Alfonso Martínez-Taboas

Stimulant and Psychosocial Treatment of ADHD in Latino/Hispanic Children

OBJECTIVE To examine to what extent Latino/Hispanic children with and without attention-deficit/hyperactivity disorder (ADHD) are receiving treatment and to identify variables that predict treatment with stimulant medication. METHOD Primary caretakers of a probability household sample (N = 1,897) of Puerto Rican children aged 4-17 years were administered structured interviews (response rate: 90.1%) from 1999-2000 to ascertain psychiatric disorders and types of services received. RESULTS Only 7.0% of children with ADHD received stimulant medication during the last year; moreover, only 3.6% had actually continued this treatment at the time of the interview. One fourth or less of those with ADHD received school-based services or psychosocial treatment. The male-female ratio in stimulant medication use was 10 to 1. In addition, only 0.2% of those with no psychiatric diagnosis received this treatment. ADHD and ADHD-not otherwise specified, impairment, and being male significantly predicted stimulant treatment. CONCLUSIONS Children with ADHD in this Latino/Hispanic population are not receiving the most efficacious treatments based on scientific findings and relevant clinical consensus. This population is undertreated rather than overtreated.

Dissociative identity disorder: An empirical overview:

Objective: Despite its long and auspicious place in the history of psychiatry, dissociative identity disorder (DID) has been associated with controversy. This paper aims to examine the empirical data related to DID and outline the contextual challenges to its scientific investigation. Methods: The overview is limited to DID-specific research in which one or more of the following conditions are met: (i) a sample of participants with DID was systematically investigated, (ii) psychometrically-sound measures were utilised, (iii) comparisons were made with other samples, (iv) DID was differentiated from other disorders, including other dissociative disorders, (v) extraneous variables were controlled or (vi) DID diagnosis was confirmed. Following an examination of challenges to research, data are organised around the validity and phenomenology of DID, its aetiology and epidemiology, the neurobiological and cognitive correlates of the disorder, and finally its treatment. Results: DID was found to be a complex yet valid disorder across a range of markers. It can be accurately discriminated from other disorders, especially when structured diagnostic interviews assess identity alterations and amnesia. DID is aetiologically associated with a complex combination of developmental and cultural factors, including severe childhood relational trauma. The prevalence of DID appears highest in emergency psychiatric settings and affects approximately 1% of the general population. Psychobiological studies are beginning to identify clear correlates of DID associated with diverse brain areas and cognitive functions. They are also providing an understanding of the potential metacognitive origins of amnesia. Phase-oriented empirically-guided treatments are emerging for DID. Conclusions: The empirical literature on DID is accumulating, although some areas remain under-investigated. Existing data show DID as a complex, valid and not uncommon disorder, associated with developmental and cultural variables, that is amenable to psychotherapeutic intervention.

Methodological Challenges in Assessing Children's Mental Health Services Utilization

This paper describes the reliability and validity of the service assessment for children and adolescents (SACA) for use among Spanish-speaking respondents. The test-retest reliability of the instrument was assessed in a randomly selected clinical sample of 146 Puerto Rican children and adolescents aged 4–17. Both parents and children were administered the SACA twice by independent interviewers over an average 12-day follow-up period. The accuracy of parental and youth self-reports was assessed by comparing these reports to information obtained from medical records. The results showed that parents and children (aged 11–17) were able to report with fair to moderate reliability any last year use of mental health services, any outpatient mental health services, and school services. Residential and hospitalization services were reported by both informants with substantial test-retest reliability. Slight or no test-retest reliability was obtained for parent and child on the use of the specific type of mental health professionals, as well as parental reports of several treatment modalities. Substantial sensitivity of the SACA was obtained when comparing medical records to parental and child reports to lifetime use of any service and outpatient mental health service. Moderate sensitivity was obtained for last year use of mental health services for both parent and child informants.

The Cross-Cultural Assessment of Dissociation

Dissociation is a human capacity that can fulfill an adaptive or maladaptive function in specific circumstances, and which appears to be particularly recruited as a response to trauma in most cultural settings around the world. Although much of the initial work on dissociation was done in Europe and the United States, recent expansion of research on this topic in other cultural regions has led to welcome progress toward a more global understanding of dissociation. This progress is reflected in a greater ethno-cultural diversity of populations under study, expansion of the known phenomenology of dissociation and thus the conceptualization of the construct, creation of new assessment instruments, and renewed debate over existing diagnostic categories. This chapter reviews current understandings of the phenomenology and classification of dissociation from a cross-cultural perspective, including its relationship to trauma, with a focus on current assessment methodologies. These topics are illustrated with recent dissociation research from two non-US, nonEuropean cultural settings, Puerto Rico and Turkey.

The Psychometric Properties of a Shortened Version of the Spanish Adolescent Dissociative Experiences Scale

ABSTRACT The aim of this study was to examine the psychometric properties of a Spanish translation of an eight-item version of the Adolescent Dissociative Experiences Scale (ADES-8). The eight items were selected to assess pathological forms of dissociative experiences. The scale was administered to a representative sample of 459 medically indigent adolescents, ages 11 to 17, who received mental health services in Puerto Rico. Results indicated that the ADES-8 demonstrated satisfactory internal consistency and test-retest reliability. As expected, most adolescents evidenced very low scores, with nearly half (46%) scoring zero. The scale showed expected patterns of convergent validity with variables that are hypothesized to be related to dissociative disorders, such as psychiatric impairment, comorbidity, and abusive experiences. Logistic regression analyses suggested that a cutoff score of three on the ADES-8 was the best screening rule for identifying persons with higher values on the convergent validity variables. The findings provide support for the clinical and research promise of the ADES-8 as a screening instrument for dissociative disorders in referred youths.

Psychogenic Seizures in an Espiritismo Context: The Role of Culturally Sensitive Psychotherapy.

A case of a Puerto Rican woman with a complex clinical presentation of psychogenic seizures (PS) is discussed to illustrate how cultural practices and beliefs transform such dissociative somatoform disorders. In this case, the PS revolved around some deeply ingrained spiritist beliefs and possession experiences, which permitted the externalization of the client’s guilt feelings for not having averted the suicide of her grandmother. It also shows how a psychotherapist can integrate the client’s cultural beliefs in spiritism (or espiritismo) with some well-known traditional therapeutic techniques. Also, it illustrates the benefits of using a cultural conceptualization that takes into account the client’s religious attribution of her illness and describes how the effectiveness of traditional therapeutic modalities can be enhanced by reframing them according to the phenomenological framework of the client.

The Role of Hypnosis in the Detection of Psychogenic Seizures

Abstract In this preliminary clinical investigation, hypnosis was used in the differential diagnosis of epileptic versus psychogenic seizures (PS). Eight patients with a clinical profile suggesting the presence of PS were given a hypnotic suggestion in which they had to go back in time to the exact moment of their last seizure. They were then asked to concentrate their attention on any unusual feeling or bodily sensation. All 8 patients presented a PS during the age regression protocol. In 6 cases, independent testimony from family members corroborated the morphological similarity of the induced attack and the ones presented in their natural environment. Also, the seizures ended abruptly after a command was given to stop them. A control group of 5 epileptic subjects did not present any signs of discomfort or seizure behavior during the hypnotic protocol. It is argued that a simple procedure as the one described in this investigation can be useful as a diagnostic tool in the differentiation of epileptic from PS attacks.

Dissociative experiences in children with abuse histories: a replication in Puerto Rico.

ABSTRACT This study examined the use of a Spanish version of the Child Dissociative Checklist (CDC) in Puerto Rico. The CDC was administered to the primary caretakers of three groups of children: 31 with documented abuse histories, 30 with Attention Deficit Hyperactivity Disorder (ADHD), 33 with no abuse or psychiatric record. Results confirmed the reliability and validity of the CDC and revealed that Puerto Rican children with abuse histories showed significantly higher levels of dissociation than the children in the other two groups. Moreover, more than half of the abused children had a score above the usual cut-off point of 12 in the CDC, while only a handful of the ADHD children and none in the control group evidenced such a pattern. The results also showed that there were significant correlations between the CDC and the duration of the abusive experiences. Implications of our findings and subsequent clinical recommendations are offered.

Separating fact from fiction : an empirical examination of six myths about dissociative identity disorder

AbstractDissociative identity disorder (DID) is a complex, posttraumatic, developmental disorder for which we now, after four decades of research, have an authoritative research base, but a number of misconceptualizations and myths about the disorder remain, compromising both patient care and research. This article examines the empirical literature pertaining to recurrently expressed beliefs regarding DID: (1) belief that DID is a fad, (2) belief that DID is primarily diagnosed in North America by DID experts who overdiagnose the disorder, (3) belief that DID is rare, (4) belief that DID is an iatrogenic, rather than trauma-based, disorder, (5) belief that DID is the same entity as borderline personality disorder, and (6) belief that DID treatment is harmful to patients. The absence of research to substantiate these beliefs, as well as the existence of a body of research that refutes them, confirms their mythical status. Clinicians who accept these myths as facts are unlikely to carefully assess for dissociation. Accurate diagnoses are critical for appropriate treatment planning. If DID is not targeted in treatment, it does not appear to resolve. The myths we have highlighted may also impede research about DID. The cost of ignorance about DID is high not only for individual patients but for the whole support system in which they reside. Empirically derived knowledge about DID has replaced outdated myths. Vigorous dissemination of the knowledge base about this complex disorder is warranted.

Post-Traumatic Stress Disorder, Dissociation, and Neuropsychological Performance in Latina Victims of Childhood Sexual Abuse

This study compared the memory, attention/concentration, and executive functioning of 12 women with histories of child sexual abuse with a control group of 12 women without childhood abuse. Participants completed a neuropsychological test battery and various instruments assessing post-traumatic stress disorder and dissociation. The child sexual abuse group had lower performance than the control group on long- and short-term visual and verbal memory and presented more limited performance on executive functioning tasks. Functioning in these areas showed a negative correlation with post-traumatic stress disorder and dissociative symptoms. These findings suggest that child sexual abuse is associated with memory and executive functioning deficits and supports the idea that people with trauma histories and increased post-traumatic stress disorder and dissociation symptoms may have alterations in neuropsychological functioning.