George M. Realmuto

Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society

Part I: Background Issues and History. van der Kolk, McFarlane, The Black Hole of Trauma. McFarlane, van der Kolk, Trauma and its Challenge to Society. van der Kolk, Weisaeth, van der Hart, History of Trauma in Psychiatry. Part II: Acute Reactions. Shalev, Stress versus Traumatic Stress: From Acute Homeostatic Reactions to Chronic Psychopathology. Solomon, Laror, McFarlane, Acute Posttraumatic Reactions in Soldiers and Civilians. Part III: Defining and Diagnosing Posttraumatic Stress Disorder. Brett, The Classification of Posttraumatic Stress Disorder. McFarlane, Girolamo, The Nature of Traumatic Stressors and the Epidemiology of Posttraumatic Reaction. McFarlane, Resilience, Vulnerability and the Course of Posttraumatic Reactions. van der Kolk, The Complexity of Adaptation to Trauma: Self-regulation, Stimulus Discrimination, and Characterological Development. van der Kolk, The Body Keeps the Score: Approaches to the Psychobiology of Posttraumatic Stress Disorder. Newman, Kaloupek, Feane, Assessment of Posttraumatic Stress Disorder in Clinical and Research Settings. Part IV: Memory: Mechanisms and Processes. van der Kolk, Trauma and Memory. van der Kolk, van der Hart, Marmar, Dissociation and Information Processing in Posttraumatic Stress Disorder. Part V: Developmental, Social, and Cultural Issues. Pynoos, Steinberg, Goenjian, Traumatic Stress in Childhood and Adolescence, Recent Developments and Current Controversies. Prior Traumatization and the Process of Aging: Theory and Clinical Implications. Pitman, Sparr, Saunders, McFarlane, Legal Issues in Posttraumatic Stress Disorder. de Vries, Trauma in Cultural Perspective. Part VI: Treatment. van der Kolk, McFarlane, van der Hart, A General Approach to Treatment of Posttraumatic Stress Disorder. Ursano, Grieger, McCarroll, Prevention of Posttraumatic Stress: Consultation, Training, and Early Treatment. Raphael, Wilson, Meldrum, McFarlane, Acute Preventive Interventions. Turnbull, McFarlane, Acute Treatments. Rothbaum, Foa, Cognitive-Behavioral Therapy for Posttraumatic Stress Disorder. Davidson, van der Kolk, The Psychopharmacological Treatment of Posttraumatic Stress Disorder. Lindy, Psychoanalytic Psychotherapy of Posttraumatic Stress Disorder: The Nature of the Therapeutic Relationship. Turner, McFarlane, van der Kolk, The Therapeutic Environment and New Explorations in the Treatment of Posttraumatic Stress Disorder.

Practice parameters for the assessment and treatment of children, adolescents, and adults with autism and other pervasive developmental disorders

Autism and the related pervasive developmental disorders are characterized by patterns of delay and deviance in the development of social, communicative, and cognitive skills, which arise in the first years of life. Although frequently associated with mental retardation, these conditions are distinctive in terms of their course and treatment. These conditions have a wide range of syndrome expression, and their management presents particular challenges for clinicians. Individuals with these conditions can present for clinical care at any point in development. The multiple developmental and behavioral problems associated with these conditions often require the care of multiple providers; coordination of services and advocacy for individuals and their families is important. Early, sustained intervention is indicated, as is the use of various treatment modalities (e.g., pharmacotherapy, special education, speech/communication therapy, and behavior modification).

Prevalence of ADHD and comorbid disorders among elementary school children screened for disruptive behavior

In the context of a school-based prevention of conduct disorder program, 7,231 first- through fourth-grade children were screened for cross-setting disruptive behavior. Frequencies of DSM-III-R psychiatric disorders and patterns of comorbidity were assessed. We also examined the association of psychiatric diagnosis with child and parent characteristics to determine differential risk based on diagnostic subgroups. Attention deficit hyperactivity disorder (ADHD) and oppositional-defiant disorder (ODD) were the most frequent diagnoses. Mood and anxiety disorders were infrequent as single diagnoses. Patterns of comorbidity demonstrated that both externalizing and internalizing disorders commonly cooccurred with ADHD. More severe degrees of psychopathology and psychosocial risk accrued to the subgroup of youths with ADHD plus a comorbid externalizing disorder.

An integrated components preventive intervention for aggressive elementary school children: the early risers program.

The Early Risers prevention program aims to alter the developmental trajectory of children with early onset aggressive behavior. The program features 4 CORE components: (a) an annual 6-week summer school program, (b) a teacher consultation and student mentoring program, (c) child social skills groups, and (d) parent education and skills-training groups, all delivered in tandem with a FLEX family support program individually tailored to address the unique needs of families. At baseline, the mean age of the sample was 6.6 years. Following 2 years of intervention, program children showed significant improvement relative to controls in academic achievement and school behaviors. Change on behavioral self-regulation was moderated by level of child aggression, with intervention effects found for only the most severely aggressive children. Parents with high program attendance rates showed improvement in discipline methods.

Comorbidity of Psychiatric Diagnoses with Posttraumatic Stress Disorder in Survivors of Childhood Trauma

OBJECTIVE This study examines posttraumatic stress disorder (PTSD) symptoms, trauma exposure, gender, and diagnostic comorbidity in a sample of 59 Cambodian young adults (29 male and 30 female) who survived massive trauma as children. METHOD Psychiatric diagnoses were made using the Structured Clinical Interview for DSM-III-R-Non-Patient version, a structured diagnostic interview, and trauma exposure was measured with a Traumatic Life Events Questionnaire. RESULTS A significant number of those with PTSD (59%) had one or more additional DSM-III-R Axis I disorders. Major depression and generalized anxiety disorder were the most common comorbid disorders. Somatoform pain disorder was also found to coexist with PTSD but only among females. Women were also found to have higher levels of both current and lifetime PTSD symptoms. CONCLUSION Trauma symptoms were related to exposure and exposure was related to age, but age was not related to symptoms. The findings suggest that the significant levels of comorbid diagnoses previously found to exist with PTSD in people traumatized as adults can be found among survivors of massive childhood trauma. Also, the rate of PTSD diagnoses found in this sample 15 years after the trauma of Pol Pot is comparable to findings previously reported in studies of Cambodian youths and shows that the effects of trauma experienced in childhood persist into early adulthood.

Clinical effect of buspirone in autistic children

Buspirone is a novel antianxiety agent with no chemical similarity to other psychotropic medications. Pharmacological effects include inhibition of serotonin neurons, decrease of striatal levels of serotonin and metabolites, and reduction in serotonin binding sites. Buspirone also has effects on dopamine, norepinephrine, and the GABA systems. To pursue an antiserotonergic treatment rationale for autistic disorder, an open-blind 4-week trial comparing buspirone to fenfluramine or methylphenidate was conducted. Hyperactivity was a target symptom in three children with improvement noted in two with buspirone. Behavioral toxicity was encountered in one of two autistic subjects treated with methylphenidate and very mild improvement in another subject on fenfluramine. An autistic child with obsessive ideation was unchanged. No adverse reaction to buspirone was encountered. Further investigation in a double-blind trial of buspirone is warranted for treatment of symptoms of autism, especially aggression and hyperactivity.

Dissemination of an evidence-based prevention innovation for aggressive children living in culturally diverse, urban neighborhoods: the Early Risers effectiveness study

This study evaluated the effectiveness of the Early Risers “Skills for Success” Program when implemented by neighborhood family resource centers available to urban children and their families. Kindergarten and first-grade children (n=327) enrolled in 10 schools were screened for aggressive behavior, and randomized to two model variations of the Early Risers Program or a no-intervention control condition. The full-strength model (CORE + FLEX) included child and parent/family components whereas the partial model (CORE-only) offered only the child component. The intervention was delivered over two continuous years. CORE + FLEX children showed higher levels of program attendance than their CORE-only counterparts but no differences on outcomes measures were observed between models. When both program models were collapsed and compared to controls, program children showed significant gains on measures of school adjustment and social competence, the most aggressive program children showed reductions in disruptive behavior, and program parents reported reduced levels of stress.

Catatonia in autistic disorder: A sign of comorbidity or variable expression?

Catatonia, once solely attributed to schizophrenia, is now thought to be associated with many disorders. Autistic disorder shares some symptoms with catatonia, namely, mutism, echopraxia/echolalia, and stereotypies. Catatonia in autism may therefore be a variant of the autistic condition. However, organic deficits and psychiatric disorders, such as bipolar disorder, have also been linked with the manifestation of catatonia. Individuals with autism presenting with these comorbid conditions may therefore be at increased risk for catatonia. Little is written of the association of autism and catatonia to clarify the possibility of catatonia as a variant or a sign of a comorbid condition. The authors discuss three autistic patients and suggest specific etiologies for the symptoms of catatonia which presented in these cases. The therapeutic and diagnostic importance of comorbid disorders in autism is stressed.

Can Evidence-Based Prevention Programs be Sustained in Community Practice Settings? The Early Risers’ Advanced-Stage Effectiveness Trial

This study evaluated institutional sustainability of the Early Risers “Skills for Success” conduct problems prevention program. In a previous early-stage effectiveness trial Early Risers had been successfully implemented by a nonprofit community agency with guidance, supervision, technical assistance and fiscal support/oversight provided by program developers. The current advanced-stage effectiveness trial applied a randomized, control group design to determine whether this community agency could replicate earlier positive findings with a new cohort of participants, but with less direct involvement of program developers. An intent-to-intervene strategy was used to compare children randomly assigned to Early Risers or a no-intervention comparison group. Compared to results obtained in an early-stage effectiveness trial, program attendance rates were much lower and only one positive outcome was replicated. Failure to replicate program effects was not attributed to poor program implementation, because data collected pertaining to exposure, adherence and quality of delivery were acceptable, and a participation analysis showed that families who attended at higher levels did benefit. It was difficulties that the community agency experienced in engaging families in program components at recommended levels that primarily accounted for the results. Possible organizational barriers that impeded sustainability included unreliable transportation, poor collaboration between the agency and the local public school system, high staff turnover, agency downsizing, and fiduciary responsibility and accountability. It was concluded that both program developers and program providers need to be proactive in planning for sustainability.

Patterns and Temporal Changes in Peer Affiliation Among Aggressive and Nonaggressive Children Participating in a Summer School Program

Examined the behavior and affiliation patterns of 118 highly, moderately, and nonaggressive 7-year-old children over the course of a 6-week summer school program. During free play, participants did not selectively associate on the basis of behavioral similarity, but initial mutual friendship choices did show a preference for similarly behaved peers. Nonreciprocated friendships at the beginning and end of the program and mutual friendships at the end revealed a preference of all children to befriend nonaggressive peers. Moderately aggressive children increased their number of mutual friendships and their association with nonaggressive peers during free play, whereas highly aggressive children lost mutual friends. The aggressiveness of a childs playmates predicted the likelihood of that child behaving inappropriately during free play. Results suggest that selective affiliation may be the result of peer rejection rather than an active process of seeking similarly aggressive peers.