Foster care: an update.

OBJECTIVE: To inform child and adolescent psychiatrists about the almost 500,000 children now residing in the American foster care system. This overview surveys the pediatric, developmental, and psychiatric needs of these children. METHOD: Child and adolescent psychiatrists, pediatricians, a child welfare researcher, a social worker, and a psychologist developed a consensus paper from their experience with child welfare and a review of the literature in their respective fields. RESULTS: Being in foster care is a defining experience in these children's lives. They are at risk in myriad ways: for instance, being poor, having chronic health deficits, experiencing the trauma of abuse and neglect, and suffering from a gamut of emotional challenges. Evolutionary developments in foster care such as therapeutic foster homes, kinship care, and changes in Medicaid funding will continue to alter the system. CONCLUSIONS: Foster children are a huge reservoir of unmet pediatric and psychiatric needs; research on them is spotty at best. It is hoped that child and adolescent psychiatrists will meet the challenges these youngsters present and will advocate for them.

Children living through a Desert Storm.

Mental health professionals have long been concerned about how children react to war. This paper reports a small, naturalistic study of how children reacted to Operation Desert Storm. Although no actual danger threatened these affluent east coast children, television transported the battle zone's gory pictures right into the living room. That experience had a deep impact on many children. Not only did they empathize with the wounded and maimed; they also resented the way injured people's privacy was invaded and were bewildered by news reporters' "bizarre" behavior when danger was imminent.

Familial bathing patterns: implications for cases of alleged molestation and for pediatric practice.

In a cross-sectional study of how 576, upper-middle class children were socialized around bathing behaviors, families were found to be variable in their handling of bathing practices. But as a group, children were found to bathe alone more frequently as they grew older, and parents were found to bathe less frequently with the child of the opposite sex, particularly as children grew older. It was uncommon for mothers to bathe or shower with sons older than 8 years of age or for fathers to bathe or shower with daughters older than 9 years of age, although most had stopped before that age. This cross-sex aversion may be a reflection of the incest taboo. Several suggestions are made about the development-related changes in bathing practices identified in the study.

Therapeutic considerations with adult children of alcoholics.

Children from alcoholic homes frequently develop defenses similar to those found in children who have been physically abused. During adulthood these defenses lead to over-control of one's emotions and interpersonal interactions. Therapeutic implications involve management of grief reactions as illusions of the "good" parent are relinquished.

Play assessment in the differential diagnosis of autism and other causes of severe language disorder.

The autistic child's problems with language may be an impairment in symbolic functioning that affects all forms of communication, including representational thought and the ability to play creatively. The hypothesis that autistic children specifically do not project symbolic meaning onto toys (which is not associated with other conditions causing severe language disorder) was tested in a group of 15 severely language-impaired children. Data were obtained from a parent interview/questionnaire and analysis of a video-taped play session. The findings suggest that language-disordered children who meet DSM III criteria for autism most consistently show absence of symbolic play, and those who do have symbolic play fall into a wide range of diagnostic categories excluding autism. The report presents valuable observational and interpretational clinical factors, useful in the assessment and differential diagnosis of a language-impaired child.

Sleeping patterns in upper-middle-class families when the child awakens ill or frightened.

Prior research on whether parents and children ever share a bed is scanty. Some experts have written that if parents take their frightened child into bed with them, there will be "devil to pay." Using a questionnaire, we surveyed 415 upper-middle-class parents of 576 children. We asked if, when their child awoke ill or frightened, they took the child into their bed. They commonly did. We question whether explanations that ascribe the cause of psychopathologic disorders to specific events may not be too simplistic. To date, too much attention may have been paid to the events, such as parents and children sharing a bed, are not enough has been devoted to the context, motivation, and setting in which these events occur.

The primal scene: a study of prevalence.

Although primal scene experiences have been implicated as causal agents in innumerable psychopathologic states, no study of their actual prevalence exists. The authors conducted five separate studies, in which parents reported that 9%-41% of their children had seen parental intercourse. If the times children see parental intercourse without the parents knowing it and the times children hear parents making noises during intercourse were included, the prevalence would be much higher. In view of the frequent occurrence of primal scene experiences, factors other than the viewing itself must influence psychopathological outcomes when they occur.

Problems in the psychotherapy of children with histories of incest.

Therapists must be cognizant of the meaning of the patients' presentation and the extreme need for therapeutic safety. The therapists must be keenly aware of the deprivation issues for these patients and not be seduced by the sexual "red herring." At the same time, the therapist must be careful that his own discomfort does not make him run away from the sexual material. Thus the therapist must strike a difficult balance between the two. The therapist must avoid allying with the child solely as a victim, an alliance which would hinder an understanding of the child's motivation and subsequent guilt, and thus foster further difficulties. The therapist must work through his own outrage that a child has been molested so that he may avoid blame seeking. By attending to these issues, the individual psychotherapist will pass the patients' "test" and take the first step in helping patients and their families in forming a therapeutic working alliance.

Incidence of a history of incest among 18 female psychiatric patients.

The author ascertained the frequency of reports of a history of incest among the 18 female psychiatric outpatients he first evaluated or treated in a one-year period. Six of these patients (33%) reported a history of incest. The author suggests that if this figure reflects actual prevalence, previous estimates of a history of incest among female psychiatric patients may have been mistakenly low. He discusses the implications and limitations of the statistics.

Fantasy and reality in patients reports of incest.

This paper explores some of the complex difficulties facing clinicians trying to assess whether a patient's report of incest is fantasy or reality. The role of sexualized family interactions, the age of the child, the nature of the act, and the quality of the reports are discussed as relevant variables. Cases are used to illustrate various points. In conclusion, we provide 8 questions the clinician should review before making any judgments about a report of incest being reality, especially when legal procedures are involved.

Endogamic incest and the victim-perpetrator model.

Traditionally incest has been seen as the aggressive act of a deranged adult perpetrator against a child victim. While this conceptualization is true for some cases of incest, it ignores the family dynamics and the underlying affectional neglect and deprivation that the child has experienced in the home environment. It can lead to interventions such as immediate incarceration of the perpetrator in all cases, which may cause more harm than good; furthermore, it may permit the state to provide no therapeutic services to the child. By using a more realistic conceptualization of prolonged endogamic incest, useful interventions and therapeutic plans can be designed.