John E. Schowalter

Evolution and Revolution in Child Psychiatry: ADHD as a Disorder of Adaptation

Current knowledge about early plasticity and childrens responsiveness to environmental modifications as well as the atheoretical nature of current nosological systems necessitate alternative models to explain the phenomena of childhood behavioral and emotional disturbances. Evolutionary biology provides one such framework. It organizes data from the behavioral and cognitive sciences and parallels similar efforts in other areas of medicine and biology. Through an evolutionary biological lens, some mental disorders are better viewed as an adaptive response to early pathogenic environments and/or reflect the optimization of brain function to some environments at the cost of poorer response to the demands of other environments. As an example, the authors examine attention-deficit/hyperactivity disorder (ADHD) in relation to evolutionary theories of psychology and biology and clarify the potentially adaptive nature of characteristics of inattention, impulsivity, and motoric hyperactivity, depending on the nature of childs environments. Reframing ADHD characteristics according to evolutionary theory has important treatment implications for clinicians and offers researchers opportunities for novel scientific discoveries.

Psychological Reactions to Physical Illness and Hospitalization in Adolescence: A Survey

Abstract This paper surveys some of the psychoanalytic and psychosomatic literature which comments on the developmental aspects of adolescence and on the impact of bodily illness. Special attention is paid to the influence of debilitation on an adolescent patients self-esteem and ego-ideal formation. It is suggested that the encouragement of self-care, the facilitation of the appropriate use of signal anxiety, anticipator mourning and/or denial, as well as education in adaptive skills, are specific measures which are psychologically felicitous for the care of physically ill adolescents.

Death and the pediatric house officer

Pediatric house officers treating dying children often tend to withdraw from the patient and from their own feelings. Routine supervision by experienced faculty early in the house officers career may be crucial for the modifications of these tendencies.

Countertransference in Work with Children: Review of a Neglected Concept

Because the instrument of psychotherapy is the therapist, countertransference has important implications for treatment. The concept has been largely ignored in the literature. Yet, because psychotherapy has come under intense scrutiny by researchers, third-party payers, and patients, an awareness of concepts such as countertransference as an aid in a positive therapeutic outcome is important.

Bipolar Affective Disorder in Children and Adolescents

For many children and adolescents, psychiatric disorders are likely to have far-reaching consequences. In addition to having an immediate impact on everyday functioning, they may contribute to adjustment problems beyond childhood and adolescence by interfering with the mastery of important developmental tasks, such as regulation of emotions, acquisition of competencies, and establishing and maintaining social relationships. For this reason alone, childhoodand early adolescent-onset bipolar illness may carry greater risk for poor outcomes than bipolar illness beginning in late adolescence or adulthood. Evidence of high loadings of affective disorders in families of bipolar children and adolescents suggests further that very early onset manicdepressive illness may have a genetic basis and, because of its early manifestation, may be an especially severe and devastating form of the disorder. The Child and Adolescent Disorders Research Branch of the Division of Clinical and Treatment Research, National Institute ofMental Health (NIMH) recently convened a workshop to explore what is known about bipolar disorder in children and adolescents and set directions for future research. Four papers in this special section are based on presentations at that meeting-one on phenomenlogy (Weller et al.), rwo on

Psychodynamics and Medication

In many training programs and for many practitioners there is conflict between the importance and use of psychotherapy and pharmacotherapy. Some of the historical, political, interpersonal, and intrapersonal roots of the problem are summarized in the hope that understanding and self-scrutiny will help break down the splitting that remains all too common.

The Use and Abuse of Pets

Animals commonly influence childrens behavior and development. Children involve animals in their use of such defense mechanisms as displacement, projection, splitting, and identification. These same mechanisms may also be used to deal with their experiences with animals. Therapists are encouraged to inquire into childrens associations with animals as a means of more thoroughly understanding their patients.

How to manage conflicts of interest with industry

The use of medications has risen steadily in psychiatry. Perhaps in response, during the past few years there has been increasing scrutiny of alleged unethical behaviours by medical researchers, educators, and practitioners secondary to influence by the pharmaceutical industry. Research is quite consistent that gifts and generous financial arrangements can dampen skepticism, sometimes unconsciously, and thereby persuade recipients to advocate for or prescribe medications that are more expensive, but no more effective, than alternatives. Interestingly, this research-backed premise that physicians can be lured by gifts remains often disbelieved by recipients. Adding to such inducements to prescribe new, expensive medications are pressures from patients due to the increasing ubiquity of direct-to-consumer advertising. Criticism from patient advocate groups, government agencies, and the press has sparked debate within the profession. Many medical journals, academic medical centre research and educational endeavours, and medical organizations are reviewing policies to eliminate, or better manage, their conflicts of interest with industry. The basic ethical standard is that although pharmaceutical companies’ primary concern is for its shareholders, physicians’ primary concern must be for their patients.

Best Interests of the Child in the Family and Community: Social, Legal, and Medical Implications for Pediatricians

Pediatricians play a large role in social-legal efforts to assure children of appropriate priorities in a democratic society. Pediatricians must be aware of the social, legal, and medical ramifications of divorce, physical or sexual abuse, and medical/pediatric problems and how to serve the best interests of the child.

The minor's role in consent for mental health treatment.

Abstract The evolution of legal criteria used to determine the rights of minors to pediatric care is reviewed. It is noted that little thought has been given to deciding when a minor can or should be able to request psychiatric care without parental consent. A developmental framework is suggested which would allow such treatment at the discretion of the psychiatrist when the minor is able to understand the particular treatment sufficiently to give informed consent. Clinical and legal issues raised by such a policy are discussed.