogeneity among perpetrators of violence has important theoretical and practical implications. In terms of theory, the above considerations point to the limitations of what some researchers have called single-factor explanations of intimate violence (Dutton, 1995b, 1995c; Gelles, 1993). As O'Leary (1993, p. 13) has stated bluntly, ªattempts to explain and change various acts of physical aggression among family members through singular accounts, be they feminist, constructionist, sociological, biological, or psychological are doomed.º Instead, there is a need to continue to develop multifactor theories of intimate violence such as Dutton's (1995c) nested ecological theory of wife assault, Edleson and Tolman's (1992) ecological framework, Holtzworth-Munroe and Stuart's (1994) developmental model of marital violence, Letellier's (1994) multidimensional theory of battering among gay and bisexual men, and O'Leary's (1988, 1993) social learning theory of physical aggression between spouses. These theories could help to understand how different forms of violence arise and evolve and what specific risk markers may be associated with each. On the other hand, there is often the assumption that multifactor or multidimensional theories are going to reconcile many of the inconsistencies in the literature and will eventually improve the efficacy of treatment approaches (see, e.g., Carden, 1994; Feldman & Ridley, 1995). Such a premise ignores the methodological and clinical limitations in the research and treatment of physical violence and other forms of abuse in intimate relationships. Appropriate control groups are difficult to find and other experimental manipulations raise serious ethical dilemmas. Furthermore, broad theories often do not have clear clinical applications. Those committed to working with intimate violence need not only comprehensive

References maps but also specific theories of practice to deal with individual clients under particular conditions.

9.27.7 REFERENCES Adams, D. (1988). Treatment models for men who batter: A profeminist analysis. In K. YlloÈ & M. Bograd (Eds.), Feminist perspectives on wife abuse (pp. 176±199). Newbury Park, CA: Sage. Aldarondo, E. (1996). Cessation and persistence of wife assault: A longitudinal analysis. American Journal of Orthopsychiatry, 66, 141±151. Aldarondo, E., & Straus, M. A. (1994). Screening for physical violence in couple therapy: Methodological, practical, and ethical considerations. Family Process, 33, 425±439. Aldarondo, E., & Sugarman, D. (1996). Risk makers analysis of cessation and persistence of wife assault. Journal of Consulting and Clinical Psychology, 64, 1010±1019. American Psychological Association (1996). Violence and the family: Report of the American Psychological Association presidential task force on violence and the family. Washington, DC: Author. Avis, J. M. (1992). Where are all the family therapists? Abuse and violence within families and family therapy's response. Journal of Marital and Family Therapy, 18. 225±232. Balcom, D. (1991). Shame and violence: Considerations in couples' treatment. Journal of Independent Social Work, 5, 165±181. Barling, J. N., O'Leary, K. D., Jouriles, E. V., Vivian, D., & MacEwen, C. (1987). Factor similarity of the Conflict Tactics Scales across samples, spouses, and sites: Issues and implications. Journal of Family Violence, 2, 37±53. Bodin, A. M. (1992). Relationship Conflict Inventory. Palo Alto, CA: Mental Research Institute. Bograd, M. (1984). Family systems approaches to wife battering: A feminist critique. American Journal of Orthopsychiatry, 54, 558±568. Bograd, M. (1992). Values in conflict: Challenges to family therapists' thinking. Journal of Marital and Family Therapy, 18, 245±256. Bograd, M. (1994). Battering, competing clinical models, and paucity of research: Notes to those in the trenches. The Counseling Psychologist, 22, 593±597. Bohannon, J. R., & Dosser, D. A. (1995). Using couple data to determine domestic violence rates: An attempt to replicate previous work. Violence and Victims, 10, 133±141. Bologna, M. J., Waterman, C. K., & Dawson, L. J. (1987, July). Violence in gay and lesbian relationships: Implications for practitioners and policy makers. Paper presented at the 3rd National Family Violence Research Conference, Durham, NH. Bowker, L. H. (1983). Beating wife-beating. Lexington, MA: Lexington Books. Browne, A. (1987). When battered women kill. New York: The Free Press. Browne, A., & Williams, K. R. (1993). Gender, intimacy, and lethal violence: Trends from 1976 through 1987. Gender and Society, 7, 78±98. Browning, J., & Dutton, D. (1986). Assessment of wife assault with the Conflict Tactics Scale: Using couple data to quantify the differential reporting effect. Journal of Marriage and the Family, 48, 375±379. Brush, L. D. (1990). Violent acts and injurious outcomes in married couples: Methodological issues in the National Survey of Families and Households Gender and Society, 4, 56±67.

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Buzawa, E. S., & Buzawa, C. G. (Eds.) (1996). Do arrests and restraining orders work? Newbury Park, CA: Sage. Campbell, J. C. (1995). Prediction of homicide of and by women. In J. C. Campbell (Ed.), Assessing dangerousness: Violence by sexual offenders, batterers, and child abusers (pp. 96±113). Newbury Park, CA: Sage. Cantos, M., Neidig, P. H., & O'Leary K. D. (1994). Injuries of women and men in a treatment program for domestic violence. Journal of Family Violence, 9, 113±124. Carden, A. D. (1994). Wife abuse and the wife abuser: Review and recommendations. The Counseling Psychologist, 22, 539±582. Cascardi, M., Langhinrichsen, J., & Vivian, D. (1992). Marital aggression: Impact, injury, and health correlates for husbands and wives. Archives of Internal Medicine, 152, 1178±1184. Coleman, V. E. (1994). Lesbian battering: The relationship between personality theory and the perpetuation of violence. Violence and Victims, 9, 139±152. Deschner, J. P., McNeil, J. S., & Moore, M. G. (1986). A treatment model for batterers. Social Casework, 67, 55±60. Dutton, D. G. (1994). The origin and structure of the abusive personality. Journal of Personality Disorders, 8, 181±191. Dutton, D. G. (1995a). A scale for measuring propensity for abusiveness. Journal of Family Violence, 10, 203±221. Dutton, D. G. (1995b). Intimate abusiveness. Clinical Psychology: Science and Practice, 2, 207±224. Dutton, D. G. (1995c). The domestic assault of women: Psychological and criminal justice perspectives. Boston: Allyn & Bacon. Eddy, M. J., & Myers, T. (1984). Helping men who batter: A profile of programs in the US. Austin, TX: Texas Department of Human Resources. Edleson, J. L. (1990). Judging the success of interventions with men who batter. In D. J. Besharov (Ed.), Family violence: Research and public policy issues (pp. 130±145). Washington, DC: AEI Press. Edleson, J. L., & Grusznski, R. J. (1989). Treating men who batter: Four years of outcome data from the Domestic Abuse Project. Journal of Social Service Research, 12, 3±22. Edleson, J. L., & Tolman, R. M. (1992). Intervention for men who batter: An ecological approach. Newbury Park, CA: Sage. Eisikovits, Z. C., & Edleson, J. L. (1989). Intervening with men who batter: A critical review of the literature. Social Service Review, 63, 384±414. Fagan, J. L., & Browne, A. (1994). Violence between spouses and intimates: Physical aggression between women and men in intimate relationships. In A. J. Reiss & J. A. Roth (Eds.), Understanding and preventing violence (Vol. 3, pp. 115±292). Washington, DC: National Academy Press. Feazell, C. S., Mayers, R. S., & Deschner, J. (1984). Services for men who batter: Implications for programs and policies. Family Relations, 33, 217±223. Feldman, C. M., & Ridley, C. (1995). The etiology and treatment of domestic violence between adult partners. Clinical Psychology: Science and Practice, 2, 317±348. Ferraro, K. J., & Johnson, J. M. (1983). How women experience battering: The process of victimization. Social Problems, 30, 325±339. Finkelhor, D., & YlloÈ, K. (1985). License to rape: Sexual abuse of wives. New York: Brunner/Mazel. Follingstad D. R., Laughlin, J. E., Polek, D. S., Rutledge, L. L., & Hause, E. S. (1991). Identification of patterns of wife assault. Journal of Interpersonal Violence, 6, 187±204. Ganley, A. L. (1987). Perpetrators of domestic violence: An overview of counseling the court-mandated client. In D.

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J. Sonkin (Ed.), Domestic violence on trial: Psychological and legal dimensions of family violence (pp. 155±173). New York: Springer. Geffner, R., Mantooth, C, Franks, D., & Rao, L. (1989). A psychoeducational, conjoint therapy approach to reducing family violence. In P. L. Caesar & L. K. Hamberger (Eds.), Treating men who batter (pp. 103±133). New York: Springer. Geffner, R., & Rosenbaum, A. (1990). Characteristics and treatment of batterers. Behavioral Sciences and the Law, 8, 131±140. Gelles, R. J. (1993). Through a sociological lens: Social structure and family violence. In R. Gelles & D. Loseke (Eds.), Current controversies on family violence (pp. 31±46). Newbury Park, CA: Sage. Giles-Sims, J. (1983). Wife battering: A systems theory approach. New York: Guilford. Goetting, A. (1989). Men who kill their mates: A profile. Journal of Family Violence, 4, 285±296. Goetting, A. (1991). Female victims of homicide: A portrait of their killers and the circumstances of their death. Violence and Victims, 6, 159±168. Gondolf, E. W., Mulvey, E. P., & Lidz, C. W. (1989). Family violence reported in a psychiatric emergency room. Journal of Family Violence, 4, 249±258. Gondolf, E. W., & Russell, D. (1986). The case against anger control treatment programs for batterers. Response to the Victimization of Women and Children, 9, 2±5. Goodman, L. A., Browne, A., Fitzgerald, L., Keita, G. P., & Russo, N. F. (1994). No safe haven: Violence against women at home, at work, and in the community. Washington, DC: APA. Gottman, J. M., Jacobson, N. S., Rushe, R. H., Shortt, J. W., Babcock, J, La Taillade, J. J., & Waltz, J. (1995). The relationship between heart rate reactivity, emotionally aggressive behavior, and general violence in batterers. Journal of Family Psychology, 9, 227±248. Gutsche, S., & Murray, M. (1991). The feminist meets the cybernetician: An integrated approach to spousal violence. Journal of Strategic and Systemic Therapies, 10, 76±91. Hamberger, L. K., & Hastings, J. E. (1988). Skill training for treatment of spouse abusers: An outcome study. Journal of Family Violence, 3, 121±130. Hamberger, L. K., & Holtzworth-Munroe, A. (1994). Partner violence. In F. M. Dattilio & A. Freedman (Eds.), Cognitive-behavioral strategies in crisis intervention (pp. 302±324). New York: Guilford. Hamberger, L. K., & Lohr, J. M. (1989). Proximal causes of spouse abuse: A theoretical analysis of cognitivebehavioral interventions. In P. L. Caesar & L. K. Hamberger (Eds.) Treating men who batter (pp. 53±76). New York: Springer. Hansen, M., & Harway, M. (Eds.) (1993). Battering and family therapy: A feminist perspective. Newbury Park, CA: Sage. Harris, J. (1986). Counseling violent couples using Walker's model. Psychotherapy, 23, 613±621. Hart, S. D., Dutton, D. G., & Newlove, T. (1993). The prevalence of personality disorder amongst wife assaulters. Journal of Personality Disorders, 7, 329±341. Holtzworth-Munroe, A., & Stuart, G. L. (1994). Typologies of male batterers: Three subtypes and the differences among them. Psychological Bulletin, 116, 476±497. Horton, A. L., & Johnson, B. (1993). Profile and strategies of women who have ended abuse. Families in Society: The Journal of Contemporary Human Services, 74, 481±492. Hotaling, G. T., & Sugarman, D. B. (1986). An analysis of risk markers in husband to wife violence: The current state of the knowledge. Violence and Victims, 1, 101±124. Hudson W. W., & McIntosh, S. R. (1981). The assessment

of spouse abuse: Two quantifiable dimensions. Journal of Marriage and the Family, 43, 873±888. Jaffe, P. G., & Wolfe, D. A. (1990). Children of battered women. Newbury Park, CA: Sage. Jenkins, A. (1990). Invitations to responsibility: The therapeutic engagement of men who are violent and abusive. Adelaide, Australia: Dulwich Centre. Jennings, J. P. (1987). History and issues in the treatment of battering men: A case for unstructured group therapy. Journal of Family Violence, 2, 193±213. Jennings, J. L. (1990). Preventing relapse versus stopping domestic violence: Do we expect too much too soon from battering men? Journal of Family Violence, 5, 43±60. Jennings, J. P., & Jennings, J. L. (1991). Multiple approaches to the treatment of violent couples. The American Journal of Family Therapy, 19, 351±362. Kahuna, V. (1990). Compounding the triple jeopardy: Battering in lesbians of color relationships. Women and Therapy, 9, 169±184. Kaufman, G., Jr. (1992). The mysterious disappearance of battered women in family therapists' office: Male privilege colluding with male violence. Journal of Marital and Family Therapy, 18, 233±243. Kaufman, G. K., Jasinski, J. L., & Aldarondo, E. (1994). Sociocultural status and incidence of marital violence in Hispanic families. Violence and Victims, 9, 207±222. Kelly, C. E., & Washafsky, L. (1987, July). Partner abuse in gay and lesbian couples. Paper presented at the 3rd National Family Violence Research Conference, Durham, NH. Kilpatrick, D. G., Edmunds, C. S., & Seymour, A. K. (1992). Rape in America: A report to the nation. Arlington, VA: National Victims Center and Medical Center of South Carolina. Letellier, P. (1994). Gay and bisexual domestic violence: Challenges to feminist theory and responses to violence. Violence and Victims, 9, 95±106. Lewis, B. Y. (1985). The Wife Abuse Inventory: A screening device for the identification of abused women. Social Work, 30, 32±35. Lie, G., & Gentlewarrior, S. (1991). Intimate violence in lesbian relationships: Discussion of survey findings and practice implications. Journal of Social Service Research, 15, 41±59. Lie, G., Schilit, R., Bush, J., Montague, M., & Reyes, L. (1991). Lesbians in currently aggressive relationships: How frequently do they report aggressive past relationships? Violence and Victims, 6, 121±135. Lindquist, C. U., Telch, C. F., & Taylor, J. (1985). Evaluation of a conjugal violence treatment program: A pilot study. Behavioral Counseling and Community Interventions, 3, 76±90. Lockhart L. L., White, B. W., Causby, V., & Isaac, A. (1994). Letting out the secret: Violence in lesbian relationships. Journal of Interpersonal Violence, 9, 469±492. Mantooth, C. M., Geffner, R., Franks, D., & Patrick, J. (1987). Family preservation: A treatment manual for reducing couple violence. Tyler, TX: University of Texas at Tyler Press. Margolies, L., & Leeder, E. (1995). Violence at the door: Treatment of lesbian batterers. Violence against Women, 1, 139±157. Margolin, G., & Burman, B. (1993). Wife abuse versus marital violence: Different terminologies, explanations, and solutions. Clinical Psychology Review, 13, 59±73. Marshall, L. L. (1992). Development of the Severity of Violence Against Women Scales. Journal of Family Violence, 7, 103±121. McLaughlin, I. G., Leonard, K. E., & Senchak, M. (1992). Prevalence and distribution of premarital aggression among couples applying for a marriage license. Journal of Family Violence, 7, 309±319.

References Morse, B. J. (1995). Beyond the conflict tactics scale: Assessing gender differences in partner violence. Violence and Victims, 10, 251±272. Neidig, P. H., & Friedman, D. H. (1984). Spouse abuse: A treatment program for couples. Champaign, IL: Research Press. Neidig, P. H., Friedman, D. H., & Collins, B. S. (1985). Domestic conflict containment: A spouse abuse treatment program. Social Casework, 66, 195±204. O'Leary, K. D. (1988). Physical aggression between spouses: A social learning theory perspective. In V. Van Hasselt, R. Morrison, A. Bellack, & M. Hersen (Eds.), The handbook of family violence (pp. 31±55) New York: Plenum. O'Leary, K. D. (1993). Controversies regarding psychological explanations of family violence. In R. J. Gelles & D. Loseke (Eds.), Current controversies on family violence (pp. 7±30). Newbury Park, CA: Sage. O'Leary, K. D., Barling, J., Arias, I., Rosenbaum, A., Malone, J., & Tyree, A. (1989). Prevalence and stability of physical aggression between spouses: A longitudinal analysis. Journal of Consulting and Clinical Psychology, 57, 263±268. O'Leary, K. D., & Curley, A. D. (1986). Assertion and family violence: Correlates of abuse. Journal of Marital and Family Therapy, 12, 281±289. O'Leary, K. D., & Murphy, C. (1992). Clinical issues in the assessment of spouse abuse. In R. T. Ammerman & M. Hersen (Eds.), Assessment of family violence: A clinical and legal source book (pp. 26±46). New York: Wiley. O'Leary, K. D., Vivian, D, & Malone, J. (1992). Assessment of physical aggression against women in marriage: The need for multimodal assessment. Behavior Assessment, 14, 5±14. Pence, E., & Paymar, M. (1993). Education groups for men who batter: The Duluth model. New York: Springer. Pirog-Good, M., & Stets-Kealy, J. (1985). Male batterers and battering prevention programs: A national survey. Response to the Victimization of Women and Children, 8, 8±12. Reiss, A. J., & Roth, J. A. (Eds.) (1993). Understanding and preventing violence Vol. 2, Washington, DC: National Academy Press. Rhodes, N. R. (1992). The assessment of spousal abuse: An alternative to the Conflict Tactics Scale. In E. C. Viano (Ed.), Intimate violence: Interdisciplinary perspectives (pp. 27±36). Philadelphia: Hemisphere. Rodenburg, F. A., & Fantuzzo, J. W. (1993). The Measure of Wife Abuse: Steps toward the development of a comprehensive assessment technique. Journal of Family Violence, 8, 203±228. Rosenbaum, A., & Maiuro, R. (1990). Perpetrators of spouse abuse. In R. T. Ammerman & M. Hersen (Eds.), Treatment of family violence: A source book (pp. 280±309). New York: Plenum. Rosenbaum, A., & O'Leary, K. D. (1981). Marital violence: Characteristics of abusive couples. Journal of Consulting and Clinical Psychology, 49, 63±71. Rosenbaum, A., & O'Leary, K. D. (1986). The treatment of marital violence. In N. S. Jacobson & A. S. Gurman (Eds.), Clinical handbook of marital therapy (pp. 385±405). New York: Guilford. Rosenfeld, B. D. (1992). Court-ordered treatment of spouse abuse. Clinical Psychology Review, 12, 205±226. Russo, N. F., Koss, M. P., & Goodman, L. (1995). Male violence against women: A global health and development issue. In L. L. Adler & F. L. Denmark (Eds.), Violence and the prevention of violence (pp. 121±128). Westport, CT: Praeger. Saunders, D. G. (1989). Cognitive and behavioral interventions with men who batter: Application and outcome. In P. L. Caesar & L. K. Hamberger (Eds.), Treating men who batter (pp. 77±99). New York: Springer.

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Saunders, D. G. (1992a). A typology of men who batter: Three types derived from cluster analysis. American Journal of Orthopsychiatry, 62, 264±275. Saunders, D. G. (1992b). Woman battering. In R. T. Ammerman & M. Hersen (Eds.), Assessment of family violence (pp. 208±235). New York: Wiley. Saunders, D. G. (1995). Prediction of wife assault. In J. C. Campbell (Ed.), Assessing dangerousness: Violence by sexual offenders, batterers, and child abusers (pp. 68±95). Newbury Park, CA: Sage. Sedlak, A. J. (1988). Prevention of wife abuse. In V. Van Hasselt, R. Morrison, A. Bellack, & M. Hersen (Eds.), The Handbook of family violence (pp. 319±358). New York: Plenum. Sheppard, M. E., & Campbell J. A. (1992). The Abusive Behavior Inventory: A measure of psychological and physical abuse. Journal of Interpersonal Violence, 7, 291±305. Sherman, L. W. (1992). Policing domestic violence: Experiments and dilemmas. New York: Free Press. Snyder, D. K., & Snow, A. (1995). Evaluating couples' aggression in marital therapy. Paper presented at the annual meeting of the American Psychological Association, New York. Sonkin, D. J. (1987). The assessment of court-mandated male batterers. In D. J. Sonkin (Ed.), Domestic violence on trial: Psychological and legal dimensions of family violence (pp. 174±196). New York: Springer. Stets, J. E., & Straus, M. A. (1990). Gender differences in reporting marital violence and its medical and psychological consequences. In M. A. Straus & R. J. Gelles (Eds.). Physical violence in American families: Risk factors and adaptations to violence in 8,145 families (pp. 151±165). New Brunswick, NJ: Transaction Publishers. Straus, M. A. (1979). Measuring intrafamily conflict and violence: The Conflict Tactics Scales. Journal of Marriage and the Family, 41, 75±88. Straus, M. A. (1990). The Conflict Tactics Scale and its critics: An evaluation and new data on validity and reliability. In M. A. Straus & R. J. Gelles (Eds.), Physical violence in American families: Risk factors and adaptations to violence in 8,145 families (pp. 49±73). New Brunswick, NJ: Transaction Publishers. Straus, M. A. (1992). Children as witness to marital violence: A risk factor for life long problems among a nationally representative sample of American men and women. In D. F. Schwarz (Ed.), Children and violence: Report of the 23rd Ross roundtable on critical approaches to common pediatric problems (pp. 98±104). Columbus, OH: Ross Laboratories. Straus, M. A. (1993). Physical assaults by wives: A major social problem. In R. J. Gelles & D. Loseke (Eds.), Current controversies on family violence (pp. 67±87). Newbury Park, CA: Sage. Straus, M. A. (1996). Manual for the Conflict Tactics Scales. Durham, NH: University of New Hampshire, Family Research Laboratory. Straus, M. A., & Gelles, R. J. (1990). Physical violence in American families: Risk factors and adaptations to violence in 8,145 families. New Brunswick, NJ: Transaction Publishers. Straus, M. A., & Gelles, R. J., & Steinmetz, S. K. (1980). Behind closed doors: Violence in the American family. Garden City, NY: Anchor Press. Straus, M. A., Hamby, S. L., Boney-McCoy, S., & Sugarman, D. B. (1996). The revised Conflict Tactics Scales (CTS2). Journal of Family Issues, 17, 283±316. Straus, M. A., & Kaufman-Kantor, G. (1994, June). Change in spouse assault rates from 1975 to 1992: A comparison of three national surveys in the United States. Paper presented at the 13th World Congress of Sociology, Bielefeld, Germany. Sugarman, D. B., & Hotaling, G. T. (1989). Violent men in

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intimate relationships: An analysis of risk markers. Journal of Applied Social Psychology, 19, 1034±1048. Szinovacz, M. E. (1983). Using couple data as a methodological tool: The case of marital violence. Journal of Marriage and the Family, 45, 663±644. Taylor, J. W. (1984). Structured conjoint therapy for spouse abuse cases. Social Casework, 65, 11±18. Tham, S. W., Ford, T. J., & Wilkinson, D. G. (1995). A survey of domestic violence and other forms of abuse. Journal of Mental Health, 4, 317±321. Tolman, R. M. (1989). The initial development of a measure of psychological maltreatment of women by their male partners. Violence and Victims, 4, 159±178.

Tolman, R. M., & Bennett L. W. (1990). A review of quantitative research on men who batter. Journal of Interpersonal Violence, 5, 87±118. Walker, L. E. (1984). The battered woman syndrome. New York: Springer. Walker, L. E. (1995). Current perspectives on men who batter women. Journal of Family Psychology, 9, 264±271. Wallace, B., & Nosko, A. (1993). Working with shame in the group treatment of male batterers. International Journal of Group Psychotherapy, 43, 45±61. Woffordt, S., Mihalic, D. E., & Menard, S. (1994). Continuities in marital violence. Journal of Family Violence, 9, 195±225.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

9.28 Children with Aggressive Sexual Behavior BARBARA L. BONNER University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA and WILLIAM E. FAHEY Virginia Commonwealth University, Richmond, VA, USA 9.28.1 INTRODUCTION

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9.28.2 NATURE

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9.28.3 PREVALENCE

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9.28.4 ASSESSMENT

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9.28.4.1 Child Evaluation 9.28.4.1.1 Diagnosis and overall psychopathology 9.28.4.1.2 Behavior and affective problems 9.28.4.1.3 Self-esteem 9.28.4.1.4 Sexual behavior problems 9.28.4.2 Parent/Caretaker Evaluation 9.28.4.2.1 Psychological status 9.28.4.2.2 Level of stress 9.28.4.3 Family Evaluation 9.28.5 TREATMENT

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9.28.5.1 Children with Sexual Behavior Problems Program 9.28.5.1.1 The cognitive-behavioral group therapy approach 9.28.5.1.2 Case study: cognitive-behavioral treatment approach 9.28.5.1.3 Dynamic play group therapy approach 9.28.5.1.4 Case study: dynamic play therapy treatment approach 9.28.5.1.5 Treatment 9.28.5.2 STEP Program

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9.28.7 SUMMARY

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9.28.1 INTRODUCTION Sexual abuse and aggressive sexual behavior continue to be serious and widespread problems. Prevalence rates for being sexually abused as a child in the USA have been reported at 27% for females and 16% for males (Finkelhor, Hotaling, & Lewis, 1990). The short- and long-term psychological effects of sexual abuse have been well documented in the literature. Historically, it has been believed that adult males were primarily responsible for sexual aggression and assault. However, more recent studies indicate that not only adult males, but also adult females, commit sexual crimes against children. Of even more concern are crime statistics showing that these crimes are committed also by juveniles. The 1990 uniform crime reports indicated that 15% of all arrests for forcible rape were of youth under 18 years of age (Federal Bureau of Investigation, 1990). In the 1990s, professional attention has begun to focus on sexual behavior problems in young children. Given that many people have difficulty accepting the premise that children are sexual beings, there is an even more extreme reaction to the idea that children can have problematic or aggressive sexual behavior. In the mental health field, professionals have devoted many years of research and clinical treatment to aggressive sexual behaviors in adolescents and adults. As a field, we have now reached the point of needing to better understand children who engage in aggressive sexual behavior. Until recently, sexual interactions involving children have been typically ignored with the explanation that the children were ªplaying doctorº or just being curious. However, we have begun to realize that while the sexual behavior of some children may be ªnormalº or developmentally expected, the sexual behavior of other children is of great concern and requires professional assessment and mental health intervention. Only since the late 1980s has the mental health field begun to provide clinical interventions and conduct research for children with aggressive sexual behavior. This chapter will review what has been reported in the literature on children with aggressive sexual behavior including definitions, typologies, characteristics of the children and their families, assessment of children with aggressive sexual behavior, and current treatment approaches. 9.28.2 NATURE There is no definition of children with aggressive sexual behavior that is widely

accepted and utilized by the various professions that are involved with these children, that is, mental health, medicine, law enforcement, and child protective services. The children have been referred to as mini-perps, children who molest (Gil & Johnson, 1993), abuse-reactive children (Cunningham & MacFarlane, 1991), sexually reactive children (Friedrich, 1990), pre-ads (preadolescent sex offenders), child perpetrators (Johnson, 1989; Okami, 1992), and very young perpetrators (Cantwell, 1988). The proliferation in terminology is most likely a reflection of the lack of resolution by the field as to whether the children should be defined by the supposed etiology of their behavior, that is, reacting to their own abuse or by more legal terms such as perpetrator. It should be noted that only in rare cases does the juvenile justice system adjudicate a child under 12 as delinquent for illegal sexual behavior. Friedrich (1990) defined sexually reactive children as those who display sexual behaviors seemingly in direct response to their own abuse experiences. Resultant behaviors may ªinclude masturbation, increased sexual exploration, exhibitionism, and a temporary breakdown in the children's interpersonal boundariesº (p. 254). By sexually reactive, Okami (1992) spoke of ªchild perpetrators of sexual abuse,º or the very young juvenile sexual perpetrator. A more comprehensive definition was suggested by Berliner and Rawlings (1991), who defined sexual behavior problems in children as those ªsexual behaviors which are disturbing to others or have negative consequences for the childº (p. 1). Given the young age of these children and the lack of clarity regarding the degree to which sexual abuse is related to later aggressive sexual behavior in children, clinicians and researchers tend to use a more behavioral and less pejorative definition, that is, children with sexual behavior problems or children with aggressive sexual behavior, to describe this population. Sexual behaviors in children range from those that are developmentally expected and considered normal, to those that are inappropriate and cause concern, to those that are aggressive and highly problematic. For example, masturbation is a common sexual behavior in children. If and when it constitutes a problem is largely determined by family, societal, and cultural norms. At the other extreme, aggressive sexual behavior in children is (i) not responsive to parental limit-setting, (ii) interferes with developmentally appropriate activities, and (iii) may be indicative of serious mental health difficulties (Gordon & Schroeder, 1995). A thorough assessment and understanding of the behavior, its antecedents, and its consequences are

Nature necessary to better discriminate healthy, developmentally expected sexual behavior from abnormal sexual behavior that demands therapeutic intervention. A major issue for the field is how to discriminate between developmentally expected or ªnormalº sexual play and aggressive sexual behavior. Lamb and Coakley (1993) asked where should the line be drawn between normal childhood sexual play and abuse. Historically, society has viewed sexual contact involving children as ªplaying doctorº and other such seemingly innocent interactions. As with many relatively new phenomena in the mental health field, there has been both an underresponse and an overresponse to the evaluation of children's sexual behavior, and it has been suggested that professionals need to avoid overreacting to childhood sex play (Okami, 1992). It is not clear to what extent sexual play among children is normal (Cantwell, 1988). However, two studies with similar findings provide an empirical basis for comparison. From their study of sexual behaviors in 800 children ages two through 12, Friedrich, Grambsch, Broughton, Kuiper, and Beilke (1991) found that a variety of sexual behaviors in children appear to be normal and that their frequency decreases with age. Overt sexual behaviors by children were found to decline with age after peaking at ages three to five. Lindblad, Gustafsson, Larsson, and Lundin (1995) studied 251 preschoolers' sexual behavior at daycare centers in Sweden. As with the Friedrich et al. (1991) study, more serious sexual behaviors were uncommon. Behaviors such as touching an adult's genitals, attempting to make the adult touch the child's genitals/anus, and masturbating compulsively without pleasure or in a way that caused pain were unusual behaviors in very young children. Several theories have been suggested to explain the etiology of aggressive sexual behavior in children (Ryan, 1997b). Learning theory is the basis of several explanatory models of sexual offending in adolescents and adults (e.g., Freeman-Longo, 1982; Groth, 1979) and has been applied to children. This theory hypothesizes that sexually aggressive behavior develops as a result of learned behavior and interpersonal reactions. This theory would support the idea that aggressive sexual behavior can come about as a direct result of being sexually abused, that is, abuse-reactive children (Cunningham & MacFarlane, 1991). Support for this theory is found in the high rates of sexual abuse in the histories of children with sexual behavior problems (Adams, McClellan, Douglass, McCurry, & Storck, 1995; Bonner, Walker, & Berliner, 1997; Gray, Busconi,

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Houchens, & Pithers, 1997). However, children with no known history of sexual abuse display aggressive sexual behavior and numerous sexually abused children have no sexual behavior problems. Garland and Dougher (1990) have cautioned against overreliance on learning theory alone: ªThe belief that sexual abuse causes sexual abuse, the so-called `abused± abuser hypothesis' is simplistic and misleadingº (p. 505). The trauma model has also been posited to explain sexual behavior problems in children (van der Kolk, 1989). Following a traumatic event (e.g., sexual abuse), a child may compulsively repeat the trauma as it may provide a temporary sense of mastery. The traumatized child may reenact the event, going from a helpless victim to a powerful perpetrator, in an attempt to integrate the experience or discharge affect associated with the trauma (Gil & Johnson, 1993). It is generally accepted that in cases of sexually aggressive children, mastery should be accomplished through other means and the repetition compulsion should be addressed therapeutically. Aggressive sexual behavior may be the result of other psychopathology in the child and/or the family. Children with serious mental health difficulties, such as disruptive behavior disorders, thought disorders, or affective disorders, can demonstrate problems with sexual aggression toward other children. In addition, factors in the family dynamics, such as inappropriate boundaries or a lack of nurturance, could contribute to the child's sexual behavior problems. At this point, it appears that there are several pathways to inappropriate or aggressive sexual behavior in children and treatment programs now subscribe to an integrated theory with attention to child, family, and contextual factors (Ryan, 1997b). Several typologies or classification systems for children with sexual behavior problems have been developed to assist clinicians in differentiating levels of problematic behavior and in planning appropriate treatment interventions. A system developed by Berliner and Rawlings (1991) defined three levels of sexual behavior: (i) Inappropriate sexual behavior, which includes a number of less serious although highly atypical sexual behaviors, such as persistent and/or public masturbation, highly sexualized behavior or play, and preoccupation with sexual matters; (ii) Precocious sexual behavior, which includes oral±genital contact or intercourse between pre-adolescents with no evidence of coercion or force involved; and (iii) Coercive sexual behavior, which refers to sexual acts in which coercion or force is

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threatened or used, or a significant disparity in development or size exists. A research study on boys and male adolescents aged 6.5±14 in Canada, the USA, and Bermuda found four categories of sexual behavior in these boys (Hall, Mathews, Pearce, Sarlo-McGarvey, & Gavin, 1996): (i) Developmentally ªexpectedº sexual behavior, in which children engage in sexual behavior which is developmentally appropriate; (ii) ªSexualizedº behavior, referring to children who are ªself-focused/sexualizedº in their interests or behaviors but who do not engage in problematic sexual behavior with other children; (iii) Sexually ªintrusiveº behavior, refers to children who engage in problematic sexual behavior, including touching or contact, but without planning or the use of force; and (iv) Sexually ªoffendingº behavior in which children are involved in problematic sexual behavior that includes planning and does/does not include force. Two national research studies funded by the National Center on Child Abuse and Neglect in the Department of Health and Human Services (NCCAN/DHHS) are nearing completion in the USA (Bonner et al., 1997; Gray et al., 1997). These studies were designed to establish empirically-based typologies of children ages six to 12 with sexual behavior problems and to test the effectiveness of two approaches to treatment. One of these studies generated five subtypes of children with sexual behavior problems: abuse reactive, rule breakers, highly traumatized, nondisordered, and sexually aggressive (Pithers, Gray, Busconi, & Houchens, in press). The preliminary findings from the Bonner et al. (1997) study delineated three groups of children with sexual behavior problems: (i) Inappropriate sexual behavior, such as public masturbation or highly sexualized talking and gestures, but no direct contact with other children; (ii) Inappropriate sexual behavior, including minimal contact with other children, such as touching other children's genitals; and (iii) Aggressive sexual behavior, including full contact with other children, such as oral± genital contact and intercourse. Although the nature of sexual behavior problems in children is not yet clearly defined and understood, consensus on some aspects is being reached. It is now accepted that children do engage in sexual behavior and for some children, the behavior crosses the line of what is normal or developmentally expected for this age. For those children whose behavior is aggressive and coercive, steps need to be taken

immediately to provide appropriate intervention for the aggressive child and protection for other children. 9.28.3 PREVALENCE The incidence and prevalence of sexual behavior problems in children is unknown and will be difficult to establish in the future. This is due to various reasons. First, sexual behavior problems or when the behavior becomes aggressive is not well-defined and professionals do not agree on what constitutes sexually aggressive behavior in children. Ryan (1997a) pointed out that the evaluation of inappropriate sexual behavior between children becomes more difficult as the ages of the participants become younger and closer. Ryan indicated that in evaluating a sexual interaction to determine whether that contact is abusive, one must assess three factors: equality, consent, and coercion. The following should be evaluated for equality: Differences in physical, cognitive, and emotional development; passivity and assertiveness; power and control; and authority. The ability to give consent implies full knowledge, understanding, and choice. Coercion describes the overt or covert pressures that prevent a child from making a choice about participation. It is obvious that these factors are difficult to determine in cases involving young children. Second, the child's abusive behavior, like other forms of sexual offenses, is often unacknowledged and not reported to authorities even when it is clearly aggressive. It has been noted that the identification and reporting of child offending was almost nonexistent before 1985 (National Adolescent Perpetrator Network, 1993). Throughout the USA different criteria are used to determine when children are sexually aggressive and there is no systematic approach to collecting this type of data across states by child protective services or by law enforcement authorities. There are, however, indicators that the number of children with aggressive sexual behavior is not insignificant. For example, children under age 12 were found to be responsible for about 13% of all child sexual abuse cases substantiated in the state of Vermont in 1991 (Gray & Pithers, 1993). In addition, surveys conducted by the National Adolescent Perpetrator Network and the Safer Society Foundation in the early and mid 1990s showed a substantial increase in the number of professionals and programs providing services to children with sexual behavior problems, from 25 in 1991 to almost 400 in 1995 (FreemanLongo, Bird, Stevenson, & Fiske, 1995; Interchange, 1991). While it is clear that aggressive

Assessment sexual behavior by children is increasingly recognized and treatment provided, it is also clear that uniform definitions and data collection on the national level are necessary to establish reliable estimates of incidence and prevalence. 9.28.4 ASSESSMENT In the field of child sexual abuse, two distinct areas of assessment or evaluation are emerging, forensic and clinical. The goals, purposes, and uses of these two forms of evaluation are distinctly different and it has been recommended that they be conducted separately by different professionals. In cases where inappropriate or aggressive sexual behavior has occurred, a forensic evaluation is conducted to determine whether or not a child committed the behavior or whether or not a particular child has been sexually abused. These interviews are typically conducted by Child Protective Services (CPS) personnel, law enforcement officers, or a member of a multidisciplinary team at a children's advocacy center. In some cases, mental health professionals are involved in conducting forensic evaluations. It is imperative that the clinician is clear as to which type of assessment is being conducted and that this is conveyed to the parent, child, and other professionals involved with the child prior to beginning the evaluation. A clinical evaluation is designed to obtain information for treatment planning and is not used to determine whether a child committed a particular act. A comprehensive clinical assessment of the child and parents or caretakers is necessary in order to develop an effective treatment plan. The assessment should be conducted by a professional who is knowledgeable about sexual abuse and children with sexual behavior problems and who is trained in the administration and interpretation of psychological tests. Prior to the assessment, the following information should be obtained and reviewed: reports of previous testing or treatment, school records, and any information from child protective services, law enforcement, or juvenile court regarding the child or the reported current incidents of sexual behavior. A comprehensive assessment includes clinical interviews and the use of psychological instruments to assess both the child's and parent/caretaker's current affective and behavioral functioning. Before beginning the interviews with the parent and child, the limits of confidentiality should be explained clearly. For some clients, it may be helpful to have a written copy of the limits of confidentiality for later reference. If child and parent completely deny that the child

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has had a sexual behavior problem, the clinician would need to decide whether to terminate the session and discuss the issue with the referral agency (school, law enforcement, CPS), complete the evaluation and discuss the findings and recommendations with the family, or some other course of action. The clinician can then proceed to gather information through separate clinical interviews with the parent and child. This would include standard information obtained from clinical interviews for other problems in childhood, including a developmental and medical history, school performance, history of psychological or psychiatric problems, alcohol or drug use by family members, the child's social relationships with peers and siblings, and family functioning and previous changes or moves by the child or family. This information is relatively standard in mental health settings and should not provoke resistance by the child or parent. If the child is in foster care, this information may need to be obtained from the child's caseworker. In addition, the assessment should include an in-depth history of the child's sexual behavior, keeping in mind that (i) a great deal of sexual behavior between children is seen as normal and not highly problematic, that is, playing doctor with or showing their genitals to same-age peers or siblings; (ii) children and their parents may be quite reluctant to discuss the child's sexual behavior, and (iii) it is unlikely that all of the child's sexual behavior will be disclosed during the initial interview. If a court has ordered that reports be sent to the CPS or the school, for example, this must be clearly explained to the parents and child. If the parent agrees that the reports can be sent, we recommend that the parent sign a release of information to document their consent. In many cases with children under 12, the court is not involved and the typical limits of confidentiality for children can be observed. To begin the initial interview, it is suggested that the therapist say: ªHello Jason, Ms. Jackson. I understand that you are here today because you (your son) has had a problem with his sexual behavior.º This takes a more direct approach, labels the problem behavior, and appears to take some of the pressure off the clients. In our experience, children are quite reluctant to discuss their inappropriate or aggressive behavior and this can be interpreted as denial. This can also be reflected in their parents' responses to inquiries about their children's behavior. We view it more as being reluctant, embarrassed, afraid, or ashamed of the behavior and the current consequences. The therapist could then explain that the session will entail talking to the child and the parent and the

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Children with Aggressive Sexual Behavior

completion of some paper and pencil tests to help plan the treatment program. The assessment should include questions on the child's normal or expected sexual behavior and problematic behavior, including: (i) masturbation; (ii) playing doctor; (iii) looking at others' private parts; (iv) the types, duration, and frequency of the child's inappropriate or aggressive sexual behavior; (v) any use of threats, coercion, tricks, or bribes to involve other children sexually; and (vi) the child's response to discipline or correction regarding their sexual behavior, for example, did he/she stop or become more secretive; and (vii) the overall attitude toward sexuality in the family. After the clinical interviews are completed, it is recommended that a thorough psychological assessment be conducted. This will provide important information on the child's diagnosis and general intelligence, overall psychopathology, behavior and affective problems, and sexual behavior. The following instruments can be used to assess the child's and parents' psychological state, level of stress, and family functioning. 9.28.4.1 Child Evaluation In this section we provide a brief overview of the instruments that can be used in evaluating children who engage in aggressive sexual behavior. 9.28.4.1.1 Diagnosis and overall psychopathology The Child Assessment Schedule (CAS; Hodges, 1993) is a 226-item structured diagnostic interview developed for the assessment of school-age children in clinical or research settings. The responses are summed across the 226 items for a general pathology score and subscales generate assessments of depression, anxiety and fear, self-image, conduct disorders, and somatic complaints. The CAS should be conducted with a child by a trained interviewer. 9.28.4.1.2 Behavior and affective problems The Child Behavior Checklist (CBCL; Achenbach, 1991) is a 134-item standardized checklist of children's behavior problems and social competence in children ages four to 18. It has forms that can be completed by the child, parent, and/or teacher about the child. The CBCL measures factors such as depression, somatic complaints, hyperactivity, aggressiveness, sexual behavior, anxiety, and delinquent behavior. In addition, the CBCL yields overall scores on a child's externalizing (aggressive and antisocial behavior) and internalizing (with-

drawal, fearfulness, inhibition, and depression) behaviors. The test reflects whether or not a child's level of behavior falls into the clinical range for children of the same age and gender. The Revised Children's Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1985) is a 37-item inventory that assesses a variety of anxiety symptoms. The instrument is completed as a self-report by the child. Reliability and validity studies indicate that the instrument acts as a satisfactory measure of chronic anxiety. The State±Trait Anxiety Inventory for Children (STAIC; Speilberger, 1973) is a 40-item instrument developed as a research tool to evaluate anxiety in elementary school children. The items are divided into two, 20-item, selfreport scales. The Anxiety±State subscale reflects transitory anxiety that tends to fluctuate over time. The Anxiety±Trait subscale reflects relatively stable differences in children's levels of anxiety. 9.28.4.1.3 Self-esteem The Harter Perceived Self-Competence Scale (Harter, 1982) is a 28-item questionnaire in which a child self-reports his/her perceived competence in social, cognitive, physical, and global esteem. The child is asked to select which of two described children he/she is most like and the degree to which he/she is similar. 9.28.4.1.4 Sexual behavior problems The Child Sexual Behavior Inventory (CSBI; Friedrich et al., 1992) is a 36-item instrument completed by a parent or caretaker to rate sexual behaviors shown by children ages two to 12 during the prior six months. The behaviors are scored 0 to 4 to indicate the frequency of the problematic behaviors. Clinicians should note that this version of the CSBI does not contain items that assess highly aggressive sexual behavior in children ages two to 12. These should be covered in the clinical interview or through other paper and pencil items or questions designed by the clinician. There is no standardized measure to assess the levels of appropriateness and/or aggressiveness in children's sexual behavior. Two Likert-type scales have been designed and utilized to measure these aspects of children's sexual behavior (Bonner et al., 1997). The 7-point scales are from 1 (very appropriate) to 7 (very inappropriate) and 1 (not at all aggressive) to 7 (very aggressive). The raters, which can be the parents, the referral source, and/or the clinician, take into account the child's age, gender, and the total referral sexual behaviors in making the ratings.

Treatment 9.28.4.2 Parent/Caretaker Evaluation 9.28.4.2.1 Psychological status The Brief Symptom Inventory (BSI; Derogatis, 1991) is a 53-item self-report version of the Symptom Checklist-90 (Derogatis, 1977). The symptom items are rated on a five-point scale to indicate the degree of distress within the last week. Scores are obtained for nine primary symptom dimensions and three global indices of distress. 9.28.4.2.2 Level of stress The Parenting Stress Index (PSI; Abidin, 1990) is a 120-item parent self-report instrument designed to measure the degree of stress in the parent-child system and to identify the sources of distress. Three major sources of stress, child characteristics, mother characteristics, and situational-demographic life stress, are assessed by the instrument. 9.28.4.3 Family Evaluation The Family Environment Scale (FES; Moos & Moos, 1981) is a 90-item, true/false instrument that measures the social-environmental attributes of various kinds of families. The test assesses three dimensions of family functioning: relationship, with subscales for cohesion, expressiveness, and conflict; personal growth, with subscales for independence, achievement orientation, intellectual±cultural orientation, and moral±religious emphasis; and system maintenance, with subscales for organization and control. The Child Version of the Family Environment Scale (CVFES; Pino, Simmons, & Slowski, 1984) is a 30-item instrument presented in pictorial form to the child. Children ages five through 12 are shown cartoon images depicting family scenes, with only one dimension changing across multiple choice response options. The child selects the cartoons that best represent how he/she feels about his/her family. The CVFES provides information similar to the adult version described above. Information from the child's and parents/ caretakers' evaluation can be used to develop a comprehensive treatment plan which may include individual, group, and family therapy. The child's sexual behavior problems will be addressed in individual and/or group therapy, along with parent/caretaker support and education. If the child has other significant affective or behavioral problems, these will need to be addressed in individual therapy. The parent/ caretaker may also need to be seen or referred for additional treatment for other psychological

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issues. Family sessions may need to be scheduled to address boundary issues, safety within the home, and other problems that emerge during the evaluation. 9.28.5 TREATMENT The literature contains descriptions of several treatment approaches for children with inappropriate or aggressive sexual behavior (e.g., Ballester & Pierce, 1995; Becker & Bonner, 1998; Cunningham & MacFarlane, 1991, 1996; Friedrich, 1990; Gil & Johnson, 1993; Gray & Pithers, 1995; Johnson, 1991). In general, the treatment approaches have several common objectives for treatment, such as reducing the child's inappropriate sexual behavior, improving the child's self-esteem, and addressing family problems. Depending on the length of treatment, that is, time-limited or open-ended, there are other issues that may be addressed, such as the child's history of abuse and other problematic behaviors. In a book of therapeutic exercises for child abuse victims and children with sexual behavior problems, Johnson (1995) listed 10 goals for treatment. These include: (i) decrease children's problematic sexual behavior; (ii) understand and integrate issues related to prior victimization, including maltreatment, family separations, and deaths; (iii) increase children's understanding of their unhealthy beliefs about sex and sexuality; (iv) increase children's understanding of healthy sexuality; (v) increase children's understanding of personal and family patterns related to sexual abuse and other problematic behavior; (vi) assist children to understand their needs and develop their goals and internal resources to reach the goals; (vii) help children assess and understand the precipitants to their own behavior and to think of the consequences before they act; (viii) increase children's ability to meet their social needs in appropriate ways; (ix) increase children's empathy for others; and (x) increase children's positive relationships and attachment to others and build internal objects that enhance future development. These goals are quite comprehensive and treatment typically will utilize individual, group, and family therapy as modalities. While treatment programs may differ in length and degree of comprehensiveness, typically they cover a set of general topics related to the child's sexual behavior. In general, these programs have incorporated, but significantly

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Children with Aggressive Sexual Behavior

modified, aspects of treatment techniques or issues addressed in the treatment of adolescent or adult sex offenders. These include sex education and sexuality, social skills, impulse control, and problem-solving skills. Specific focus is placed on topics related to the inappropriate or aggressive sexual behavior, such as acknowledging and discussing their sexual behavior, taking responsibility for their sexual behavior, identifying risk factors, and developing a plan to prevent the abuse from happening again. The literature supports the necessity of focusing specifically on the inappropriate or aggressive sexual behavior as it indicates that children's sexual behavior problems may be more resistant to change and respond better to a targeted treatment intervention (Finkelhor & Berliner, 1995). Several treatment programs were established in the mid-to-late 1980s to provide treatment for abuse reactive children, for example, children under age 13, most of whom had been sexually abused and who were referred for inappropriate sexual behavior with other children. One of these early treatment programs has been described in the literature. The Support Program for Abuse Reactive Kids (SPARK) was established at Children's Institute International in Los Angeles in 1985 (Ballester & Pierce, 1995). It utilizes the concept of monster therapy to treat boys ages four to 13 who have been sexually aggressive toward their siblings, peers, and other younger children. Group therapy for the children and their parents or caretakers is the primary treatment modality, although other treatment interventions are also utilized. Monster therapy is described as a systematic, play therapy approach that is used to increase self-esteem, impulse control, anger management, and a sense of mastery in the children. The children's impulsive sexually inappropriate behavior is personified as monster behavior. The therapists report that with this approach the children see their problem, or their monster, as something outside of themselves that can be brought under control and conquered. The therapy sessions and group activities are built on the monster theme and therapy is depicted as a battle to conquer the monster. The therapists note that it is the children's impulsive behavior that is labeled, not the children themselves. SPARK has six stages of therapy although the stages do not necessarily proceed in a linear fashion. (i) Creating a Therapeutic Environment. Addresses shame, guilt, assertiveness, secrecy, control, safety, and introduces the monster metaphor. (ii) Enhancing Self-Awareness. Addresses identification of feelings, disclosure, self-blame,

homophobia, power and control, denial, cognitive distortions, responsibility, projection, and risk factors (time, circumstances, behavior, and feelings). (iii) Learning Alternative Behaviors and Skills. Addresses impulse control through cognitive restructuring, self-talk techniques, and high-risk strategies; social skills such as appropriate affection and socialization, managing anger and anxiety, and communication skills; empathy; and sex education. (iv) Identifying and Using Resources. Addresses identifying resources and support systems, assertiveness skills, and problem solving. (v) Putting Skills into Practice. Addresses empowerment, locus of control, and internalizing skills. (vi) Skill Mastery and Relapse Prevention. Addresses application of skills and concepts to other situations, foreseeing potential problems, and techniques to prevent relapse. Various group activities are used to enhance the children's learning of the concepts and skills. The children earn small plastic monsters as tokens each week that they put into a cup with their name on it. Other groups make a monster cage from small wood sticks to hold their monster tokens. The monsters are earned each week for learning new skills or rules and are exchanged every three to four weeks for treats from a goody bag. This technique has been found useful in increasing the boys' self-esteem, providing a visual means of self-assessment of progress in therapy, and giving the parents a way to gauge their child's progress. The group treatment program runs for 14 weeks followed by a two- to four-week break. Children can graduate at this time or continue to participate in the next cycle with new participants and their parents. Families are typically in treatment from 12 to 18 months. Termination is planned when the child has successfully completed the stages of treatment and met all of the treatment goals. A parallel group treatment program is conducted for the parents or caretakers of the children attending SPARK (Griggs & Boldi, 1995). Parental participation is mandatory for a child to be accepted into SPARK as the home environment is seen as a crucial factor in reducing the child's sexual behavior problems. The group is directed by a male±female cotherapy team that provides education, support, and therapeutic intervention. The group focuses on assisting the parents to resolve their own victimization issues, strengthening the relationship between the parent and child, and providing education on child sexual abuse and human sexuality. The two main goals of parental treatment are to (i) strengthen the family

Treatment through increasing healthy communication and interactions, and (ii) decrease the pathology by encouraging healthy family dynamics. The following issues are addressed in the parents' program: (i) assisting parents to negotiate the various systems involved in these cases, that is, legal, law enforcement, child protective services, school, and child care systems; (ii) providing information on general child development, child sexual abuse issues, children's sexual development, and distinguishing between normal and sexually reactive behavior; (iii) assisting parents to provide supervision of the reactive child and the victim; (iv) teaching skills in parenting and behavior management; (v) helping parents understand how family dynamics contribute to reactive behaviors; (vi) assisting parents to normalize their responses and to strengthen the parents' support and resources; and (vii) helping parents to develop appropriate expectations and treatment goals. At present, two national treatment outcome studies to verify the effectiveness of different treatment approaches with this population of children are nearing completion (Bonner et al., 1997; Gray et al., 1997). These two studies are particularly important in that they were implemented early in the development of treatment interventions for these children. The results from these studies can provide direction for future clinical programs providing services to this population. Each of the research studies utilizes standardized assessment instruments and is gathering two-year follow-up data on the children. 9.28.5.1 Children with Sexual Behavior Problems Program The Oklahoma Program, conducted through the Center on Child Abuse and Neglect in the Department of Pediatrics at the University of Oklahoma Health Sciences Center, compared two approaches to time-limited group therapy (Bonner et al., 1997). The groups are for children ages six to 12 and separate educational groups are conducted for the parents or caretakers. The children and the caretakers are randomly

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assigned to one of two treatment approaches, cognitive-behavioral group therapy or dynamic play therapy. The treatment program is timelimited and consists of 12 one-hour group sessions for both the children and the parents. The primary goal of both approaches is to reduce the children's inappropriate or aggressive sexual behavior. However, the techniques used to reduce the behavior are markedly different in the two treatment approaches. 9.28.5.1.1 The cognitive-behavioral group therapy approach The cognitive-behavioral therapy (CBT) approach presumes that the inappropriate or aggressive sexual behavior has been learned and can, therefore, be unlearned with new information, practice, and rewards for more appropriate behavior. It is a highly-structured approach in which the two therapists, one male and one female, are active and directive. Girls and boys from age six to 12 participate together in the group. In the CBT approach, the children's inappropriate behavior is addressed directly in the first session. After the children and therapists introduce themselves to each other and some initial rapport is established, the children are told that they are in the group because they broke a sexual behavior rule. They are told that the group will help them learn the sexual behavior rules and how not to break the rules in the future. As the treatment is time-limited, the program focuses on the most relevant topics related to the children's inappropriate sexual behavior, that is, learning and implementing the sexual behavior rules (see Table 1), learning basic sex education, improving impulse control, and preventing future abuse. These topics are introduced, repeated frequently over the sessions, and positively reinforced. In order to assess the cognitive or learning aspects of the program, a five-item assessment is administered at the end of each session to determine if the children are learning the didactic content. The child's behavior is assessed weekly by child and parent report. The group sessions for parents also utilize a cognitive-behavioral approach in which the therapists take an active, directive role. The

Table 1 Sexual behavior rules. 1. It's OK to touch your private parts when you are alone 2. It's not OK to touch other people's private parts 3. It's not OK for other people to touch your private parts 4. It's not OK to show your private parts to other people

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Children with Aggressive Sexual Behavior

topics from the children's group are explained and discussed in the parents' group the week before they are introduced to the children. The parents' group covers the sexual behavior rules, the turtle technique (used to decrease impulsive behavior), sex education materials, safety rules in the home, and prevention of reabuse. Other topics are covered in the parents' group, such as developmentally expected sexual behavior in children, supervision of children with sexual behavior problems, family rules about sexual behavior, talking about sexuality with children, and general behavior management (see Table 2 for an outline of sessions). 9.28.5.1.2 Case study: cognitive-behavioral treatment approach VS was a 10-year-old boy referred by a community psychologist for aggressive sexual behavior. The referral behaviors included attempted penetration of his four-year-old sister, mutual masturbation with his sister, performing oral sex on his 12-year-old male cousin, and exposing himself and grabbing the genitals of two nine-year-old friends who were spending the night. VS had recently reported that his father had anal and oral intercourse with him when he was three and again when he was six. During a previous evaluation in which his father, mother, he, and his sister participated, VS recanted the accusations. His parents had been separated for over a year and a divorce was pending. The CPS later conducted an investigation and confirmed VS's sexual abuse by his father as valid. VS was cooperative during the assessment. He reported that his grades had gone from ªstraight Asº to ªstraight Fsº because of his parents' divorce. He stated that he was afraid of being away from his mother. VS said that he wanted to commit suicide last year because of all the fighting due to the divorce but that he did not have thoughts of suicide at the current time. VS's test scores indicated that he was functioning in the normal range of intelligence (IQ = 91). His scores were in the clinical range for sexual behavior problems on both the CBCL and the CSBI. On a scale of 1 (very appropriate) to 7 (very inappropriate), his sexual behavior had an average rating of a 6.4. The level of aggressiveness was 6.0 on a scale of 1 (not at all aggressive) to 7 (very aggressive). On the CBCL, VS was seen to have significant difficulties in internalizing problems, including being withdrawn, having somatic complaints, showing thought problems, and having difficulty attending. His mother rated VS in the clinical range on internalizing and total scores on the CBCL. Ratings on the PSI

indicated that his mother had difficulty accepting VS and that she was experiencing significant life stress. VS and his mother attended all 12 treatment sessions. VS was compliant, agreeable, and participated well throughout the program. He learned the sexual behavior rules and the selfcontrol procedures (turtle technique). Over the course of treatment, VS acknowledged his sexual behaviors that had been reported. He was seen as having successfully completed the treatment program. The mother was advised to monitor his behavior closely and contact the therapists if further sexual behavior problems arose. At the end of the 12 treatment sessions, and at a one-year follow-up, VS's mother reported that he had adjusted to the divorce, his visitation with his father was supervised, and that no further sexual behavior problems had been reported to her.

9.28.5.1.3 Dynamic play group therapy approach The second treatment approach utilized by the Oklahoma Program was chosen to contrast with the cognitive-behavioral approach. The dynamic play therapy group was less structured and utilized group play activities as the intervention. The children's inappropriate or aggressive behavior was not directly addressed by the therapists unless it emerged during the group sessions. The group was designed to provide a safe, positive atmosphere in which the children could express their thoughts and feelings, develop a better understanding of themselves and others, and interact appropriately with other children. The therapists were nondirective and provided reflection and interpretation to the children. It was a more permissive, child-centered intervention than the cognitive-behavioral approach. Various play and expressive activities were utilized by the therapists to encourage the expression of feelings and group interaction. These included the use of clay, puppets, group story telling, costumes, group board games, and other art materials and activities. The parents' group was conducted from a dynamic approach, which utilized the members of the group and the group process as the modality of change. The therapists were again nondirective and used reflection and interpretation as primary interventions. The group processed problems and issues that the parents or caretakers raised each week. The therapists did not set the agenda but followed the direction set by the parents.

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Treatment Table 2 Cognitive-behavioral therapy session outline. Children's group

Parents' group

Session 1 Introduce:

Introduce:

Group purpose Group rules Group format Sexual behavior rules

Review: Introduce:

Sexual behavior rules Parental expectations Discussing feelings

Introduce:

Rules in your home Supervision guidelines

Introduce:

Turtle technique Expected sexual behavior in children

Review:

Turtle technique Sexual behavior in children

Introduce:

Behavior management techniques

Introduce:

Managing sexual misbehavior Sex education

Review: Introduce:

Managing sexual misbehavior Abuse prevention

Introduce:

Talking with your child about sex

Review: Introduce:

Materials from previous sessions Open discussion

Group purpose Group rules Describe activities Assessment: (5 items) Session 2 Review: Purpose of group, rules Introduce: Sexual behavior rules Private parts Applying sexual behavior rules Assessment: (5 items) Session 3 Review: Group purpose, rules Private parts Sexual behavior rules Introduce: Discussing feelings Assessment: (5 items) Session 4 Review: Group purpose Sexual behavior rules Introduce: Disclosure Assessment: (5 items) Session 5 Review: Sexual behavior rules Disclosure Introduce: Turtle technique Assessment: (5 items) Session 6 Review: Sexual behavior rules Turtle technique Disclosure Assessment: (5 items) Session 7 Review: Turtle technique Assessment: (5 items) Session 8 Review: Private parts Introduce: Sex education Talking about sex Assessment: (5 items) Session 9 Review: Turtle technique Sex education Assessment: (5 items) Session 10 Review: Turtle technique Sex education Introduce: Abuse prevention Assessment: (5 items) Session 11 Review: Sexual behavior rules Turtle technique Abuse prevention Assessment: (5 items) Session 12 Saying goodbye

Individual meetings between therapists and parents to discuss information on child's progress and recommendations Postassessment session for parents to complete instruments

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9.28.5.1.4 Case study: dynamic play therapy treatment approach NH was an eight-year-old girl who participated in the dynamic play therapy group. She was referred by a psychologist who was seeing NH for a brain injury she had sustained during infancy. NH was referred after she was observed licking the genitals of a six-year-old girl in a bathroom stall at school; it was also reported that another adult had seen NH with her mouth on her four-year-old cousin's penis. NH was the only survivor of a murder/suicide in which her father had shot her mother and an older brother, and then killed himself. NH had been diagnosed with learning disabilities and was on medication for seizures. She had been living with a maternal aunt and uncle since infancy and had no reported history of abuse. Mrs. H. reported that she thought an adult had possibly allowed NH to see a pornographic video but she did not know who it could be, and that NH would not discuss the issue. Mrs. H's view was that NH was acting out of curiosity but she acknowledged the need for treatment regarding the sexual behavior. She reported that NH had not asked many questions about sex. Mr. and Mrs. H. had often told NH never to let anyone touch her private parts but they were unaware of the extent of NH's sexual knowledge. NH was attentive and cooperative during the testing session. When the items became more difficult, she readily said, ªThat's too hard for me,º or ªI can't do that one.º She reported that she sometimes had difficulty with schoolwork but that she made good grades in the learning lab. Her intelligence scores indicated that she was functioning in the Below Average range (IQ = 80). On the CBCL (completed by her aunt), NH was found to be in the clinical range on social problems, delinquent behavior, sex problems, aggressive behavior, and attention problems. Her Externalizing and Total scores were in the clinical range. The CSBI score was not in the clinical range. The ratings of her sexual behaviors by four national experts were 6.0 (7 = very inappropriate) on level of appropriateness and 4.0 (7 = very aggressive) on level of aggressiveness. The aunt's responses on the PSI indicated significant stress in her relationship with NH, her parenting, and her relationship with her spouse. All six categories in the parent scale and the total stress score were in the high range. On the BSI, all of her scores were within normal limits. In the dynamic play group, NH was initially quiet but pleasant and friendly to the other group members. She participated in the group activities and appeared to prefer the company of

the other children to that of the therapists. When the therapists paid attention to her, she tended to giggle nervously and move away. Over time, NH sought attention from other children by encouraging disruptive behavior and became more oppositional with the therapists. At times, she flatly refused to comply until pressured by the group members. NH and her aunt and uncle attended 11 of the 12 scheduled sessions. The adults participated actively in the parents' group and openly discussed their concerns about NH. They understood the necessity of supervising NH closely to prevent any further inappropriate sexual behavior and the need for her to interact with other children as much as possible in a supervised setting. Over the course of the group, they both discussed how to communicate with NH about appropriate and inappropriate sexual behavior. No additional treatment was recommended. At the end of the treatment program, no additional inappropriate sexual behavior was reported and no further treatment was recommended. Similarly, the one- and two-year follow-up reports indicated that NH's overall behavior had improved and that no inappropriate or aggressive sexual behavior had occurred. 9.28.5.1.5 Treatment The research design for this study included random assignment to either cognitive-behavioral or dynamic play therapy, the use of standardized instruments for assessment, and follow-up at the end of treatment and at one and two years post-treatment. The initial results show that both treatment approaches were effective in reducing the children's inappropriate sexual behavior. The incidence of repeated inappropriate or aggressive behavior was approximately 15% for children who completed treatment in both treatment approaches. 9.28.5.2 STEP Program The second research project funded by the National Center on Child Abuse and Neglect was conducted in Vermont by Pithers et al. (in press). This study examined the effectiveness of two treatment models, both of which utilized 32 weeks of 90 minute parallel treatment groups for children and their caregivers. One approach was Sex Abuse Specific Treatment (SAST), a modified relapse prevention approach that emphasized the involvement of caregivers as external monitors of their child's behaviors. The second approach, Abuse Prevention Treatment (APT), was an expressive approach that focused

References

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on improving self esteem, reducing anxiety, and increasing emotional regulation. The effects of each treatment were examined across five types of children with sexual behavior problems that had been identified through cluster analytic procedures. The data indicated that SAST provided more immediate benefits for highly traumatized children, suggesting that the modified relapse treatment approach helped children and caregivers manage sequelae associated with the child's history of abuse. However, over time, the differences between treatment approaches eroded, a finding thought to be attributable to the later onset of benefits from the less structured expressive treatment approach. In summary, treatment programs for children with sexual behavior problems have increased dramatically since the early 1990s. In general, the programs have similar approaches and utilize adapted concepts from treatment programs for adolescents and adults. The treatment outcome research currently being conducted will provide useful information on effective approaches to treating this population of children.

It is also recommended that communities provide a range of services for children with inappropriate or aggressive sexual behavior, including outpatient treatment for children and their families, therapeutic foster care, and when necessary, specialized group homes and residential treatment centers. The present studies funded by the National Center on Child Abuse and Neglect (Bonner et al., 1997; Gray et al., 1997) will add valuable information to the knowledge base about children with aggressive sexual behavior and the effectiveness of the treatment approaches utilized in the studies, that is, cognitivebehavioral, dynamic play therapy, modified relapse prevention, and expressive therapy, in group settings for children and parents. Additional research is needed on other approaches and modalities of treatment, such as individual and family therapy. It is imperative that future research use sufficient numbers of subjects, standardized instruments, and rigorous methodology in order to reliably establish the findings. The importance of well-designed longitudinal studies of children with sexual behavior problems cannot be understated.

9.28.6 FUTURE DIRECTIONS

9.28.7 SUMMARY

The results of initial treatment outcome research with children with sexual behavior problems is promising. It appears that several treatment interventions are useful and that the rates of repeated aggressive sexual behavior are between 10±15%. While we lack an empirically derived theory to explain the etiology of this behavior in children, it appears, both from existing literature and clinical practice, that multiple factors rather than a single cause are involved. As this area of clinical practice is in its infancy, there are numerous factors that need to be addressed. There is a clear need for the development of a set of agreed upon definitions or criteria for what constitutes aggressive sexual behavior in children and when a system outside the family, that is, CPS, law enforcement, or the courts, needs to become involved. Future research could be instrumental in clarifying a set of definitions and establishing a data base on incidence and prevalence. There is also a need for the development of standardized instruments to measure the level and severity of aggressive sexual behavior in children. The well-normed CSBI developed by Friedrich et al. (1991) has added a set of questions assessing the presence of more aggressive sexual acts by children. This type of measure could be utilized as a pre-post measure for future treatment outcome studies.

The extant literature and clinical reports indicate that problematic sexual behavior, including aggressive sexual assaults by children under age 12, is increasing. As this behavior has been reported to occur in schools and other public facilities, numerous professionals are concerned for the safety of children under their supervision. To date, several group approaches have been found effective in reducing aggressive sexual behavior in children, including cognitivebehavioral, dynamic play therapy, modified relapse prevention, and expressive therapy. Future research should focus on the development of treatment models that are both timeand cost-efficient and can be implemented easily in community mental health centers. 9.28.8 REFERENCES Abidin, R. R. (1990). Parenting Stress Index. Charlottesville, VA: Pediatric Psychology Press. Achenbach, T. M. (1991). Manual for the Child Behavior Checklist 4±18 and 1991 Profile. Burlington, VT: University of Vermont, Department of Psychiatry. Adams, J., McClellan, J., Douglass, D., McCurry, C., & Storck, M. (1995). Sexually inappropriate behaviors in seriously mentally ill children and adolescents. Child Abuse and Neglect, 19, 555±568. Ballester, S., & Pierce, F. P. (1995). Monster therapy: The use of a metaphor in psychotherapy with abuse reactive children. In M. Hunter (Ed.), Child survivors and perpetrators of sexual abuse (pp. 125±146). Thousand Oaks, CA: Sage.

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Becker, J. V., & Bonner, B. L. (1998). Sexual and other abuse of children. In R. J. Morris & T. R. Kratochwill (Eds.), The practice of child therapy (3rd ed., pp. 367±389). Boston: Allyn & Bacon. Berliner, L., & Rawlings, L. (1991). A treatment manual: Children with sexual behavior problems. Seattle, WA: Harborview Sexual Assault Center. Bonner, B. L., Walker, C. E., & Berliner, L. (1997, March). Group treatment approaches for children with sexual behavior problems. Presented at the Spurwink Institute, Newport, RI. Cantwell, H. B. (1988). Child sexual abuse: Very young perpetrators. Child Abuse and Neglect, 12, 579±582. Cunningham, C., & MacFarlane, K. (1991). When children molest children: Group treatment strategies for young sexual abusers. Orwell, VT: Safer Society Press. Cunningham, C., & MacFarlane, K. (1996). When children abuse: Group treatment strategies for children with impulse control problems. Brandon, VT: Safer Society Press. Derogatis, L. R. (1991). Brief Symptom Inventory. Baltimore: Clinical Psychometric Research. Derogatis, L. R. (1977). SCL-90: administration, scoring, and procedures manual for the revised version. Baltimore: Clinical Psychometric Research. Federal Bureau of Investigation (1990). Uniform crime reports of the United States. Washington, DC: US Government Printing Office. Finkelhor, D., & Berliner, L. (1995). Research on the treatment of sexually abused children: A review and recommendations. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 1408±1423. Finkelhor, D., Hotaling, G. T., & Lewis, F. T. (1990). Sexual abuse in a national survey of adult men and women: Prevalence, characteristics, and risk factors. Child Abuse and Neglect, 14, 19±28. Freeman-Longo, R. E. (1982). Sexual learning and experience among adolescent sexual offenders. International Journal of Offender Therapy and Comparative Criminology, 26, 235±241. Freeman-Longo, R. E., Bird, S., Stevenson, W. F., & Fiske, J. (1995). 1994 nationwide survey of treatment programs and models: Serving abuse reactive children, adolescent, and adult sex offenders. Brandon, VT: Safer Society Press. Friedrich, W. N. (1990). Psychotherapy of sexually abused children and their families. New York: Norton. Friedrich, W. N., Grambsch, P., Broughton, D., Kuiper, J., & Beilke, R. L. (1991). Normative sexual behavior in children. Pediatrics, 88, 456±464. Friedrich, W. N., Grambsch, P., Damon, L., Koverola, C., Hewitt, S. K., Lang, R. A., & Broughton, D. (1992). Child Sexual Behavior Inventory: Normative and clinical comparisons. Psychological Assessment, 4, 303±311. Garland, R. J., & Dougher, M. J. (1990). The abused/ abuser hypothesis of child sexual abuse: A critical review of theory and research. In J. Feierman (Ed.), Pedophilia: Biosocial dimensions (pp. 488±509). New York: Springer. Gil, E., & Johnson, T. C. (1993). Sexualized children: Assessment and treatment of sexualized children and children who molest. Rockville, MD: Launch Press. Gordon, B. N., & Schroeder, C. S. (1995). Sexuality: A developmental approach to problems. New York: Plenum. Gray, A., Busconi, A., Houchens, P., & Pithers, W. (1997). Children with sexual behavior problems and their caregivers: Demographics, functioning, and clinical patterns. Sexual Abuse: A Journal of Research and Treatment, 9, 267±290. Gray, A., & Pithers, W. (1993). Relapse prevention with sexually aggressive adolescents and children: Expanding treatment and supervision. In H. E. Barbaree, S.

Hudson, & W. Marshall (Eds.), The juvenile sexual offender (pp. 289±319). New York: Guilford Press. Griggs, D. R., & Bolbi, A. (1995). Parallel treatment of parents of abuse reactive children. In M. Hunter (Ed.), Child survivors and perpetrators of sexual abuse (pp. 147±165). Thousand Oaks, CA: Sage. Groth, A. N. (1979). Sexual trauma in the life histories of rapists and child molesters. Victimology, 4, 10±16. Hall, D., Mathews, F., Pearce, J., Sarlo-McGarvey, N., & Gavin, D. (1996). The development of sexual behavior problems in children and youth. Toronto, Canada: Central Toronto Youth Services. Harter, S. (1982). The perceived competence scale for children. Child Development, 53, 87±97. Hodges, K. (1993). Structured interviews for assessing children. Journal of Child Psychology and Psychiatry and Allied Disciplines, 34, 49±68. Interchange (1992, Fall). Results of a survey regarding the treatment of preadolescent sexually abusive behavior. Denver, CO: Kempe National Center. Johnson, T. C. (1989). Female child perpetrators: Children who molest other children. Child Abuse & Neglect, 13, 571±585. Johnson, T. C. (1991). Children who molest children: Identification and treatment approaches for children who molest other children. APSAC Advisor, 4(4), 9±11, 23. Johnson, T. C. (1995). Treatment exercises for child abuse victims and children with sexual behavior problems. South Pasadena, CA: Author. Lamb, S., & Coakley, M. (1993). ªNormalº childhood sexual play and games: Differentiating play from abuse. Child Abuse and Neglect, 17, 515±526. Lindblad, F., Gustafsson, P. A., Larsson, I., & Lundin, B. (1995). Preschoolers' sexual behavior at daycare centers: An epidemiological study. Child Abuse & Neglect, 19, 569±577. Moos, R. H., & Moos, B. S. (1981). Manual for the Family Environment Scale. Palo Alto, CA: Consulting Psychologists Press. National Adolescent Perpetrator Network (1993). The revised report for the National Task Force on Juvenile Sexual Offending. Juvenile and Family Court Journal, 44, 1±120. Okami, P. (1992). ªChild perpetrators of sexual abuseº: The emergence of a problematic deviant category. Journal of Sex Research, 29, 109±130. Pino, C. J., Simmons, N., & Slowski, M. J. (1984). Children's version of the Family Environment Scale. East Aurora, NY: Slosson. Pithers, W., Gray, A., Busconi, A., & Houchers, P. (in press). Five empirically-derived subtypes of children with sexual behavior problems: Characteristics potentially related to juvenile delinquency and adult criminality. Irish Journal of Psychology. Reynolds, C. R., & Richmond, B. O. (1985). Revised Children's Manifest Anxiety Scale (RCMAS). Los Angeles: Western Psychological Services. Ryan, G. (1997a). Sexually abusive youth: Defining the population. In G. D. Ryan & S. L. Lane (Eds.), Juvenile sexual offending (pp. 3±9). Lexington, MA: Lexington Books. Ryan, G. (1997b). Theories of etiology. In G. D. Ryan & S. L. Lane (Eds.), Juvenile sexual offending (pp. 19±35). Lexington, MA: Lexington Books. Speilberger, C. D. (1973). Manual for the State±Trait Anxiety Inventory for Children. Palo Alto, CA: Consulting Psychologists. van der Kolk, B. (1989). The compulsion to repeat the trauma: Re-enactment, revictimization, and masochism. Psychiatric Clinics of North America, 12, 389±411.

Copyright © 1998 Elsevier Science Ltd. All rights reserved.

9.29 Perpetrators of Racial Violence and Hatred ALAN S. W. WINTON Massey University, Palmerston North, New Zealand and NIRBHAY N. SINGH and KRISTEN McALEAVY Virginia Commonwealth University, Richmond, VA, USA 9.29.1 INTRODUCTION

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9.29.2 NATURE

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9.29.2.1 Race, Ethnicity, and Culture 9.29.2.2 Prejudice and Hatred 9.29.2.3 Stereotypes 9.29.3 VIOLENCE 9.29.3.1 9.29.3.2 9.29.3.3 9.29.3.4

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Theories of Violence Factors in Violence Violence and Hatred Collective Violence

9.29.4 PERPETRATORS 9.29.4.1 9.29.4.2 9.29.4.3 9.29.4.4

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Influences on Violence Influences on Racial Violence Problems of Measurement of Racial Violence and Hatred Extent of Racial Violence and Hatred

9.29.5 INTERVENTIONS

475 475 476 477 478

9.29.5.1 Treatment 9.29.5.2 Prevention 9.29.5.3 Tolerance of Violence

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9.29.6 FUTURE DIRECTIONS

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9.29.7 SUMMARY

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9.29.8 REFERENCES

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attacks, but also threats of violence, intimidation, and damage to property. Further, many people from racial and ethnic minorities report multiple instances of ªlower-levelº harassment, such as verbal abuse, where their race or ethnicity is seen as a crucial factor. These are

9.29.1 INTRODUCTION Nearly every day there are reports in the news media of acts of harassment and hatred perpetrated on people because of their race or ethnicity. These include not only overtly violent 467

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not simply instances of bigotry, prejudice, and discrimination, but constitute real threats to their safety and well-being. Problems of racial violence and hatred are worldwide; while the form and extent of the problems vary widely, no country is free of them. In some parts of the world, racial violence and hatred are part of conflicts between countries or regions within a country, threatening the lives of all people within these countries and often of those from other countries as well. The conflicts may involve other nations directly or indirectly due to the displacement of large numbers of people from neighboring countries, creating racial and ethnic tensions. In most nations, even without such conflicts, tensions and conflicts between different racial and ethnic groups exist which have the potential to develop into violence and other overt expressions of hatred. Racial violence and hatred are increasing in many parts of the world because of increasing population and rapid political and social changes. Since the United Nations began in 1945, there have been over 150 small-scale wars with deaths estimated at over 20 million, and disablement and displacement of over 80 million people (Hamburg, 1993). Even without such conflicts, widespread movements of large numbers of people necessitate the sharing of finite resources, not only with more people, but also with people of diverse races and cultures. Successful ways of dealing with the inevitable racial tensions that arise are needed. The destructive power of modern warfare has made the necessity to find solutions to control violence and hatred between people most urgent. Given the diverse causes of violence, it is necessary to balance theory and practice to find effective ways to lessen violence (National Research Council, 1993). The important focus for clinical psychologists wishing to reduce racial violence and hatred should be on the individual perpetrators, and factors in their lives that can change their attitudes and behavior. However, psychologists can also play an important role by increasing our understanding of the nature of the factors that produce racial violence and hatred, and by researching methods which may prevent their development. This chapter focuses on the nature of racial violence and hatred. It begins with a brief discussion on some key concepts related to race and hatred. This is followed by a brief overview of violence, including factors that may lead to racial violence, and issues related to collective violence, such as riots and mob violence. Then there is a discussion of the characteristics of perpetrators of violence in general and racial violence in particular. Questions about our

knowledge of the number of perpetrators of racial violence and hatred are raised because long-term policy and intervention decisions are dependent on accurate information about the extent of the problem. Finally, issues of treatment and the need for further research are discussed. 9.29.2 NATURE A variety of analyses have been offered to explain the nature of racial violence and hatred. One major distinction has been made between essentialist explanations and historical-deterministic explanations (Baird & Rosenbaum, 1992a). Essentialist explanations point to causes that are intrinsic to our human nature, involve deep-seated tendencies, and are difficult, if not impossible, to overcome. Historical-deterministic explanations emphasize factors in our environment that change over time and situation, and often are reasonably amenable to manipulation, such as inadequate housing or poverty. To understand the nature and development of racial violence, we must first define several key concepts. 9.29.2.1 Race, Ethnicity, and Culture Use of the term race, and its derivatives racial, racism, racist, raises a number of potential problems. The term is based on distinguishing amongst peoples on the basis of physical characteristics and traits that are biologically inherited, although the construct of race no longer has any scientific status. It has been defined in a variety of ways that have included biological, national, ethnic, and cultural variables (Solomos, 1993). Many people have argued that it is, at best, a term of limited value which is better avoided altogether because any racial categorizations invariably involve surplus meaning (Gadlin, 1994). However, notions of race continue to be used widely across societies and discourses and can be salient even in situations where race is said to be irrelevant. Racism has been broadly defined to cover ideologies and social processes which discriminate against others on the basis of racial categories. This has been extended to cover discrimination based on assumed superiority, which is itself based on assumed biological differences (Solomos, 1993). In many societies, such racism is mediated in a variety of ways, including political discourse and the media, and through educational and other institutions. Racism usually has unspoken implications of domination and oppression or subordination of minority cultures (Gadlin, 1994).

Nature Researchers have classified racism in a number of ways. For example, Dovidio and Gaertner (1986a) distinguished three types of racism: individual racism, institutional racism, and cultural racism. Individual racism is similar to racial prejudice but emphasizes biological considerations and encompasses discriminatory acts. Institutional racism refers to institutional policies, whether intentional or not, that unfairly restrict opportunities for certain groups of people. Cultural racism involves elements of the other two types that argue for the superiority of one race's cultural heritage over another's. A related term, ethnocentrism, can be distinguished from racism. Racism involves discriminating against groups of people on the basis of assumed racial characteristics, including behavior interpreted as being due to their race. Ethnocentrism involves discriminating against groups on the basis of their ethnicity and emphasizes a cultural group's unique characteristics. Ethnicity has had a number of definitions, ranging from those where it is largely a euphemism for race through to broader definitions that include language and customs. In broader definitions of ethnicity, physical characteristics are usually part of the definition, but are not the preeminent defining aspect. Regardless of how it is defined, ethnicity is an important concept because a substantial amount of violence around the world involves groups who define themselves on the basis of ethnicity (Nagel, 1995). Culture has been given a very wide range of meanings extending from very broad universalistic ones to quite narrow ones (Carter & Qureshi, 1995). Culture can be thought of as ª an ordered system of meaning and symbols in terms of which individuals define their world, express their feelings, and make their judgementsº (Geertz, 1962, p. 724). Broadly defined, culture includes ªthe shared values, traditions, arts, history, folklore, and institutions of a group of people that are unified by race, ethnicity, nationality, language, religious beliefs, socioeconomic status, social class, sexual orientation, politics, gender, age, disability, or any other cohesive variableº (Singh, 1996, p. 123). Most definitions of prejudice emphasize negativity towards a group or an individual based on their membership in that group. Dovidio and Gaertner (1986a) defined prejudice as an attitude with cognitive (e.g., irrationally based beliefs), affective (e.g., dislike), and conative (e.g., avoiding) components. Prejudice is seen as highly embedded in psychological and social processes, developing from fundamental biases in the ways in which humans process information. Further, Dovidio and Gaertner (1986a) distinguished motivational from cogni-

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tive perspectives. Motivational perspectives assume that prejudice is caused and maintained to achieve goals and needs, or because of negative feelings and beliefs acquired through socialization. Cognitive perspectives emphasize information processing biases in the form of stereotyping and the consequences on intergroup interactions, with more favorable attributions and greater differentiation towards members of in-groups when compared to those from out-groups. Discrimination is regarded as selective, unjustified behavior towards members of a group that denies them equality. 9.29.2.2 Prejudice and Hatred The literature on the nature and causes of racial prejudice is large and varied. For example, psychological theories about the nature of prejudice stress psychosocial explanations that emphasize the role of in-groups and out-groups, and the development of stereotyping. There are a number of different accounts that emphasize different causes for the development of prejudice. Some involve religious notions, such asªoriginal sin,º as being causative; others stress biologically determined factors; while many provide psychosocial explanations. Even with psychosocial explanations, there are differences both in the actual factors stressed and whether they have an inherent basis or are largely ontogenic. For instance, a lot of the literature stresses the role of stereotyping in the development of prejudice, but the tendency to stereotype seems to be considered as being inherent in human nature (AlboÂ, 1994; Dovidio & Gaertner, 1986b). Not only do the explanations differ in terms of the nature of prejudice, they also differ in terms of the remedy. For instance, if the only cure for the effects of original sin is redemption through a religious conversion, those not subscribing to the need for such a change will remain prejudiced. The outlook for overcoming prejudice is even less promising when biologically determined factors are considered to be of prime importance because there is little that can be done about these factors. Psychosocial viewpoints, although varying in the nature and importance of various factors, stress learning in a social context. Psychosocial viewpoints provide a much more positive prognosis, because if something can be learned it can also be unlearned, or alternative learning can overcome the negative effects of prejudice. Fundamentalist religious, biological, and social psychological views are examples of essentialist thinking that have been used to explain prejudice and hatred (Baird & Rosenbaum, 1992b). The fundamentalist religious

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view holds that prejudice and hatred are part of a person's inherently sinful nature, and these can be overcome only by a radical transformation of the self through God's mercy. Another type of essentialist thinking is found in biological views which suggest that evolution has selected the tendency to maintain the genetic integrity of our own group, and it is this tendency that produces prejudice and hatred. This will occur inevitably under certain conditions, even without awareness, and little can be done to avoid its occurrence if these eliciting conditions are present. While most psychosocial explanations point to factors in the environment of the individual as the cause of prejudice and hatred, many researchers regard stereotyping as critical. Further, other researchers have argued that we have a deep-seated need to simplify our interactions with others and this produces a tendency to stereotype people of other cultures. Prejudice and hatred are considered a side effect of this intrinsic tendency. 9.29.2.3 Stereotypes Various theories point to the tendency of humans to stereotype other humans who are different from them. Stereotypes involve the process of generalization, an important and unavoidable part of learning, where potentially discriminable differences are treated as the same. But stereotypes are generalizations with two important features: they totally obscure individual differences among members of a group, and they tend to resist any contradictory evidence, no matter how compelling it may be. Individuals who do not fit the stereotype will be seen as the exception to the rule and may even be used to justify the group stereotype by arguing how few in that group possess those individuals' characteristics. If stereotypes are repeated, even in jokes, they become accepted and, once accepted, are used as the basis for dealing with individuals from the group being stereotyped. Stereotypes usually involve negative evaluations of perceived attributes, such as aggression rather than motivation, or positive ones that are used for the purpose of being critical, such as being good at music (meaning not much else) or being powerful (meaning too powerful). Stereotypes often categorize the group as inherently inferior. For instance, if members of a group are seen as an economic threat, they may be categorized as greedy, having obtained their wealth in suspect ways, or not in need of any assistance. A stereotype tends to be held as true over long periods because it is neither tested nor even thought necessary to be tested. Hence, distortions of social realities can be demonstrated by

the considerable misinformation that many people have about members of other groups. This distortion has considerable ramifications, because decisions affecting the lives of members of other groups are often made on the basis of the stereotypes.

9.29.3 VIOLENCE There is no universally accepted definition of violence (Bradby, 1996). The concept of violence covers a diverse range of behaviors and situations and can involve various levels of explanation (National Research Council, 1993). Aggression is an important concept in many analyses of violence and a lot of research, both basic and applied, has investigated causes and control of aggressive behavior. Studies on aggression are frequently cited in discussions of the development, maintenance, and control of violence, especially those emphasizing psychosocial perspectives (e.g., Pepler & Slaby, 1994). Some caution is warranted, however, because aggression is defined in some studies differently from the way violence is usually defined, and the relationship may not always be clear. It is also true that some definitions of violence include types of violence where overt aggression may be absent, such as in structural violence. Violence, like culture, has no single agreed definition (Rupesinghe, 1994). Some definitions are very broad, such as that of Galtung (1990), who defined violence as anything avoidable that impedes human self-realization. Galtung identified three types of violence: direct violence, structural violence, and cultural violence (see MacGregor & Rubio, 1994). Direct violence refers to the use of physical force that is directed at other humans. It involves face-to-face aggression where the perpetrator can or may be identified. Structural violence refers to the indirect violence caused by social structures, not persons, although the structures are created and changed by persons and affect all persons in the society, especially the relationships between them. Structural violence includes broad differences in wealth distribution; inequitable administration of justice; authoritarian family socialization; discrimination based on such things as age, gender, race, and religion; and the repression of speech. Institutional violence is a form of structural violence embedded in institutions and accepted, or at least tolerated, by complicity. It can either be formal, such as an army explicitly trained to repress subversion, or true, where it exists despite being not formally acknowledged or even prohibited. Cultural violence which, according to Galtung (1990), can be defined as the denial of identity, security,

Violence and symbolic meaning, are those aspects of a culture that legitimize direct or structural violence. This includes societal rules that are not strictly cultural but which have a cultural layer, such as economic policies that are theoretically fair but in reality disadvantage certain groups. While the three types of violence are distinguishable, they are closely related and not mutually exclusive. For instance, factors resulting in structural violence may not of themselves produce direct violence but, in the presence of other factors, may contribute to direct violence. One distinction between the three types of violence is in their relation to time. Direct violence is a present fact, structural violence is a process which may change over time, while cultural violence is nonvariant over very long periods of time. In addition, it is also important to distinguish violence from its effects. For instance, an injury suffered in a brawl is the effect of violence inflicted by a person but is not direct violence per se. Similarly, widespread poverty is not structural violence per se but the rules organizing unequal distribution of wealth are. Direct violence is of major concern, because perpetrators of this type of violence are likely to be the ones with whom clinical psychologists are directly involved. Structural and cultural violence, however, are also important because of their long-term and widespread effects on culturally diverse groups. In trying to deal with the causes of violence, psychologists should be concerned with dealing with short- and longterm factors involved in violence. Further, there is strong evidence that structural factors set the conditions that increase the likelihood of outbreaks of direct, and possibly widespread, violence. Toplin (1994) has provided another typology of violence. The first type is collective and political violence, which includes group activities, such as protests, demonstrations, strikes, and riots. The second type is criminal violence, which includes acts of violence by individuals or small groups. The third type is psychopathic violence, which includes assassinations, mass gratuitous violence, and serial killing. The final type is foreign policy violence. These distinctions may be very useful from a sociological viewpoint, but they do not define violence in terms of the perpetrator.

9.29.3.1 Theories of Violence It is clear that violence is multidetermined and can be best understood by considering not only a variety of psychological studies that have

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investigated the nature and causes of human aggression, but also studies from other disciplines, in particular criminology and sociology (Berkowitz, 1993; Eron & Slaby, 1994). As with prejudice, there are a variety of theories as to how violence develops. Some theories stress inherent factors which are largely genetically determined or, as in psychodynamic theories, inherent structures of the mind. Many psychological explanations stress psychosocial factors. In an overview of current research on violence, Eron and Slaby (1994) concluded that there is overwhelming evidence that human aggression is largely learned and not mainly (and hence, inevitably) determined by biology. Biological factors may interact with learning processes and predispose a person to violence, but they do not make violence inevitable. In particular, violence is not the direct and inevitable result of extreme anger or inadequate impulse control, although inadequate control may put some individuals at greater risk for violence if they have previously learned to be violent. Because violence is largely learned behavior, it should be possible to reduce or prevent violence through learning. Berkowitz (1993), among others, distinguished two forms of aggression, instrumental aggression and hostile aggression. Instrumental aggression refers to violence perpetrated on the victim largely as a by-product of achieving some goal, such as attaining money or social status. In hostile aggression, however, inflicting violence on the victim is a primary purpose. Berkowitz (1993) argued that hostile aggression is often accompanied by strong emotion (called emotional aggression) but may be inflicted without emotion. Behavior can be modified by two fundamental conditioning procedures: respondent (or classical) and operant (or instrumental). In respondent conditioning, events in the environment (including the internal and social environments) come to elicit behaviors by association with reflexes or other genetically determined environment±behavior relationships. In operant conditioning, behaviors are modified by their consequences. Thus, both instrumental and hostile aggression are produced by operant conditioning; what distinguishes them is the reinforcing consequences that maintain them. This is a difference in motivation, an important consideration in explaining violent behavior (Tsytsarev & Callahan, 1995). In hostile aggression, the infliction of injury or pain on the victim is an important consequence. Emotional aggression involves, at least in part, respondent conditioning, but this would be an accompaniment of the hostile aggression rather than a cause. Berkowitz (1993) argued that anger is an emotion that

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may or may not accompany an act of aggression and, even when it does accompany it, is not the cause of the aggression. It is likely that some forms of hostile aggression would involve respondent conditioning, with it being elicited by someone or something in the environment rather than it being maintained by its effects on the victim.

9.29.3.2 Factors in Violence While most reviews of the causes of violence have not focused specifically on racially motivated violence, it seems clear that many of the factors identified as important for understanding violence are also important for understanding racially motivated violence. Studies looking at hate crimes in general and racially motivated hatred in particular will be considered in the next section. A number of factors have been implicated for understanding the psychology of violence and its development (Berkowitz, 1993; Hill, Soriano, Chen, & LaFromboise, 1994; National Research Council, 1993; Pepler & Slaby, 1994). These can be grouped in various ways but include social factors (both macro- and microsocietal), individual characteristics (both psychosocial and biological), and factors labeled as predisposing (including processes), situational, and activating (triggers). Social and cultural factors increase the probability that members of certain groups will be perpetrators. Major structural factors that have been implicated include low socioeconomic status, ethnic heterogeneity, and residential mobility. Research has further identified a wide range of specific factors, including concentrations of poor families in particular geographical areas, differential income equality, differential social organization affecting supervision of youth, high population turnover, community transitions, family disruption, housing and population density, lack of legitimate business opportunities, lack of legitimate social activities and contacts to gain social status, easy availability of drugs, presence of opportunities associated with violence (e.g., illegal markets in drugs and firearms), and inadequate child care and schooling. The effects of poverty on patterns of violent behavior have not been well researched and are interwoven with racial differences, making it difficult to untangle their differential effects. Research evidence suggests, however, that group violence is predicted by economic inequality rather than absolute level of material deprivation and also by the absence of available opportunities (Eron & Slaby, 1994).

Other major societal influences on violence that are not formal ecological and sociological variables are the media, guns, mobs, and gangs. The influence of the media has been greatly underestimated despite clear evidence that violence can be acquired through social learning and not just through personal experiences (Berkowitz, 1994; Eron & Slaby, 1994). Repeated viewing of violence can have long-term cumulative effects that include a propensity to engage in violence, an indifference to violence perpetrated by others, and an exaggerated view of the prevalence and inevitability of violence in the real world. Despite some conflicting findings, there is overwhelming evidence that TV violence leads to aggressive behavior and that TV and films can spread the potential for violence rapidly through the community (National Research Council, 1993). However, TV and other media can also play a strong positive role in reducing the potential for violence. The call for greater gun control to reduce violence has given rise to strong debate, especially in countries like the United States, where the right to carry a gun has long been in existence and where the ownership of guns is widespread. Berkowitz (1993, 1994) has argued that, while the number of violent incidents may not be greater due to the availability of guns, the severity of injuries and the number of deaths are. He contended that any protection guns may afford is strongly offset by the greater probability of death due to guns, especially for innocent people, and any reduction in gun numbers will lower this probability. He further argued that even the sight or presence of a gun can increase the probability of aggression, especially during situations when great emotion is coupled with violent action. Other factors vary in terms of their temporal proximity to a violent event. Some individual characteristics occur before birth and in early childhood (e.g., temperamental disposition), while others occur later in life (e.g., experiences in adulthood increasing frustration and anger). Some societal factors occur after centuries (e.g., cultural acceptance of violence), while others occur over comparatively shorter periods (e.g., poverty). While various factors have been implicated in violent behavior, it is important to understand that none by itself will inevitably lead to violence. Violence is multidetermined, with each risk factor contributing to the likelihood of its occurrence (Eron & Slaby, 1994). When several factors converge, violence is likely but still not inevitable. This means that the more factors are present, the greater is the probability of violence occurring. (Berkowitz, 1993). In each violent event, there are variations in the role of each of

Violence these factors and in the potential for violence of the individuals involved. Hence, there are many different opportunities to intervene to reduce or even prevent violence from occurring.

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always clear why they perceive a particular victim as being a representative of the hated group. 9.29.3.4 Collective Violence

9.29.3.3 Violence and Hatred While our focus is on racial and ethnic hate violence, some useful insights can be derived from considering how hate violence may be distinguished from violence in general. Some studies have looked at hate crimes perpetrated on individuals characterized not by race or ethnicity (e.g., Herek & Berrill, 1992a) or not solely by race or ethnicity (e.g., Levin & McDevitt, 1993). These studies show that many perpetrators of hate violence show a number of common characteristics, irrespective of what groups their victims belong to, and many of them exhibit violence and hatred towards people from more than one cultural group (Levin & McDevitt, 1993). In analyzing hate crimes in the United States, Levin and McDevitt (1993) noted that the distinguishing feature of hate violence is that it is motivated by hate rather than greed or opportunity. It may be executed on people directly or on their property, but it is usually excessively brutal. Hate violence towards people typically involves using force beyond that necessary to simply subdue the victim. It tends to be executed on strangers, emphasizing that anyone from the group the victim belongs to could be a target and should be fearful because victims are interchangeable. This is tantamount to domestic terrorism, because it sends out signals of hatred and threats of violence and harm to all people with the characteristics by which the victim is being identified and not merely to the actual victims. This type of violence tends to be perpetrated by multiple offenders rather than individuals acting alone. Levin and McDevitt (1993) distinguished reactive hate violence from mission hate violence. Reactive hate violence is based on the perceived need to eliminate the threat of encroaching outsiders. This violence usually involves narrowly focused attacks aimed at particular persons; it ceases once the threat is perceived as gone. An example might be the destruction of a shop owned by a person of a minority race who has recently come into a community and set up a business that threatens the livelihood of one or more members in the community. Mission hate violence is violence directed towards groups perceived to be a threat to some general concept such as a country's way of life, or to basic moral standards. Perpetrators of this kind of violence often perceive these groups to be part of a conspiracy, but it is not

Forms of collective violence that have been distinguished include group violence, gang violence, mob violence, riots, terrorism, and various forms of state-sanctioned violence, such as that by police and armies. Staub and Rosenthal (1994) used the term group violence to describe organized violence by the state or a dominant group against a minority race or culture. Mob violence, on the other hand, can be enacted by both majority and minority groups and may occur with either organized or spontaneous groups. A riot is an instance of mob violence, and a mob is a crowd that is likely to engage in illegal acts and violence. A crowd is a group of people who share a common interest and whose emotions may be easily aroused; whether they will become a mob depends on the presence of factors that can increase their susceptibility to violence. Riots clearly illustrate the danger of not dealing with structural problems associated with violence (Staub & Rosenthal, 1994). The 1968 President's Commission on Civil Disorders listed five powerful ingredients that are catalysts for riots (Toch, 1992). These included: (i) frustrated hope generated in the civil rights struggle; (ii) a climate that approved and encouraged violence; (iii) frustration due to feeling powerless to change the system; (iv) a new mood, especially in the young, of selfesteem and racial pride; and (v) the police being viewed as a symbol of white power, racism, and oppression. In concert, these factors lead to the view that riots occur at the end of a chain of events involving unrealized attempts to redress a number of grievances by more acceptable means; riots occur as a last resort after an accumulation of despair, anger, and frustration, although they can be triggered by a relatively minor event that is unrelated to the major grievances of the group(s) involved. Major themes that can be identified from interviews with riot participants include: (i) police brutality, which is seen as largely racist; (ii) a retaliation against White exploitation; (iii) a chance to get back at Whites, which is sometimes seen as worthwhile at any cost; (iv) an expression of hopelessness; (v) anonymity, which allows members of an oppressed minority group to be collectively noticed and taken seriously; and (vi) a finding of identity and even pride in their own cultural group. Research suggests that the following are possible precipitating factors for riots: (i) persons

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being predisposed to action by many unredressed grievances; (ii) a situation that allows the event to be interpreted as a further act of insult or humiliation, even if legitimate and innocent; (iii) ambiguity or a development within the incident; (iv) temperature, especially a heat wave; (v) a change in background factors (e.g., hopes recently raised by changes elsewhere); and (vi) the recent occurrence of riots elsewhere. All of these factors have the potential for inciting racial and ethnic riots, as well as violence. One important factor in many riots is that it involves perpetrators who would not normally engage in violent behavior. In analyzing race riots in the United States and England, Grimshaw (1969a) has argued that racial violence is due mainly not to conscious policy decisions but to reactions of the dominant group to real or perceived threats to its accommodative structure. Throughout the history of the United States, when African-Americans accepted a submissive role, Black±White violence was relatively rare; when the status quo was challenged, race conflict often ensued. Grimshaw has suggested that Blacks in England have largely accepted or tolerated their situation because of their shorter history and because there have been fewer of them. He argued that even when prejudice and discrimination have given rise to strong social tensions, the occurrence of social violence has depended on the extent of constraint by external forces. Social violence is not always preceded by a gradual build up of social tension. Grimshaw (1969b) has identified a number of macro- and microsocial factors that contribute to the build up of the social tensions underlying social conflicts. Macrosocial factors include changes in the intellectual milieux, in the economic organization, in international relationships, and urbanization and industrialization. Microsocial factors include specific incidents that provide occasions for social disturbances but which depend on a sufficient level of social tension and a sufficiently low level of external control. He argued that deteriorating relations between conflicting groups leads to violence. The usual sequence is the identification of an opposing group, relationships with that group become strained, social tensions gradually increase, which eventually leads to social and physical violence.

9.29.4 PERPETRATORS In general, much less is known about perpetrators than victims of violence (see Chapter 23 this volume). The National Re-

search Council (1993) has summarized the characteristics typical of perpetrators of violence. The perpetrators usually: (i) are from mainstream society rather than deviant types in organized hate groups; (ii) share similar demographic profiles to victims; (iii) are males (89% of all arrested) below 30 years of age; (iv) are disproportionately drawn from racial and ethnic minorities; (v) are somewhat older than their victims; (vi) are multiple offenders in 25% of nonfatal offenses; and (vii) commit violent crimes infrequently. In summarizing the features of many young violent perpetrators in the United States, Eron and Slaby (1994) noted that the form and absolute level of individual aggression may vary over a lifetime but, for an individual, their level of aggression relative to peers remains remarkably constant and predictable. For most, the pattern of violence at an early age is a good predictor of their violence decades later. Many young perpetrators tend to share common social experiences, especially strong rejection by peers, but they differ in a variety of ways in personality characteristics and how they deal with social problems. Their cognitions seem to play an important role. Violent individuals tend to perceive environmental events and responses by others differently from their nonviolent peers. They frequently show a history of ineffective parenting, drug use, school failure, and poor employment history. They report thoughts that demonstrate poor problem-solving skills, greater hostility, and a greater acceptance of aggression and violence than their nonviolent peers. These thoughts typically develop early, become habitual, and are associated with violent behavior. Therefore, if their thoughts can be modified, it may be possible to modify their overt violent behavior (Berkowitz, 1993). Toch (1992) has also analyzed the characteristics of perpetrators of violence. He suggested that the two types of orientations that are most especially likely to produce violence are when a person sees others as tools to serve his needs, and when a person is feeling vulnerable to diminishment. Both of these are based on the premise that human relationships are powercentered and that efforts at self-assertion have a desperate, feverish quality suggestive of selfdoubt. Toch argued that all violent people may not initially fit this categorization, but when they engage in violence they learn to respond in this way. The propensity to violence appears to be due to a failure of socialization and positive self-perception; this probably starts with experiences early in life, when it was largely elicited behavior that was subsequently reinforced and later maintained by others.

Perpetrators 9.29.4.1 Influences on Violence It is clear that there is no one set of factors, whether individual characteristics, family and other interpersonal interactions, or social situations that can account for the development of the potential for violence. Also, some factors may only put individuals at risk if certain conditions are present. For instance, some studies have shown that prenatal and perinatal complications are related to later aggression but only for those raised in unstable homes (National Research Council, 1993). However, the mechanisms by which these factors work to encourage the development of aggression is not clear. There also appear to be protective factors which may actually reduce the effect of other risk factors. The National Research Council (1993) reported on several studies that had focused on why many children at risk for violence do not offend. These studies found evidence that shyness, nervousness, or social isolation, being firstborn, having a high IQ, having parents who regularly attended religious services, and coming from smaller families with low discord are factors associated with low or reduced risk. These factors, however, may not work in a simple additive way; for example, in one study, shyness predicted later offending only if coupled with early aggressiveness. Individual personality characteristics found to be present in violent offenders during childhood include hyperactivity-impulsivity-attention deficit, restlessness and lack of concentration, high risk-taking, poor at delaying gratification, low empathy, and (more often than other offenders) low IQ (although it may not be IQ per se that is predictive of aggression, but rather the aggression that can develop at a young age with low IQ being a factor). There is some evidence that early temperament correlates highly with later temperament, especially for those who are very inhibited or very uninhibited (National Research Council, 1993). A very uninhibited temperament is a risk factor for later aggressiveness, while a very inhibited temperament may be a protective factor against later aggressiveness, and these effects may be especially true in children from homes which have a high risk for violence. Because aggression usually appears earlier, the effect of puberty is probably not a major cause of aggression. It may, however, affect the frequency or intensity of aggression. Family factors that have been implicated are poor parental child rearing methods, including physical abuse, lack of warmth, rejection and hostility, poor supervision, and no caring adult or friend for support. Many violent people have

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alcoholic or criminal parents and many have been separated from parents as children. They often come from low-income, large-sized families, with poor housing in deprived inner city locations. Many violent offenders have been victims of physical abuse and this has been implicated by many as a causative factor. A causal connection, however, has not been established. The methodology of many studies in this area has been weak, and the causal link did not hold strongly for females and Whites. Many violent adults were neglected in childhood but were not subjected to undue violence. Further, parental abuse may have been a reaction to the child's aggressiveness. The best predictor of adult aggressiveness is child aggressiveness, irrespective of parental behavior. What may be passed on is a parental genetic predisposition to aggression rather than any modeling or reinforcement of aggression. There is clear evidence that people from ethnic minorities in the United States are at much greater risk of being both perpetrators and victims of violence (Eron, Gentry, & Schlegel, 1994). This may not be due to any inherent propensity or a result of any direct encouragement of violence by the culture, but rather due to societal factors interacting with these cultures to put them at much greater risk (National Research Council, 1993). By the time children are five to six years old, they have learned to identify or share psychological characteristics with their parents, and ethnic and class groups. If these are defined as undesirable and evoke hostility by the dominant culture, and are seen as barriers to achieving desired goals, these create strong psychological conditions for making these children disproportionately at risk for aggressive and violent behavior.

9.29.4.2 Influences on Racial Violence Racial violence appears to have its roots in an individual's learned prejudices against particular groups of people. While much is known about the development of prejudice, little is known about the relationship between prejudice and racial or hate violence. Some generalizations can be made about perpetrators of racial violence and hatred, although these do not apply to all individuals. The perpetrators of different types of hate violence show somewhat different characteristics, and even perpetrators of similar types of violence are not all identical. Levin and McDevitt (1993) noted that many perpetrators of racial violence live on the margins of their community. They have been

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designated as cowards because they often offend in groups, where they may find safety in numbers and achieve some anonymity. Being in a group often encourages mutual incitement to increase the intensity of hatred, with some individuals seemingly out to prove themselves by surpassing previous atrocities. Many who perpetrate hate violence against one group also seem to perpetrate it against other groups (Berrill, 1992; Herek & Berrill, 1992b). Perpetrators usually see their actions as justified and even necessary; resentment against the group the victim belongs to often forms a significant part of this justification. Many perpetrators appear to have lost self-esteem or status, often with economic loss, and they blame the presence or action of out-groups for this. These factors are often present in both reactive and mission hate crimes. Reactive hate crimes often involve adult perpetrators who see the need to defend themselves against the encroachment by outsiders. However, they tend to stop committing violent acts when the perceived threat is no longer present and may never be violent again. Perpetrators of mission hate crimes tend to be extremists and incredibly bigoted. Although they are often seriously paranoid and delusional, not all are considered mentally ill. Other perpetrators, usually young males, appear to commit hate crimes largely for the fun of it. For them, acceptance by a group is often very important and provides a major motivation for committing the crime.

9.29.4.3 Problems of Measurement of Racial Violence and Hatred It is difficult to assess prevalence rates of acts of racial violence and hatred. For example, exactly how do we define racially motivated acts? How can racially motivated violence be distinguished from other forms of violence? Clearly, all acts of violence by one person towards a person of a different race or ethnicity, such as in a robbery, should not be automatically considered to be racially motivated. Even where there is clear evidence that a violent act is motivated by hatred, how can this be distinguished from hate violence because of other factors, such as gender or sexual orientation? Another set of problems concerns whom the statistics are collected on. In many countries, people from diverse cultural backgrounds are not distinguished on the basis of race and ethnicity, or are lumped into single large groupings. In addition, while figures are being kept in some countries on the prevalence of violence among different racial or ethnic groups, these are not usually broken down

further on the basis of the race or ethnicity of the victim, so it is difficult to distinguish intergroup from intragroup acts of violence. Further, there are serious concerns regarding how violent events are defined and the data on them collected. There is no single way to define, classify, and measure violent events, and most national systems vary in what they count and how they count it. Many measures are derived from police records, which tend to deal only with the most serious acts that are likely to lead to criminal prosecution. Police officers often have discretion in classifying and counting violent crimes and the definitions of violent behavior as crimes often change over time. Some classifications include social constructions which provide more complete information than those that do not, but these can cause distortions as they involve various persons' perceptions and classifications which can vary in such things as to what secondary information is included. Finally, a society's interpretation of violent events as crimes, changes over time. These issues are particularly true of racial violence, which is distinguished from other violence by the presumed role of social relationships in the motivation of the perpetrator (National Research Council, 1993). Determining unequivocally that a motive is racist can be difficult, especially in instances where there is an absence of clear signals, such as graffiti or organizational identity. Classifying a violent act as a racially motivated crime can depend very much on the view of the law enforcement officers dealing with the complaint. This makes accurate documenting and analyzing of patterns of racial violence very difficult. This is particularly true in instances where some crime, like robbery, has been committed, but where a hate component may be present as well. Also important is that racially motivated events may not be recognized as crimes by the police and other law enforcement officials and therefore not reported. Hence, there is value in examining other statistics, such as those that have been kept by advocacy organizations. However, these data may also provide distorted prevalence figures because these organizations often lack the resources for classifying and counting according to rigorous criteria, may interpret ambiguous events as evidence of racial hatred and violence, and may include crimes other than violent ones (National Research Council, 1993). Figures based on interviews among samples of particular populations do tend to show much higher rates of hatemotivated violence than those reported in official figures, probably because they may include a much wider range of incidents and not just criminal offenses (Eron & Slaby, 1994).

Perpetrators These may include acts of racial violence and hatred labeled as ªlow-level harassment.º Related to this is the increasing use of broader definitions of racial violence which include incidents caused by structural violence, but which may not result in personal violence. With increasing acceptance of the need to collect data on hate crimes, there may be a greater tendency for people to report these than previously. For instance, in the United Kingdom the early police figures showed a much lower prevalence of hate crimes than were indicated by more informal data collection (Virdee, 1995). Following social pressure for the police to keep hate crime statistics, reported hate crimes showed a considerable increase for some time, while informal methods of collecting data showed them to be fairly static. This indicates a greater willingness to officially report hate offenses and, therefore, the increase in official figures was more of an increase in reporting than an actual increase in these offenses. A related problem is the evidence that many racially motivated acts, even violent acts, are not reported. When members of minority groups are interviewed by a researcher, many will report being victims of acts of violence which they have never told anyone about, often out of fear. This fear may be due to a belief that authorities would not act on the complaint, fear of losing a job or perhaps being deported, and a fear of retaliatory violence for making a complaint. Other reasons include shame and guilt felt by victims, especially in relation to their families. Finally, it must be remembered that most of the available figures report on the prevalence of the violence in general and do not provide systematic data on the perpetrators. Again, this is particularly true of perpetrators of racial violence and hatred. Even when some characteristics of the perpetrators are given, the data are not detailed enough to address a number of important issues. These include whether the perpetrators are repeat offenders, vary for different forms of racial violence, vary from country to country, or can be distinguished from those who engage in other kinds of violence.

9.29.4.4 Extent of Racial Violence and Hatred In the United States, there is evidence that much of the overt racial violence of the past has been declining although new forms of racism are already developing (Baird & Rosenbaum, 1992a; Dovidio & Gaertner, 1986a). This has resulted in new inter-racial tensions, because events regarded as racially discriminatory by

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one group are not so regarded by another. The former group may propose solutions to deal with this that the latter group regard as being racially discriminatory. There are also increasing reports of new levels of racial conflict occurring in neighborhoods, workplaces, and university campuses, these are predicted to worsen (Levin & McDevitt, 1993). A sharp increase has been reported in hate crimes which, with increasing diversity and complexity, is likely to get worse (Levin & McDevitt, 1993). Other forms of racism are also on the increase which, while seemingly a small problem in comparison to problems such as increasing illicit drug use, have the potential to disrupt communities and spark violence. For example, Levin and McDevitt (1993) have documented evidence of increasing racism in humor aimed at groups that are vulnerable and sometimes defenseless, humor which, by being used repeatedly, helps reinforce stereotypes about these groups. Hate rhetoric aimed at different groups and peoples, particularly minorities, is increasing in pop music (sometimes intertwined with overt themes of violence), and also in public statements by religious leaders, politicians, and media commentators. On college campuses, racial hatred is occurring increasingly, usually involving harassment but sometimes also including physical violence. This upsurge of racist expression is seen as reflecting a deeper strain of prejudice throughout American society. There is a new rising tide of conservatism that is becoming more vociferous in its attacks on minorities, multiculturalism, and diversity (Singh, 1996). Levin and McDevitt (1993) have argued that not all promoters of hate intend to harm others, but that hatred is becoming more accepted; one indication of this acceptance is the increasingly wide variety of audiences who enjoy media depicting hate messages. One of the dangers in this is that it allows racist people to justify venting hatred on those being stereotyped. This is a particular problem for the younger generation of a society who have not yet developed their own positions and who have the highest representation among the perpetrators of hate violence. In the United States, the most important official data on hate violence are provided by the Hate Crime Statistics Act enacted in 1990. This act requires annual national reporting on crimes perpetrated on persons or property that manifest evidence of prejudice based on several characteristics, including race and ethnicity. It is designed to remedy inconsistent reporting by individual states by having all information collected in a single format by a single agency (i.e., the FBI). It has resulted in some positive

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effects in improving data collection and sensitivity of police forces to hate crimes, although there is still some way to go to achieving overall consistency and eliminating problems of reliability and validity due to variations in systems across states (Levin & McDevitt, 1993). Other national sources of data on violent behaviors considered crimes are the National Crime Statistics (NCS), which are derived from national household samples, and Uniform Crime Reporting (UCR) based on crimes detected by or reported to police. However, it is difficult to discover the exact figures on the involvement of interethnic violence from these data. Vontress (1995) quoted figures showing that homicide is the primary cause of death for members of African-American communities aged between 15 and 34 yearsÐ121 times that of Whites in the same age group. While they do show that there is a disproportionate perpetration of violence by people from ethnic minorities, the greatest proportion of this is intra-ethnic (Eron et al., 1994). 9.29.5 INTERVENTIONS 9.29.5.1 Treatment Few studies have dealt specifically with perpetrators of racial violence and hatred, but an increasing number have looked at treating violent people; these provide some relevant data on how one might deal with perpetrators of racial violence and hatred. Measures for dealing with violence have varied, again, in part, based on the discipline of the investigators. Although there may be considerable overlap, criminologists have looked at the effects of legislation and legal sanctions, public health professionals and educators have investigated the effects of institutional changes and education programs, sociologists at the effects of broad changes in social structures and conditions, and psychologists at the effects of various therapies on individual perpetrators. Each has provided important insights into dealing with the problem holistically, supporting the need for a multidisciplinary approach (Berkowitz, 1993; Hammond & Yung, 1994). Risk assessment studies suggest that the strongest indicator of the risk of an individual perpetrating violence is aggressive behavior as a child; hence intervention should begin as early as possible. While intervening with violent teenagers is difficult, it is even harder with adults, as learned violent behavior is resistant to extinction. However, because of the seriousness of the behavior it is probably never too late to intervene. Whether or when to intervene requires a good knowledge of the role of all

the risk factors and characteristics of the perpetrators; however, this knowledge is still lacking. Further, a lot of predictive accuracy concerns risk factors associated with aggressive behavior rather than violence in general or racial violence in particular. Consequently, there are few good outcome studies on the treatment of perpetrators of racial violence. Treatment strategies for both perpetrators and victims should be directed at community, family, and individual levels. These strategies would include targeting those groups of individuals who are at highest risk for engaging in racial violence. 9.29.5.2 Prevention The prognosis for successfully treating violent offenders with psychological procedures ranges from hopeful (Eron et al., 1994) to pessimistic (Berkowitz, 1993). However, there is agreement that much can be done to lessen the probability of violent offending. For example, educational interventions can be aimed at reducing prejudice, such as encouraging positive intergroup interactions. Aronson (1992) described an interesting set of studies in classrooms where the usual independent and competitive behaviors gave way to interdependent and cooperative behaviors which had the effect of increasing academic performance and self-esteem in many students, increasing empathy with other students, and in reducing prejudice between students. The interventions had the greatest effect on young children. Working with children at the earliest stages has been recommended by others. Racism is learned at a very early age and therefore it is important to deal with instances of it among the very young, even when the racism may be being maintained at home (Siraj-Blatchford, 1994). It is harder to change racism and bigotry at an older age, and prevention is much easier than treatment. There is no question that changes to legislation with accompanying enforcement methods are important approaches for reducing racial violence and hatred. Most of these methods, however, do little to reduce the underlying hatred and prejudice. 9.29.5.3 Tolerance of Violence In most societies, violence per se is not condemned, only certain expressions of violence. People are not being taught to be nonviolent, but rather when to be violent. In some cultures the range and extent of violence encouraged, or at least tolerated, is considerable. In many

Summary societies, there are times when hatred and violence are positively encouraged or even glorified, such as during wars and intercountry conflicts. However, even in peacetime, many societies tolerate high levels of violence by taking action only against some forms of violence and under some circumstances. Many allow sports, movies, and television programs which present both explicit and implicit violence in ways which, if not directly encouraging, are accepting and made entertaining. Although many viewers will not engage in the violence witnessed or portrayed, the widespread acceptance of it is an encouragement to those with a tendency to violence. Often there is an implicit acceptance of the inevitability and, indeed, the justification of violence as a viable and even singular solution. Even acts of terrorism are not universally condemned but are accepted or deplored depending on the particular commentators and the particular group committing the terrorist act (Takooshian & Verdi, 1995). Perhaps even more widespread is the tolerance of racial harassment and hatred where there may be no overt acts of physical violence. As has been pointed out, words may not simply constitute racial harassment, but ultimately constitute an act of racial violence (MacKinnon, 1993). In a number of countries (e.g., the United States, United Kingdom, Canada, Australia and New Zealand), specific laws are being enacted to deal with this type of racism. A lot more needs to be done to create a climate where such expressions of racism will be actively discouraged.

9.29.6 FUTURE DIRECTIONS The causes of racial violence and hatred are both widespread and complex. A great deal of work is required both to gain a full understanding of these phenomena, and to find real and long-lasting methods for preventing and reducing them. While there are no easy solutions, there are indications that real progress is possible. What is clear, however, is that further research into finding solutions is urgent because of the threat to the very fabric of many societies. Racial conflicts show no sign of abating and will likely increase with increasing populations and greater mobility. Effective solutions will require the input of a wide range of disciplines. The recommendations from a number of studies on violence are clearly relevant (e.g., Eron et al., 1994; National Research Council, 1993). Of equal importance for long-term prevention are recommendations emerging from studies on the causes of prejudice, bigotry, and discrimination. If these

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are not reduced, hatred and harassment will be inevitable and violence will remain a high probability. We do not have a clear indication of the extent of racial violence and hatred even though these are common events in most of our lives. There is a need for longitudinal studies that provide prevalence figures within and between culturally diverse groups (National Research Council, 1993). Current reporting of racial violence is fraught with definition problems, mechanisms for data gathering, and the specificity of the data gathered. We need to know not only that an incident of racial violence occurred, but also details of the incident, including sociodemographic characteristics of the perpetrators and the victims. At present, we have more information on the victims of racial violence than on its perpetrators. There is a paucity of good studies on the various risk factors for racial violence. There is little information on how developmental processes in ethnically and socially diverse communities affect the emergence, maintenance, and prevention of violence. Public policy response to the rise in racial violence and hatred has largely been driven by fear and anxiety rather than a genuine concern to do the right thing. Central government funding of research on risk factors for racial violence in both the dominant and minority cultures is long overdue. With immigration increasing in many countries, there will be increasing tensions as more and more of the traditional power will be challenged, and more and more minority groups will demand a share in the nation's wealth and opportunities. Resentment and hostility will increase for a variety of reasons based on perceptions of the migrants' financial success or sharing of the community's limited resources (Peach, 1994; Wickberg, 1994), willingness to work for lower wages (Daniels, 1994), lack of commitment to the host country (Wickberg, 1994), or abuse of welfare provisions (Spoonley, 1993; Werbner, 1994). Finding ways of welcoming new immigrants without heightening social and economic tensions in the community is a priority.

9.29.7 SUMMARY What are the solutions to preventing racial violence and hatred? While it is clear that there are no simple answers, the only real solutions lie in dealing with structural problems in society. There needs to be stronger legal sanctions against not only racial violence but also against all forms of racism and racial discrimination in all areas of our society. Comparisons with

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societies that have less violence and hatred may give some clues as to what needs to be done. In looking at traditional Buddhist societies with very little violence and hatred, Gielen (1995) has suggested that the emphasis on more individual rather than collective freedoms may be part of the problem rather than the solution of the social disorganization seen in Western nations, such as the United States. Some researchers have argued that psychologists, teachers, social workers, and others operating on the individual level can play an important part in finding solutions. Learning more about the nature and causes of racial violence and hatred identifies possibilities for reducing them and preventing their development. Clinical psychologists need to be strong advocates for reducing all forms of violence and should be able to help provide alternatives to social violence. Others have less faith in the ability of psychologists to deal effectively with violence and have argued for solutions at the personal level. Kappeler (1995), for example, stated that there is an urgent need to deal with the numerous individual examples of everyday violence that are condoned by our failure to treat them as a problem. She argued further that using violence to combat violence ultimately is not a solution. Certainly, one or two people inspired to work for nonviolent solutions (e.g., Ghandi, Martin Luther King) have had profound influences on the occurrence of racial violence and hatred. We need to find ways to celebrate our differences rather than use them as a basis for prejudice, discrimination, and conflict. But we must go further than resolving our interpersonal conflicts or even celebrating our differences. We need to understand that we are interdependent (Aronson, 1992; Singh, 1995) and that true harmony will come only when we realize our need for each other, and that in hating or harming another we are hating and harming ourselves. With regard to those who engage in violent behavior we need to ªlink them to the rest of humanity, while separating them from their violent actsº (Toch, 1992, p. xiv). The ultimate solution, however, is to go beyond even interdependence and find oneness. Only at the deepest level of ourselves can we discover true oneness; a level where we unite with others at their deepest level. The ways to this are prescribed in the wisdom traditions of all cultures. 9.29.8 REFERENCES AlboÂ, X. (1994). Ethnic violence: The case of Bolivia. In K. Rupesinghe & M. Rubio (Eds.), The culture of violence (pp. 119±143). Tokyo: United Nations University Press.

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