PSYCH DB and 2 replies due Tues Dec 11

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Down syndrome, p. 459

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percent, 61 percent, and 16 percent of New York’s general population.

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pale and her eyes red-rimmed as she reflects on the dark perio

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Disorders of Childhood and Adolestence :ft 4

Research has not favored one explanation for enuresis over the others. Psychody�namic theorists explain it as a symptom of broader anxiety and underlying conflicts (Friman, 2008). Family theorists point to disturbed family interactions (Fletcher, 2000). Behaviorists view the problem as the result of improper or coercive toilet training (Christophersen & Purvis, 2001).And biological theorists suspect that children with this disorder often have a small bladder capacity or weak bladder muscles (Friman, 2008).

Most cases of enuresis correct themselves even without treatment. However, therapy, particularly behavioral therapy, can speed up the process (Butler, 2004; Nield & Kamat, 2004). In a widely used classical conditioning approach, the bell-and-battery technique, a bell and a battery are wired to a pad consisting of two metallic foil sheets, and the entire apparatus is placed under the child at bedtime (Houts, 2003; Mowrer & Mowrer

1938).A single drop of urine sets off the bell, awakening the child as soon as he or she�starts to wet. Thus the bell (unconditioned stimulus) paired with the sensation of a full�bladder (conditioned stimulus) produces the response of waking. Eventually, a full blad

�

der alone awakens the child.

Another effective behavioral treatment method is dry-bed training in which children receive training in retention control, are awakened periodically during the night, practice

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sponsored by Parents Anonymous, which helps parents to develop insight into their behavior, provides training on alternatives to abuse, and teaches parenting skills (Tolan et al., 2006; Wolfe et al., 1988). Still other treatments help parents deal more effectively with the stresses that often trigger the abuse, such as unemployment, marital conflict, and feelings of depression. In addition, preven�tion programs, often in the form of home

visitations and parent training, have proved

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promising (Wekede et al., 2007).

Finally, research suggests that the psychological needs of the child victims should be addressed as early as possible (Gray et al., 2000; Roesler & McKenzie, 1994). Clinicians and educators have launched early detection programs tha

aim to (1) educate all children about child abuse, (2) teach them skills for avoiding or escaping from abusive situations, (3) encourage children to tell another adult if they are abused, and (4) assure them that abuse is never their own fault (Godenzi

& DePuy, 2001; Finkelhor et al., 1995). These programs seem to increase the likelihood that children will report abuse, reduce their tendency to blame themselves for it, and increase their feelings of effi�cacy (Goodman-Brown et al., 2003).

�

446 ://CHAPTER

table

Comparison of Childhood Disorders

Prevalence

Gender

wit

Elevated

Usual Age

Greate

Family

Recovery by

Disorder

Identificatio

All Children

Prevalence

History

Adulthood

Separation anxiety

Before 12 years

Females

Yes

Usually

disorder

Conduct disorder

7-15 years

10%

les

Yes

Often

ADH

Before 12 years

Yes

Often

Enures

5-8 years

Males

Yes

Usually

Encopresis

After 4 years

Males

Unclear

Usually

Learning disorders

6-9 years

Males

Yes

Often

Autis

0-3 years

0.17%-0.63% Males

Yes

Sometimes

1-3%

Mental retarda

tion

Before 10 years

Males

Unclear

Sometimes

.,7.

going to the bathroom, and are appropriately rewarded (Friman, 2008; Christophersen�& Purvis, 2001). Like the bell-and-battery technique, this behavioral approach is often

effective, according to research.

Encopresis

Encopresis, repeatedly defecating into one’s clothing, is less common than enuresis, and it is also less well researched.This problem usually occurs during the waking hours, not at night during sleep (Walker, 2003). It is usually involuntary, starts after the age of 4, and affects about 1 percent of 5-year-olds (see Table 14-4). The disorder is

common in boys than in girls (Friman,

2008; APA, 2000).

Encopresis causes intense social problems, shame, and embarrassment (Cox et al., 2002). Children who suffer from it usually try to hide their condition and to avoid situ�ations, such as camp or school, in which they might embarrass themselves (APA, 2000). Cases may stem from stress, biological factors such as repeated constipation, improper toilet training, or a combination of these factors. Because physical problems are so often

linked to the disorder, a medical examination is typically conducted first.

The most common and successful treatments for encopresis are behavioral and medical approaches (Friman, 2008; McGrath et al., 2000). Among other features of treatment, practitioners may try to help the children better detect when their bowels are full by the application of biofeedback training (see pages 105 and 156), eliminate the children’s constipation, and stimulate regular bowel functioning with high-fiber diets, mineral oil, laxatives, and lubricants (Friman, 2008; McClung et al., 1993). Family therapy has also proved helpful (Murphy & Carr, 2000).

�

•

Conduct Disorder, ADHD, and Elimination Disorders

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Children with opposition

I defiant disorder and conduct disorder exceed the nor�

In Their WoidS

mal breaking of rules and act very aggressively. Those with oppositional defiant disorder argue repeatedly with adults, lose their temper, and feel intense anger and resentment. Those with conduct disorder, a more severe pattern, repeatedly violate the basic rights of others; often are violent and cruel; and may deliberately destroy

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property, steal, and run away.

Disorders of Childhood and Adolescence ://

447

Children who display attention-deficit/hyperactivity disorder (ADFID) attend poorly to tasks, behave overactively and impulsively, or both. Ritalin and

other

stimulant drugs and behavioral progr

ms are often effective treatments. Children

n elimination disorder—enuresis or encopresis —repeatedly ur

to or pass

feces in inappropriate places. Behavioral appro technique, are effective treatments for enuresi

ches, such as the bell-and-battery

along- Term Disorders That Begin in hildho®

As you read at the beginning of this chapter, many childhood disorders change or subside as the person ages. Two groups of disorders that emerge during childhood, however, are likely to continue unchanged throughout life: the pervasive developmental disorders and mental retardation. Researchers have investigated both of these categories extensively. In addition, although it was not always so, clinicians have developed a range of treatment approaches that can make a major difference in the lives of people with these

prob

lems.

Pervasive Developmental Disorders

Pervasive developmental disorders

a group of disorders marked by impaired soci

�

interactions, unusual communications, and inappropriate responses to stimuli in the environment_ The group includes autistic disorder; Asperger’s disorder; Rett’s disorder; and childhood disintegrative disorder Because autistic disorder initially received more attention than the others, these disorders are often referred to as autistic-spectrum disorders. Although the patterns are similar in many ways, they differ significantly in the degree of social impairment sufferers experience and in the time of onset. Given the low prevalence of Rett’s disorder and childhood disintegrative disorder, we will examine only autistic disorder and Asperger’s disorder in this chapter.

Autis:ic Disorder A child named Mark presents a typical picture of autism:

�

In retrospect [Susan, Mark’s mother] con recall some things that

ppeared odd to her. For

example, she remembers that . . . Mark never seemed to anticipate being picked up when

she approached. In addition, despite Mark’s attachment to a pacifier (he would cornp1

if it were mislaid), he showed little interest in toys. in fact, Mark seemed to lock inter

est

in anything. He rarely pointed to things and seemed oblivious to sounds

Mark spent

much of his time repetitively tapping on tables, seeming to be lost in his own world.

After his second birthday, Mark’s behavior began to trouble his parents

Mark,

they said, would “look through” people or past them, but rarely at them. He could say a few words but didn’t seem to understand speech. In fact, he did not even respond to his own name. Mark’s time was occupied examining familiar objects, which he would hold in

front of his eyes while he twisted

nd turned them. Particularly troublesome were Mark’s

odd movements—he would jump, flap his arms, twist his hands and fingers, and perfi

all sorts of facial grim

ces, particularly when he was excited

nd what Robert [Mark’s

father] described as Mark’s rigidity. Mark would line things up in rows and scream if they were disturbed. He insisted on keeping objects in their place and would become upset

whenever Susan attempted to rearrange the living room furniture

Slowly, beginning at age five, M

rk began to improve

The pronoun in the sentence

s inappropriate and the sentence took the form of a question he had been asked previ�

oencopresiscA childhood disorder characterized by repeated defecating in inappropriate places, such as one s clothing.

ously, but the meaning was clear.

(Wing, 1976

)

�

448 ://CHAPTER

Mark was displaying autistic disorder, or autism, a pattern first identified by American psychiatrist Leo Kanner in 1943. Children with this disorder are extremely unresponsive to others, uncommunicative, repetitive, and rigid (see Table 14-5). Their symptoms appear early in life, before 3 years of age. Just a decade ago, autism seemed to affect around 1 out of every 2,000 children (APA, 2000). However, in recent years there has been a steady increase in the number of children diagnosed with autism, and it now appears that at least 1 in 600 and perhaps as many as 1 in 160 children display

Iri Their fiords

Srlas.:

2000

the disorder (Teicher et al., 2008; Fombonne, 2003).

Around 80 percent of all cases of autism occur in boys. As many as 90 percent of children with the disorder remain severely disabled into adulthood. They have enor�mous difficulty maintaining employment, performing household tasks, and leading independent lives (Benaron, 2009). Moreover, even the highest-functioning adults with autism typically have problems displaying closeness and empathy and have limited in�

terests and activities (Baron-Cohen &Wheelwright, 2003).

The individual’s lack of responsiveness—including extreme aloofness, lack of interest in other people, low empathy, and inability to share attention with others—has long been considered the central feature of autism. Like Mark, children with this disorder typically do not reach for their parents during infancy. Instead they may arch their backs when

they are held and appear not to recognize or care about those around them.

Language and communication problems take various forms in autism. Approximately half ofall sufferers fail to speak or develop language skills (Gillis & Romanczyk, 2007).

table: 1M J4

DSM Checklist

�

—

Disorders of Childhood and Adolescence :1/ 449

Those who do talk may show peculiarities in their speech. One of the most common speech problems is echolalia, the exact echoing of phrases spoken by others. The individuals repeat the words with the same inflec�tion, but with no sign of understanding. Some even repeat a sentence

‘

�

days after they have heard it (delayed echolalia).

Because they have difficulty empathizing and sharing a frame of refer�ence with others, individuals with autism may also display other speech oddities, such as pronominal reversal, or confusion of pronouns—for ex-ample, the use of”you” instead of “I.”When Mark was hungry, he would say, “Do you want dinner?” In addition, individuals may have problems naming objects, using abstract language, employing a proper tone when talking speaking spontaneously, using language for conversational pur�

. ,

–

poses, or understanding speech.

Autism is also marked by limited imaginative play and by very repetitive and rigid behavior Children with the disorder may be unable to play in a varied, spontaneous way. Unlike other individuals of the same age, the children may fail to include others in their play and have no desire to imitate or be like others (Kasari et al., 2006).Typically they become very upset at minor changes of objects, persons, or routines and resist any ef�forts to change their own repetitive behaviors. Mark, for example, lined things up and screamed if they were disturbed. Similarly, children with

autism may react with tantrums if a parent wears an unfamiliar pair of glasses, a moved to a different part of the room, or a word in a song is changed. Kanner labeled such reactions a perseveration of sameness. Furthermore,

many sufferers f

strongly attached to particular objects—plastic lids, rubber bands, buttons, wate�may collect these objects, carry them, or play with them constantly. Some are fas

by movement and may watch spinning objects, such as fans, for hou

rs.

The motor movements of people with autism may also be unusual. Mar

jump, flap his arms, twist his hands and fingers, rock, spin, and make faces. Th

are called self-stimulatory behaviors. Some individuals also perform self-injurious behaviors,

such as repeatedly lunging into or banging their head against a wall, pulling their hair,

or biting themselves.

The symptoms of this disorder suggest a very disturbed and contradictory pattern

of reactions to stimuli. Sometimes individuals with autism seem overstimulated by sights and sounds and appear to be trying to block them out, while at other times they seem understimulated and appear to be performing self-stimulatory actions.They may, for ex�ample, fail to react to loud noises yet turn around when they hear soda being poured. Similarly, they may fail to recognize that they have reached the edge of a dangerous high place yet immediately spot a small object that is out of position in their room.

Asperger’s Disorder Around the time that Kanner first identified autism, a Vien�nese physician named Hans Asperger began to note a syndrome in which children dis�play significant social impairments yet manage to maintain appropriate levels of cognitive function and language. Those with Asperger’s disorder, or Asperger’s syndrome, experience the kinds of social deficits, odd interests, and restricted and repetitive behav�iors that characterize individuals with autism, but at the same time they often have nor�

mal (or near normal) intellectual, adaptive, and language skills (Siegel & Ficcaglia, 2006).�Many individuals with this disorder want to fit in and interact with others, but their poor�social functioning makes it hard for them to do so.They wind up appearing awkward

and

°autistic disorderoA pervasive devel�opmental disorder marked by extreme unrespo nsi veness to ers, poor commu. nication sk ills, and highly repetitive and rigid behavior. Also known as autism.

unaware of social rules (ASA, 2006).

Clinical research suggests that there may be several subtypes of Asperger’s disorder. One team of researchers has distinguished three subtypes: rule boys, logic boys, and emotion boys (Sohn & Grayson, 2005). Ride boys are Asperger sufferers who need to have a set of rules that govern their lives. They are extremely stubborn about following these rules and may become aggressive when the rules are not clearly laid out. Logic boys are primarily interested in the reasons behind rules; rules alone are not sufficient.

0Asperger’s disorderoA pervasive developmental disorder in which individ�

uals display profound social impairment yet maintain a relatively high level of cognitive functioning and language skills. Also known as Asperger’s syndrome.

450 ://CHAPTER 14

They want to know how the world works, often question the logic of others’ reasoning and may have their own reasons for why things are

happening. In turn, they are typically unwilling to accept illogical events�and often become overly analytical. Emotion boys tend to be run by their�feelings.They have more tantrums than others with Asperger’s disorder.

— ‘

�

– , –

It is hard to sway them with rules or reason, and they often act out

Approximately 1 in 250 individuals displays Asperger’s disorder, again 80 percent of them boys (CADDRE, 2004). It is important to diagnose and treat Asperger’s disorder early in life so that the individual has a better chance of being successful at school and living inde�pendently. Although Asperger individuals must contend with deficits throughout their lives, many are able to complete a high level of educa�tion, even college or trade school. Similarly, they may successfully hold jobs, particularly ones that require a focus on details and limited social interactions (ASA, 2005).

�

–

�

What Are the Causes of Pervasive Developmental Disorders? Much

has been conducted on autism than on Asperger’s

der or other perva�

sive developmental disorders.Thus, this section will concentrate on the causes of autism,�keeping in mind, however, that there may turn out to be key differences between

the

causes of this disorder and those of the other pervasive developmental

disorders.

A variety of explanations have been offered for autism. This is one disorder for which sociocultural explanations have probably been overemphasized. In fact, such explanations initially led investigators in the wrong direction. More recent work in the psychological and biological spheres has persuaded clinical theorists that cognitive limitations and brain abnormalities are the primary causes of autism.

SOCIOCULTURAL CAUSES At first, theorists thought that family dysfunction and social stress

were the primary causes of autism. When he first identified autism, for example, Kanner�(1954, 1943) argued that particular personality characteristics of the parents created an unfa�

vorable climate for development and contributed to the child’s disorder. He saw these

“refrigerator parents.” These claims had enormous

parents as very intelligent yet cold

influence on the public and on the self-image of the parents themselves, but research�has totally failed to support a picture of rigid, cold, rejecting, or disturbed parents (Jones

& Jordan, 2008).

Similarly, some clinical theorists have proposed that a high degree of social and en�vironmental stress is a factor in autism. Once again, however, research has not supported this notion. Investigators who have compared children with autism to children without the disorder have found no differences in the rate of parental death, divorce, separation, financial problems, or environmental stimulation (Cox et al., 1975).

PSYCHOLOGICAL CAUSES According to certain theorists, people with autism have a central perceptual or cognitive disturbance that makes normal communication and interactions impossible. One influential explanation holds that individuals with the disorder fail to develop a theory of mind—an awareness that other people base their behaviors on their own beliefs, intentions, and other mental states, not on information that they have

no way of knowing (Hale & Tager-Flusberg, 2005; Frith, 2000).

By 3 to 5 years of age, most children can take the perspective of another person into account and use it to anticipate what the person will do. In a way, they learn to read others’ minds. Let us say, for example, that we watch Jessica place a marble in a container

°theorybof mindoAw

their behaviors on their

people

reness that other

and then we observe Frank move the marble to a nearby room while Jessica is taking a nap. We know that later Jessica will search first in the container for the marble because she is not aware that Frank moved it.We know that because we take Jessica’s perspective into account. A normal child would also anticipate Jessica’s search correctly. A person with autism would not. He or she would expect Jessica to look in the nearby room because that is where the marble actually is. Jessica’s own mental processes would be unimportant to the

person.

own beliefs, intentions, and other mental states, not on information they have no way of knowing.

Disorders of Childhood and Adolescence :1/ 451

Studies show that people with autism do have this kind of”mindblindness,” although they are not the only kinds of individuals with this limitation (Jones & Jordan, 2008). They thus have great difficulty taking part in make-believe play, using language in ways that include the perspectives of others, developing relationships, or participating in human interactions. Why do people with autism have this and other cognitive limita�tions? Some theorists believe that they suffered early biological problems that prevented proper cognitive development.

BIOLOGICAL CAUSES For years researchers have tried to determine what biological ab�normalities might cause theory-of-mind deficits and the other features of autism. They have not yet developed a detailed biological explanation, but they have uncovered some promising leads (Teicher et al., 2008; Rodier, 2000). First, examinations of the relatives

of people with autism keep suggesting a genetic factor in this disorder. The prevalence of autism am ong their siblings, for example, is as high as 6 to 8 per 100 (Teicher et al., 2008; Gillis & Romanczyk, 2007), a rate much higher than the general population’s. Moreover, the prevalence of autism among the identical twins of people with autism is 60 percent. In addition, chromosomal abnormalities have been discovered in around 10 percent of people with the disorder (Sudhalter et al., 1990).

�

-‘ 1 Kind of Talent

ost people are familiar with the

1 k I j savant syndrome, thanks to Dustin

Hoffman’s portrayal of a man with autism

in the movie Rain M

n. The savant skills

that Hoffman portrayed—counting 246 toothpicks in the instant after they fall to the floor, memorizing the phone book through the Gs, and doing numerical calculations at lightning speed—were based on the as�tounding talents of certain real-life people who are otherwise limited by autism or

mental retardation.

A savant (French for “learned” or�”clever”) is a person with a major mental

disorder or intellectual h

ndicap wh

has some spectacular ability. Often these abilities are remarkable only in light of the handicap, but sometimes they are remark�

able by any standard (Yewchuk, 1999).

A common savant skill is calendar calcu�lating, the ability to calculate what day of

the week a d

to will fall on, such as New

Year’s Day in 2050 (Kennedy & Squire, 2007; Heavey et al., 1999). A common musical skill such individuals may possess is the ability to play a piece of classical music flawl-essly from memory after hearing it only once. Other individuals can paint exact replicas of scenes they saw years ago (Hou et al., 2000).

�

Some theorists believe that savant skills do indeed represent special forms of cogni-five functioning; others propose that the skills are merely a positive side to certain cognitive deficits (Scheuffgen et al., 2000

;

Miller, 1999). Special memorization skills, for example, may be facilitated by the very narrow and intense focus often found in cases of autism.

�

452 ://CHAPTER 14

ocerebellumeAn area of the brain that coordinates movement in the body and

Some studies have also linked autism to prenatal difficulties or birth complications (Teicher et al., 2008; Rodier, 2000). The chances of developing the disorder are higher when the mother had rubella (German measles) during pregnancy, was exposed to toxic chemicals before or during pregnancy, or had complications during labor or delivery. In 1998 one team of investigators proposed that a postnatal event—the vaccine for measles, mumps, and rubella—might produce autism in some children, alarming many parents of toddlers. However, research has not confirmed a link between the vaccine and the

helps control a person’s ability tpo shifpt attention rapidly.

disorder (Cook, 2006; Institute of Medicine, 2004).

Finally, researchers have identified specific biological abnormalities that may contribute to autism. One line of research has pointed to the cerebellum, for example (Teicher et al., 2008; Pierce & Courchesne, 2002, 2001). Brain scans and autopsies reveal abnor�mal development in this brain area occurring early in the life of people with autism. Scientists have long known that the cerebellum coordinates movement in the body, but they now suspect that it also helps control a person’s ability to shift attention rapidly. It may be that people whose cerebellum develops abnormally will have great difficulty adjusting their level of attention, following verbal and facial cues, and making sense of

social information—all key features of autism.

In a similar vein, brain scans indicate that many children with autism have increased brain volume and white matter (Wicker, 2008) and structural abnormalities in the brain’s limbic system, brain stem nuclei, and amygdala (Gillis & Romanczyk, 2007). Many individuals with the disorder also experience reduced activity in the brain’s temporal and frontal lobes when they perform language and motor tasks (Escalante,

Minshew, & Sweeney, 2003).

Given such findings, many researchers believe that autism may in fact have multiple biological causes (Cook, 2006; Mueller ac Courchesne, 2000). Perhaps all of the relevant biological factors (genetic, prenatal, birth, and postnatal) eventually lead to a common problem in the brain—a “final common pathway,” such as neurotransmitter abnormali�ties, that produces the cognitive problems and other features of

the disorder.

How Do Clinicians and Educators Treat Perv.sive Developmental

Disorders? Treatment can help people with autism adapt better to their environmen

�

although no treatment yet known totally reverses the autistic pattern. Treatments of particular help are behavioral therapy, communication training, parent training, and community integration. In addition, psychotropic drugs and certain vitamins have sometimes helped when combined with other approaches (Teicher et al., 2008; Volkmar, 2001).

BEHAVIORAL THERAPY Behavioral approaches have been used in cases of autism for�more than 35 years to teach new, appropriate behaviors, including speech, social skills,

�

classroom skills, and self-help skills, while reducing negative, dysfunctional ones (Bock

�

et al., 2009). Most often, the therapists use modeling and�operant conditioning. In modeling they demonstrate a

desired behavior and guide people with the disorder to

imitate it. In operant conditioning they reinforce such

behaviors, first by shaping them—breaking them down so they can be learned step by step—and then rewarding each step clearly and consistently (Campbell et al., 2008; Lovaas, 2003, 1987). With careful planning and execution, these

�

/pp’.il

procedures often produce more functional behaviors.

A long-term study compared the progress of two groups of children with autism (Campbell et al., 2008; McEachin et al., 1993; Lovaas, 1987). Nineteen received intensive be-haviorat treatments, and 19 served as a control group. The treatment began when the children were 3 years old and

�

–

�

–

�

continued until they were 7. By the age of 7, the behavioral

�

was doing better in school and scoring higher on intelligence tests than the control group. Many were able to go to school in regular classrooms.The gains continued into

�

Disorders of Childhood and Adolescence :if 45

the research participants’ teenage years. In light of such findings, many clinicians now consider early behavioral programs to be the preferred treatment for autism.

A recent behavioral program that has achieved considerable success is the Learning

In Their Wórds

Experiences

An Alternative Program (LEAP) for preschoolers with autism (Kohler,

Strain, & Goldstein, 2005). In this program, four autistic children are integrated with 10 normal children in a classroom. The normal children learn how to use modeling and operant conditioning in order to help teach social, communication, play, and other skills to the autistic children. The program has been found to improve significantly the cognitive functioning of autistic children, as well as their social and peer interactions, play behaviors, and other behaviors. Moreover, the normal children in the classroom

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experience no negative effects as a result of serving as intervention agents.

As such programs suggest, therapies for people with autism, particularly behavioral

ones, tend to provide the most benefit when they are started early in the children’s lives (Campbell et al., 2008; Palmer, 2003).Very young autistic children often begin with services at home, but ideally, by the age of 3 they attend special programs outside the home. A federal law lists autism as 1 of 10 disorders for which school districts must make available a free and appropriate education from birth to age 22. Typically, services are provided by education, health, or social service agencies until the children reach 3 years of age; then the department of education for each state determines what services

will be offered (NRC, 2001).

Given the recent increases in the prevalence of autism, many school districts are now trying to provide education and training for autistic children in special classes that operate at the district’s own facilities. However, most school districts remain ill equipped to meet the profound needs of students with autism. The most fortunate students are sent by their school districts to attend special schools, where education and therapy are combined. At such schools, specially trained teachers help the children improve their skills and interactions with the world.The higher-functioning students with autism may eventually spend at least part of their school day returning to normal classrooms in their

own school district (Smith et al.,

2002).

Although significantly impaired, children with Asperger’s disorder have less pro�found educational and treatment needs than do those with autism. Once diagnosed, many such children are assigned to special programs (either within their own school system or at special schools) in which they receive a combination of education and cognitive-behavioral therapy tailored to their particular impairments. In one such pro�gram, cognitive social integration therapy, the children are taught to be more flexible with regard to social rules, problem solving, and behavioral choices (Sohn & Grayson, 2005).

•

‘•

—

�

454 :A/CHAPTER 14

ocugmentative communication systemeA method for enhancing the communication skills of individuals with autism, mental retardation, or cerebral palsy by teaching them to point to plc lures, symbols, letters, or words on a

The teacher works with the Asperger students in groups, acknowledging their thoughts and feelings, teaching them how to cope with change, and helping them to develop new social skills and other kinds of abilities.The teacher also helps ensure that the newly learned skills generalize to the individual’s life by using techniques such as rehearsal, role playing, and visual imaging throughout the group sessions.

communic

tion board or computer.

COMMUNICATION TRAINING Even when given intensive behavioral treatment, half of the�people with autism remain speechless. As a result, they are often taught other forms

ementai retardation®A disorder

marked by intellectual

and

of communication, including sign language and simultaneous communication, a method combining sign language and speech. They may also learn to use augmentative com�munication systems, such as “communication boards” or computers that use pictures, symbols, or written words to represent objects or needs (Gillis & Romanczyk, 2007).A child may point to a picture of a fork to give the message “I am hungry,” for example,

adaptive behavior that are well below

avera

ge.

quotient (I0)0A score

°intelligfreonmceintelligence tests that then derived

retically represents a person’s overall intellectual capacity.

or point to a radio for “I want

music.”

Some programs now use child-initiated interactions to help improve the communication skills of autistic children (Koegel et al., 2005). In such programs, teachers try to iden�tify intrinsic reinforcers rather than trivial ones like food or candy. The children are first encouraged to choose items that they are interested in, and they then learn to initiate questions (“What’s that?”; “Where is it?”; “Whose is it?”) in order to obtain the items. Studies find that child-directed interventions of this kind often increase self-initiated conununications, language development, and social participation (Koegel et al., 2005).

PARENT TRAINING Today’s treatment programs involve parents in a variety of ways. Be��havioral programs for example, often train parents so that they can apply behavioral

techniques at home (Schreibman & Koegel, 2005). Instruction manuals for parents and�home visits by teachers are often included in such programs. Research has demonstrated�that the behavioral gains produced by trained parents are often equal to or greater than

those generated by teachers.

In addition to parent-training programs, individual therapy and support groups are becoming more available to help the parents of autistic children deal with their own emotions and needs (Hastings, 2008). A number of parent associations and lobbies also offer emotional support and practical help.

COMMUNITY INTEGRATION Many of today’s school-based and home-based programs for autism teach self-help, self-management, and living, social, and work skills as early as possible to help the children function better in their communities. In addition, greater numbers of carefully run group homes and sheltered workshops are now available for teen�agers and young adults with autism. These and related programs help the individuals become a part of their community; they also reduce the concerns of aging parents whose children will always need supervision.

Mental Retardation

Ed Murphy, aged 26, can tell us what it’s like to be diagnosed as retarded:

�

What is retardation? It’s hard to say. I guess it’s having problems thinking. Some people think that you can tell if a person is retarded by looking at them. If you think that way

you don’t give pe

pie the benefit of the doubt. You judge a person by how they look

or h

w they talk or what the tests show, but you can never really tell what is inside the

person.

(Bogdan &DAN; 1976, p. 51)

�

For much of his life Ed was labeled mentally retarded and was educated and cared for in special institutions. During his adult years, clinicians discovered that Ed’s intel�lectual ability was in fact higher than had been assumed. In the meantime, however, he

Disorders of Childhood and Adolescence :1/ 455

had lived the childhood and adolescence of a person labeled retarded, and his state

ment

–I68.ifilA4ZT.Liin.tBttaTAIL

reveals the kinds of difficulties often faced by people with this disorder.

The term “mental retardation” has been applied to a varied population, including children in institutional wards who rock back and forth, young people who work in special job programs, and men and women who raise and support their families by working at undemanding jobs. In recent years, the less stigmatizing term intellectual disability has become synonymous with mental retardation in many clinical settings. As many as 3 of every 100 persons meet the criteria for this diagnosis (Brown et al., 2009; APA, 2000). Around three-fifths of them are male, and the vast majority are considered

In Their Words

�

Rohorl Zak:9c, .psydioleoisi; lnd

mildly retarded.

According to DSM-IV-TR, people should receive a diagnosis of mental retarda�tion when they display general intellectual finctioning that is well below average, in com�bination with poor adaptive behavior (APA, 2000).That is, in addition to having a low IQ (a score of 70 or below), a person with mental retardation must have great difficulty in areas such as communication, home living, self-direction, work, or safety (APA, 2000). The symptoms must also appear before the age of 18. Although these DSM-IV-TR criteria may seem straightforward, they are in fact hard to apply.

Assessing intelligence Educators and clinicians administer intelligence tests to measure intellectual functioning (see Chapter 3).These tests consist of a variety of ques�tions and tasks that rely on different aspects of intelligence, such as knowledge, reason�ing, and judgment. An individual’s overall test score, or intelligence quotient (IQ), is

thought to indicate general intellectual ability.

Many theorists have questioned whether IQ tests are indeed valid. Do they actually measure what they are supposed to measure? The correlation between IQ and school performance is rather high—around .50—indicating that many children with lower IQs do, as one might expect, perform poorly in school, while many of those with higher IQs perform better (Sternberg et al., 2001). At the same time, the correlation also suggests that the relationship is far from perfect. That is, a particular child’s school performance is often higher or lower than his or her IQ might predict. Moreover, the accuracy of IQ tests at measuring extremely low intelligence has not been evaluated adequately, so it is difficult to assess people with severe mental retardation properly

(Bebko & Weiss, 2006).

Intelligence tests also appear to be socioculturally biased, as you read in Chapter 3 (Gopaul-IVIcNicol & Armour-Thomas, 2002). Children reared in households at the middle and upper socioeconomic levels tend to have an advantage on the tests because

�

456 :1/CHAPTER 14

they are regularly exposed to the kinds of language and thinking that the tests evalu�ate. The tests rarely measure the “street sense” needed for survival by people who live in poor, crime-ridden areas—a kind of know-how that certainly requires intellectual skills. Similarly, members of cultural minorities and people for whom English is a second

language often appear to be at a disadvantage in taking these tests.

If IQ tests do not always measure intelligence accurately and objectively, then the diagnosis of mental retardation also may be biased.That is, some people may receive the diagnosis partly because of test flaws, cultural differences, discomfort with the testing situation, or the bias of a tester.

�

Reading and ‘Riling and ‘Rithniegic

etween 15 and 20 percent of chil�

1dren, boys more often than girls, de-velop slowly and function poorly compared to their peers in an area such as learning,

with phonological disorder consistently fail to make correct speech sounds at an appropriate age, so that many of them seem to be talking baby talk. Those with

expressive language disorder may struggle at learning new words, confine their speech to short simple sentences, or show a general lag in language development. And those who suffer from stuttering may repeat, prolong, or interject sounds as they speak; pause before finishing a word; or experience excessive tension in the muscles

Older children with the disorder may have great difficulty assembling puzzles, build�ing models, playing ball, and printing or

writing.

communic

tion, or coordination (Watson,

Research into the causes of these de-velopmental difficulties has been limited (Golden, 2008; Teicher et al., 2008; Watson et al., 2008). However, treat-meets have been developed, and some of the disorders do respond well to special interventions (Watson et al., 2008; Pless & Carlsson, 2000). Reading therapy, for example, is very helpful in mild cases of reading disorder, and speech therapy brings about complete recovery in most cases of phonological disorder. Further-more, learning, communication, and de-velopmental coordination disorders often disappear before adulthood, even without any treatment (APA, 2000).

Watson, & Ret, 2008; APA, 2000). The children do not suffer from mental retarda-tion, and in fact they are often very bright, yet their problems may interfere with

school performance, d

ily living, and in

some cases soci

I interactions. Similar dif�

ficulties may be seen in the children’s close biological relatives (Watson et al., 2008). According to DSM-IV-TR, these children may be suffering From a learning disorder, a communication disorder, or a develop-mental coordination disorder—problems that can cause significant psychological suffering and embarrassment for the chil-dren (Piek et al., 2007; Alexander-Passe,

used for speech.

Finally, children with developmental�coordination disorder perform coordinated�motor activities at a level well below that�of others their age (APA, 2000). Younger�children with this disorder are clumsy and�are slow to master skills such as tying shoe��Laces, buttoning shirts, and zipping pants.

2006; Daniel et al., 2006).

The skill in arithmetic, written expres�

�

or re

ding exhibited by children

with learning disorders is well below their intellectual capacity (APA, 2000). Across the United States, children with learning disorders comprise the largest subgroup of individuals placed in special education classes (Watson et al., 2008). One learn�

ing disorder is called mathematics disorder and is diagnosed in children who have markedly impaired mathematical skills. Another is reading disorder, also known

as dyslexia, in which children have great difficulty recognizing words and compre�hending as they read. They typically read slowly and haltingly and may omit, distort,

I I

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or substitute words as they go.

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The communication disorders take vari�ous forms as well (APA, 2000). Children

�

Disorders of Childhood and Adolescence :// 457

Assessing Adaptive Functioning Diagnosticians cannot rely solely on a cutoff IQ score of 70 to determine whether a person suffers from mental retardation. Some people with a low IQ are quite capable of managing their lives and functioning inde-pendently, while others are not.The cases of Brian and Jeffrey show the range of adaptive abilities.

q q’ – `4,q=7:j P1=’g;

Misguided .intervention

‘

�

Brian comes from a lower-income family. He

ys has functioned adequately at home

and in his community. He dresses and feeds himself and even takes care of himself

each day until his mother returns h

me from work. He also plays well with his friends. At

school, however, Brian refuses to participate

r do his homework. He seems ineffective, at

times lost, in the classro

m. Referred to a school psychologist by his teacher, he received

an IQ score of 60.

Jeffrey comes from an upper-middle-class home. He w

s always slow to develop, and

sat up, stood, and talked late. During his infancy and toddler years, he was put in a spe�

cial stimula

n program and given special help and attention at home. Still Jeffrey has

trouble dressing himself today and cannot be left alone in the backyard lest he hurt him�self or wander off into the street. Schoolwork is very difficult for him. The teacher must work slowly and provide individual instruction for him. Tested at age 6, Jeffrey received an IQ score of 60.

Brian seems well adapted to his environment outside of school. However, Jeffrey’s limitations are widespread. In addition to his low IQ score,Jeffrey has difficulty meeting challenges at home and elsewhere. Thus a diagnosis of mental retardation may be more

appropriate for Jeffrey than for Brian.

Several scales have been developed to assess adaptive behavior. Here again, however,

some people function better in their lives than the scales predict, while others fall short. Thus to properly diagnose mental retardation, clinicians should probably observe the functioning of each individual in his or her everyday environment, taking both the person’s background and the community’s standards into account. Even then, however, such judgments may be subjective, as clinicians may not be familiar with the standards of a particular culture or community.

What Are The Features of Mental Retardation? The most consistent feature�of mental retardation is that the person learns very slowly (Sturmey, 2008; Hodapp &

Dykens, 2003). Other areas of difficulty are attention, short-term memory, planning, and language Those who are institutionalized

with mental retardation are particularly likely

to have these limitations. It may be that the unstimulating environment and minimal in�

teractions with staff in many institutions contribute to such difficulties.

DSM-IV-TR describes four levels of mental retardation: mild (IQ 50-70), moderate (IQ 35-49), severe (IQ 20-34), and profound (IQ below 20). In contrast, the American Association o (-Mental Retardation (1992) prefers to distinguish different kinds of men�tal retardation according to the level of support the person needs—intermittent, limited, extensive, or pervasive.

Mad Retardation Between 80 and 85 percent of all people with mental retardation

the category of mild retardation (IQ 50-70) (Leonard & Wen, 2002; APA,

2000). They are sometimes called “educably retarded” because they can benefit from schooling and can support themselves as adults. Mild mental retardation is not usually recognized until children enter school and are assessed there. The individuals demon-strate rather typical language, social, and play skills, but they need assistance when under stress—a limitation that becomes increasingly apparent as academic and social demands increase. Inte restingly, the intellectual performance of individuals with mild mental

*mild retardationeA level of mental

retardation (IQ between 50 and 70) at which people can benefit from education and can support themselves as adults.

458 :41/CHAPTER 4

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Et3

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–

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Mak

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;

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retardation often seems to improve with age; some even seem to leave the label behind�when they leave school, and they go on to function well in the community (Sturmey,

li,”=L�

2008).Their jobs tend to be unskilled or semiskilled.

‘, – +11_~ r-S ~~~~ti.~ +1 -“;_ L ‘1+`.•liil.

Research has linked mild mental retardation mainly to sociocultural and psychologi�cal causes, particularly poor and unstimulating environments, inadequate parent-child interactions, and insufficient learning experiences during a child’s early years (Sturmey, 2008; Stromme & Magnus, 2000). These relationships have been observed in studies comparing deprived and enriched environments (see Figure 14-3). In fact, some corn�

I’1 ,4E-1 4 1!1-1.1iol’ (,;o1-alcHL:,’n

4 1,

munity programs have sent workers into the homes of young children with low IQ

scores to help enrich the environment there, and their interventions have often improved the children’s functioning. When continued, programs of this kind also help improve the individual’s later per-formance in school and adulthood (Spading et al., 2005; Ramey &

—

IQ 6o) 69

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Itt so to 59

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– IQ 5

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Unskilled

Semiskilled

Skilled Artisan

Professional

taborer

laborer

manual trade

nonmanual

Social Class

Ramey, 2004, 1992).

Although sociocultural and psychological factors seem to be the

leading causes of mild mental retardation, at least some biological factors also may be operating. Studies suggest, for example, that a mother’s moderate drinking, drug use, or malnutrition during preg�nancy may lower her child’s intellectual potential (Ksir et al., 2008). Similarly, malnourishment during a child’s early years may hurt his or her intellectual development, although this effect can usually be reversed at least partly if a child’s diet is improved before too much time goes by.

Moderate, Severe, and Profound Retardation Approxi�mately 10 percent of persons with mental retardation function at a�level of moderate retardation (IQ 35-49). They typically receive�their diagnosis earlier in life than do individuals with mild retardation,�as they demonstrate clear deficits in language development and play�during their preschool years. By middle school they further display�significant delays in their acquisition of reading and number skills. By�adulthood, however, many individuals with moderate mental retarda��tion manage to acquire a fair degree of communication skill, learn to�care for themselves, benefit from vocational training, and can work�in unskilled or semiskilled jobs, usually under supervision. Most such�persons also function well in the community if they have supervision�(Bebko &Weiss, 2006;APA, 2000).

Disorders of Childhood and Adolescence :1/ 459

Approximately 3 to 4 percent of people with mental retardation display severe retardation (IQ 20-34). They typically demonstrate basic motor and communication deficits during infancy. In school, they may be able to string together only two or three words when speaking. The individuals usually require careful supervision, profit some�

°moderate retardationeA level of mental retardation (IQ between 35 and 49) at which people can learn to care for themselves and can benefit from vocational training.

what from vocational training, and can perform only basic work tasks in structured and�sheltered settings. Their understanding of communication is usually better than their�speech. Most are able to function well in the community if they live in group homes, in

°severe retardationoA level of mental retardation (1Q between 20 and 34) at which individuals require careful super-vision and can learn to

work in structured and sh

community nursing homes, or with their families (Bebko &Weiss, 2006; APA, 2000).

basic

Around 1 to 2 percent of all people with mental retardation fall into the category

eltered settings.

of profound retardation (IQ below 20). This level of retardation is very noticeable at�birth or early infancy. With training, people with profound mental retardation may learn

*profound retardationol A level of mental retardation (IQ below 20) at

or improve basic skills such as walking, some talking and feeding themselves.They need

which individu

Is need a very structured

a very structured environment, with close supervision and considerable help, including�a one-to-one relationship with a caregiver, in order to develop to the fullest (Sturmey,

environment with close supervision.

2008; APA, 2000).

°Down syndrome®A form of mental retardation caused by an abnormality in the twenty-first chromosome.

Severe and profound levels of mental retardation often appear as part of larger syn- dromes that include severe physical handicaps. The physical problems are often even more limiting than the individual’s low intellectual functioning and in some cases can be fatal.

What Are the Causes of Moderate, Severe, and Profound Mental Retard•tion? The primary

of moderate, severe, and profound retardation

biological, although people who function at these levels also are affected greatly by their family and social environment (Sturmey, 2008; Hodapp & Dykens, 2003). Sometimes ge�netic factors are at the root of these biological problems, in the form of chromosomal or metabolic disorders. In fact, researchers have identified 1,000 genetic causes of mental re�tardation, although few of them have undergone much study (Dykens & Hodapp, 2001; Azar, 1995). Other biological causes of these kinds of mental retardation come from un�favorable conditions that occur before, during, or after birth, such as birth injuries.

CHROMOSOMAL CAUSES The most common of the chromosomal disorders leading to mental retardation is Down syndrome, named after Langdon Down, the British physician who first identified it. Fewer than 1 of every 1,000 live births result in Down syndrome, but this rate increases greatly when the mother’s age is over 35. Many older expectant mothers are now encouraged to undergo amniocentesis (testing of the amniotic fluid that surrounds the fetus) during the fourth month of pregnancy to identify Down

�

syndrome and other chromosomal abnormalities.

Individuals with Down syndrome may have a small head, flat face, slanted eyes, high cheekbones, and, in some cases, protruding tongue. The latter

may affect their ability to pronounce words clearly. They are often very affectionate with family members but in general display the same range of personality characteristics as people

in the general population (Carr, 1994).

Several types of chromosomal abnormalities may cause Down syndrome (Teicher et al., 2008). The most common type (94 percent of cases) is trisomy 21, in which the individual has three free-floating twenty-first chromosomes instead of two. Most people with Down syndrome range in IQ from 35 to 55 (AAMR, 2005). The individuals appear to age early, and many even show signs of dementia as they approach 40 (Bebko & Weiss, 2006; Lawlor et al., 2001). Studies suggest that Down syndrome and early dementia often occur together because the genes that produce them are located close to each

–

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(1410

-R�

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other on chromosome 21 (Selkoe, 1991).

Fragile X syndrome is the second most common chromo�somal cause of mental retardation. Children born with a frag�ile X chromosome (that is, an X chromosome with a genetic

460 :_ A/CHAPTER 14

abnormality that leaves it prone to breakage and loss) generally display mild to moderate degrees of intellectual dysfunctioning, language impairments, and, in some cases, behav�ioral problems (Teicher et al., 2008; Eliez & Feinstein, 2001).Typically, these individuals are shy and anxious (AAMR, 2005).

A60614161 ChtoiiiooMd

Eii

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METABOLIC CAUSES In metabolic disorders, the body’s breakdown or production of chemicals is disturbed.The metabolic disorders that affect intelligence and development are typically caused by the pairing of two defective recessive genes, one from each parent. Although one such gene would have no influence if it were paned with a normal gene,

livAM;.!7.01

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its pairing with another defective gene leads to major problems for the child.

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The most common metabolic disorder to cause mental retardation is phenylketonuria (PKU), which strikes 1 of every 14,000 children. Babies with PKU appear normal at birth but cannot break down the amino acid phenylalanine. The chemical builds up and is converted into substances that poison the system, causing severe retardation and several other symptoms. Today infants can be screened for PKU, and if started on a special diet

•

�

before 3 months of age, they may develop normal intelligence.

Children with Tay-Sachs disease, another metabolic disorder resulting from a pairing of recessive genes, progressively lose their mental functioning, vision, and motor ability over the course of two to four years and eventually die. One of every 30 persons of East�ern European Jewish ancestry carries the recessive gene responsible for this disorder, so that 1 of every 900 Jewish couples is at risk for having a child with Tay-Sachs disease.

‘

PRENATAL AND BIRTH-RELATED CAUSES As a fetus develops, major physical problems in the pregnant mother can threaten the child’s prospects for a normal life (Bebko & Weiss, 2006; Neisser et al., 1996).When a pregnant woman has too little iodine in her diet, for example, her child may develop cretinism, marked by an abnormal thyroid gland, slow development, mental retardation, and a dwarflike appearance.The disorder is rare today because the salt in most diets now contains extra iodine. Also, any infant born with this

disorder may quickly be given thyroid extract to bring about a normal development.

Other prenatal problems may also cause mental retardation. As you saw in Chapter 10, children whose mothers drink too much alcohol during pregnancy may be born with fetal alcohol syndrome, a group of very serious problems that includes lower intellectual functioning. In fact, a generally safe level of alcohol consumption during pregnancy has not been established by research. In addition, certain maternal infections during pregnancy—rubella (German measles) and syphilis, for example—may cause

childhood problems that include mental retardation.

°fetal alcohol

group of

Birth complications can also lead to mental retardation.A prolonged period without oxygen (anoxia) during or after delivery can cause brain damage and retardation in a baby. Similarly, although premature birth does not necessarily lead to long-term prob�lems for children, researchers have found that a birth weight of less than 3.5 pounds may sometimes result in retardation (Neisser et al., 1996).

in a childd lower intel�

, incluing

plectual functioning low birth weight, and

in the hands and face, that

result from excessive alcohol intake by the mother during pregnancy.

CHILDHOOD PROBLEMS After birth, particularly up to age 6, certain injuries and accidents�can affect intellectual functioning and in some cases lead to mental retardation. Poison��ings, serious head injuries caused by accident or abuse, excessive exposure to X rays,

estate schooleA state supported institu�tion for people with mental retardation.

enormalizationeThe principle that insti�tutions and community residences should expose people with mental retardation to living conditions and opportunities simi-lar to those found in the rest of society.

and excessive use of certain drugs pose special dangers (Evans, 2006). For example, a

case of lead poisoning,

automobile fumes, can cause retardation in children. Mercury, radiation, nitrite, and pesticide poisoning may do the same. In addition, certain infections, such as meningitis and encephalitis, can lead to mental retardation if they are not diagnosed and treated in time (MFA, 2008; Baroff & 011ey, 1999).

from eating lead-based paints or inhaling high levels of

especial education•An approach to

children with mental retarda�

interventions for People with Mental Retardation The quality of life a

t�

tamed by people with mental retardation depends largely on sociocultural factors: where they live and with whom, how they are educated, and the growth opportunities available at home and in the community. Thus intervention programs for these individuals try to provide comfortable and stimulating residences, a proper education, and social and economic opportunities. At the same time, the programs seek to improve the self-image

tion in which they are grouped together and given a separate, specially designed education.

emainstreamingeThe placement of chil�

dren with menta retaration in regluusiaorn school classes. Also known as inc

Disorders of Childhood and Adolescence :fi 461

and increase the self-esteem of individuals with mental retardation. Once these needs are met, formal psychological or biological treatments are also of help in some cases.

_–M_OM,

WHAT IS THE PROPER RESIDENCE? Until recent decades, parents of children with mental�retardation would send them to live in public institutions—state schools—as early�as possible. These overcrowded institutions provided basic care, but residents were ne-

RèsidotitialE’Shi fi

7,11; R 14

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F;D )

glected, often abused, and isolated from society.

1::!

(

�

During the 1960s and 1970s, the public became more aware of these sorry condi�tions and as part of the broader deinstitutionalization movement (see Chapter 12), demanded that many people with mental retardation be released from the state schools (Beyer, 1991). In many cases, the releases occurred without adequate preparation or su�pervision. Like deinstitutionalized people suffering from schizophrenia, the individuals were virtually dumped into the community. Often they failed to adjust and had to be

0’1 10

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institutionalized once again.

Since that time, reforms have led to the creation of small institutions and other com�munity residences (group homes, halfway houses, local branches of larger institutions, and independent residences) that teach self-sufficiency, devote more staff time to patient care, and offer educational and medical services. Many of these settings follow the principles of normalization first started in Denmark and Sweden—they attempt to provide liv�ing conditions similar to those enjoyed by the rest of society, flexible routines, and nor�mal developmental experiences, including opportunities for self-determination, sexual

fulfillment, and economic freedom (Hodapp & Dykens, 2003).

Today the vast majority of children with mental retardation live at home rather than in an institution. During adulthood and as their parents age, however, the fami�lies may become less able to provide the kinds of assistance and opportunities that the individuals need. A community residence becomes an appropriate alternative for some of them. Most people with mental retardation, including almost all with mild mental retardation, now spend their adult lives either in the family home or in a community residence

(Sturmey, 2008).

WHICH EDUCATIONAL PROGRAMS WORK BEST? Because early intervention seems to offer such great promise, educational programs for individuals with mental retardation may begin during the earliest years. The appropriate education depends on the individual’s degree of retardation (Bebko & Weiss, 2006; Patton et al., 2000). Educators hotly de�bate whether special classes or mainstreaming is most effective once the children enter school (Hardman, Drew, & Egan, 2002). In special education, children with mental retardation are grouped together in a separate, specially designed educational program. In contrast, mainstreaming, or inclusion, places them in regular classes with non-retarded students. Neither approach seems consistently

superior (Bebko & Weiss, 2006). It may well be that

mainstreaming is better for some areas of learning and

for some children, special classes for others (Cummins

�

& Lau, 2003).

Teacher preparedness is another factor that may play into decisions about mainstreaming and special educa�tion classes. Many teachers report feeling inadequately prepared to provide education and support for children

with mental retardation, especially children who have additional problems (Scheuermann et al., 2003). Brief training courses for teachers appear to help address such

concerns (Campbell, Gilmore, & Cuskelly, 2003).

�

Teachers who work with individuals with mental retardation often use operant conditioning principles to improve the self-help, communication, social, and aca�demic skills of the individuals (Sturmey, 2008; Ardoin

�

et al., 2004). They break learning tasks down into small�steps, giving positive reinforcement as each increment

?),

462 :I/CHAPTER 14

is accomplished. In addition, many institutions, schools, and private homes have set up token economy programs—the operant conditioning programs that have also been used to treat institutionalized patients suffering from schizophrenia

G I

and other severe mental disorders.

�

–

WHEN IS THERAPY NEEDED? Like anyone else, people with mental retardation sometimes experience emotional and behavioral problems. As many as 25 percent of them have a psychological disorder other than mental retardation (Hodapp et al., 2006; McBrien, 2003). Furthermore, some suffer from low self-esteem, interpersonal problems, and

�

f15,tw

difficulties adjusting to community life. These problems

helped to some degree by either individual or group therapy. In addition, large numbers of people with mental retardation are given psychotropic medications (Sturmey,

�

2008). Many clinicians argue, however, that too often the

dications are used simply for the purpose of making the individuals easier to manage.

HOW CAN OPPORTUNITIES FOR PERSONAL, SOCIAL, AND OCCUPATIONAL GROWTH BE INCREASED?�People need to feel effective and competent in order to move forward in life.Those with�mental retardation are most likely to achieve these feelings if their communities allow�them to grow and to make many of their own choices. Denmark and Sweden, where�the normalization movement began, have again been leaders in this area, developing�youth clubs that encourage those with mental retardation to take risks and function�independently (Flynn & Lemay, 1999; Perske, 1972).The Special Olympics program has�also encouraged those with mental retardation to be active in setting goals, participate

in their environment, and interact socially with others (Weiss et al., 2003).

�

Socializing, sex, and marriage are difficult issues for people with mental retardation and their families, but with proper training and practice, the individuals usually can learn to use contraceptives and carry out responsible family planning (Lumley & Scotti, 2001; Bennett-Gates & Zigler, 1999). The National Association for Retarded Citizens offers guidance in these matters, and some clinicians have developed dating skills programs

(Segal, 2008;Valenti-Hein et al., 1994).

Some states restrict marriage for people with mental retardation. These laws are

rarely enforced, however, and in fact between one-quarter and one-half of all people

–

with mild mental retardation eventually marry (Grinspoon et al., 1986). Contrary to popular myths, the marriages can be very successful. Moreover, although some individuals may be incapable of raising children, many are quite able to do so, ei�ther on their own or with special help and community services

.�- ] 4

�

(Sturmey, 2008).

Finally, adults with mental retardation—whatever the sever�ity—need the personal and financial rewards that come with holding a job (Kiernan, 2000). Many work in sheltered work�shops, protected and supervised workplaces that train them at a pace and level tailored to their abilities. After training in the workshops, many with mild or moderate retardation move on

to hold regular jobs (Moore, Flowers, & Taylor, 2000).

Although training programs for people with mental retar�dation have improved greatly in quality over the past 30 years, there are too few of them. Consequently, most of these indi�

�

viduals fail to receive a complete range of educational and oc�cupational training services. Additional programs are required so that more people with mental retardation may achieve their full potential, as workers and as human beings.

Disorders of Childhood and Adolescence :1/ 463

�

*sheltered workshoplacAe tphraot teocffteerds job and supervised workp

�

Long-Terni Disorders That Begin in Childhood

opportunities and training at

pace and

Pervasive developmental disorders and mental retardation are problems that emerge early and typically continue throughout a person’s life. People with autism, the most heavily researched pervasive developmental disorder, are extremely unresponsive to others, have poor communication skills, and behave in a very rigid and repetitive manner. Individuals with Asperger’s disorder, another kind of pervasive develop�mental disorder, display profound social impairment yet maintain relatively high

level tailored to people with various psy�chological

levels of cognitive functioning and language skills.

The leading explanations of autism point to cognitive deficits, such

s failure

to develop a theory of mind, and biological abnormalities, such as abnormal development of the cerebellum, as causal factors. Although no treatment totally reverses the autistic pattern, significant help is available in the form of behavioral treatments, communication training, treatment and training for parents, and com�

munity integration.

People with mental retardation are significantly below aver

ge in intelligence

and adaptive ability. Approximately 3 of every 100 people qualify for this diag�nosis. Mild retardation, by far the most common level of mental retardation, has been linked primarily to environmental factors such as understimulation, inadequate parent-child interactions, and insufficient early learning experiences. Moderate, se�

vere, and profound mental retardation

re c

used primarily by biological factors,

although individuals who function at these levels also are affected enormously by

their f

mily and social environment. The leading biological causes are chromosomal

abnormalities, metabolic disorders, prenatal problems, birth complications, and

childhood diseases and injuries.

Today intervention programs for people with mental retardation emphasize the

importance of

comfortable and stimulating residence, either the family home or

a small institution or group home that follows the principles of normalization. Other�important interventions include proper education, therapy for psychological prob�

lems, and programs offering training in soci

lizing, sex, marriage, parenting, and

occupational skills. One of the most intense deb

tes in the field of education centers

on whether individuals with mental retardation profit more from special classes or

from m

instreaming.

PUTTING IT… together

Clinicians Discover Childhood and Adolescence

Early in the twentieth century, mental health professionals virtually ignored children (Phares, 2008).At best, they viewed them as small adults and treated their psychological disorders as they would adult problems (Peterson & Roberts, 1991). Today the prob-. lems and special needs of young people have caught the attention of researchers and clinicians. Although all of the leading models have been used to help explain and treat these problems, the sociocultural perspective—especially the family perspective—is

�

Children in Need

�

considered to play a special role.

Because children and adolescents have limited control over their lives, they are particularly affected by the attitudes and reactions of family members. Clinicians must therefore deal with those attitudes and reactions as they try to address the problems

�

of the young. Treatments for conduct disorder, ADHD, mental retardation, and other problems of childhood and adolescence typically fall short unless clinicians educate and work with the family as well.

IGIvic:doro, 2005)

464 71/CHAPTER 14

1.4-giiP.irkv.k45119-IPALlirtk.A

At the same time, clinicians who work with children and adolescents have learned that a narrow focus on any one model can lead to problems. For years autism was ex�plained exclusively by family factors, misleading theorists and therapists alike and adding to the pain of parents already devastated by their child’s disorder. Similarly, in the past,

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the sociocultural model often led professionals wrongly to accept anxiety among young�children and depression among teenagers as inevitable, given the many new experiences

ilicip010

confronted by the former and the latter group’s preoccupation with peer approval.

The increased clinical focus on the young has also been accompanied by increased attention to their human and legal rights. More and more, clinicians have called on government agencies to protect the rights and safety of this often powerless group. In doing so, they hope to fuel the fights for greater educational resources and against child

abuse and neglect, sexual abuse, malnourishment, and fetal alcohol syndrome.

As the problems and, at times, mistreatment of young people receive greater atten�tion, the special needs of these individuals are becoming more visible. Thus the study and treatment of psychological disorders among children and adolescents are likely to continue at a rapid pace. Now that clinicians and public officials have “discovered” this population, they are not likely to underestimate their needs and importance again.

\\\ GRITIGAL THOUgHTS//

�

Although boys with psychological dis-orders outnumber girls, adult women with such disorders outnumber adult men. How might you explain this

3. What psychological effects might bullying have on its victims? Why do

80 percent. How might such centers themselves be contributing to this recidivism rate? p. 439

4.;

ny individuals seem able to over�

.,4

come the trauma of being bullied, while others do not? p. 438

5. What might be the merits and flaws

ge-related shift? pp. 429-446

of special classes versus main-streaming for people with mental retardation? pp. 461-462

Do video games that feature violence help produce oppositional defiant disorder, conduct disorder, or other childhood problems? pp. 436-437

4. The overall rate of repe

ted arrests

of adolescents sent to juvenile deten-tion, or juvenile training, centers

has been estimated to be as high as

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KEY ‘TERMS

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://: separation anxiety disorder, p. 431

self-injurious behavior, p. 449

fragile X syndrome, p. 459

.#,,.. play therapy, p. 433

oppositional defiant disorder, p. 436

Asperger’s disorder, p. 449

recessive genes, p. 460

theory of mind, p. 450

phenylketonuria (PKU), p. 460

0.conduct disorder, p. 436

cerebellum, p. 452

fetal alcohol syndrome, p. 460

attention-deficit/hyperactivity disorder

augmentative communicati

rubella, p. 460

(ADHD), p. 440

.y. methylphenidate (Ritalin), p. 442

system, p. 454

syphilis, p. 460

group home, p. 454

state school, p. 461

mental retardation, p. 455

deinstitutionalization, p. 461

p. 446

intelligence quotient (!Q), p. 455

normalization, p. 461

9e..e. pervasive developmental disorders,

mild retardation, p. 457

special education, p. 461

447

moderate retardation, p. 458

mainstre

ming, p. 461

autistic disorder, p. 448

severe retardation, p. 459

token economy progr

m, p. 462

) echolalia, p. 449

profound retardation, p. 459

sheltered workshop, p. 462

/1 self-stimul

tory behavior, p. 449

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Disorders of Childhood and Adolescence :// 465

�

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1. What are the prevalence rates and gender ratios for the various child-hood disorders? pp. 431-462, 446

What are the current tre

tments

8. Describe the different levels of mental retardation. pp. 457-459

For it, and how effective are they? pp. 440-443

9. What are the causes of mild mental

/142 What are the different kinds of child�

5. What are enuresis and encopresis? How are these disorders treated? pp. 444-446

retardation? What are the causes of moderate, severe, and profound men-tal retardation? pp. 458-460

hood anxiety and mood disorders? What are today’s leading expla�

tions and tre

tments for these

6. What are the symptoms of autistic

10. What kinds of residences, educa�tional programs, treatments, and

disorders? pp. 431-436

disorder and of Asperger’s disorder? pp. 447-450

(4 3. Describe oppositional defiant disor-der and conduct disorders. What

community progr

ms are helpful to

factors help cause conduct disorders, and how are these disorders treated? pp. 436-439

7. What are the possible causes of autism? What are the overall goals

persons with mental retardation? pp. 460-462

of treatment for autism,

nd which

What are the symptoms of attention�

interventions have been most help-ful for individuals with this disorder? pp. 450-454

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DISORDERS OF

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COGNITION

CHAPTER

i arry appeared to be in perfect health at age 58

He worked in the municipal water

TOPIC OVERVIEW

treatment plant of a small city,

nd it was at work that the first overt signs of Harry’s

mental illness appeared. While responding to a minor emergency, he became confused�about the correct order in which to pull the levers that controlled the flow of fluids. As

Old Age and Stress

Depression in Later Life

a result several thousand gallons of

w sewage were discharged into a river.

rry had been

Anxiety Disorders in Later Life

an efficient and diligent worker, so after puzzled questioning, his error was attributed to the

flu and overlooked.

Substance Abuse in Later Life

Several weeks later, Harry came home with

baking dish his wife had asked him to buy, having

sychotic Disorders in Later Life

forgotten that he h

d brought home the identical dish two nights before. Later that week, on

Disorders of Cognition

two successive nights, he went to pick up his daughter at her job in a restaurant, apparently�forgetting that she had changed shifts and was now working days. A month after that, he quite�uncharacteristically argued with a clerk at the phone company; he was trying to pay a bill that

‘

Delirium

Dementia

he had already paid three days before

Issues Affecting the Mental Health

�

Months passed and Harry’s wife was beside herself. She could see that his problem was wars�

; Putting It Togethe

•

Clinicians Discover the Elderly

ening. Not only had she been un

ble to get effective help, but Harry himself was becoming

resentful and sometimes suspicious of her attempts. He now insisted there was nothing wrong

with him, and she would catch him narrowly watching her every movement

Sometimes he

became angry—sudden little storms without apparent c

use…. More difficult for his wife was

Harry’s repetitiveness in conversation: He often repeated stories from the past and sometimes�repeated isolated phrases and sentences from more recent exchanges. There was no context

and little continuity to his choice of subjects

Two years after Harry had first

flowed the sewage to escape, he was clearly a changed man.

Most of the time he seemed preoccupied; he usually had a vacant smile on his face, and what

little he said was so vague that it lacked meaning. . . . Gradu

lly his wife took over getting him

up, toileted, and dressed each morning

Harry’s condition continued to worsen slowly. When his wife’s school was in session, his daugh�ter would stay with him some days, and neighbors were able to offer some help. But occasionally he would still manage to wander away. On those occasions he greeted everyone he met—old friends and strangers alike—with “Hi, it’s so nice.” That was the extent of his conversation,

although he might repeat “nice, nice, nice” over and over again

When Harry left a coffee

pot on a unit of the electric stove until it melted, his wife, desperate for help, took him to see�another doctor. Again Harry was found to be in good health. [However] the doctor ordered a�CAT scan [ond eventually concluded] that Harry had “Pick-Alzheimer disease” and that there

was no known cause and no effective treatment

Because Harry was a veteran

. . .

[he qualified for] hospitaliz

tion in

regional veter

ns’

hospital

bout 400 miles away from his home

Desperate, five years after the accident at

work, [his wife] accepted with gratitude [this] hospitalization

At the hospital the nursing staff sat Harry up in a chair each day and, aided by volunteers, made�sure he ate enough. Still, he lost weight and became weaker. He would weep when his wife�came to see him, but he did not talk, and he gave no other sign that he recognized her. After a

year, even the weeping stopped. Harry’s wife could no longer be

r to visit. 1-I

rry lived on until

just after his sixty-fifth birthday, when he choked on a piece of bread, developed pneumonia as a consequence, and soon died.

(Heston, 1992, pp. 87-90)

468 ://CHAPTER 15

egeropsychologyeThe field of psychol�

Harry suffered from a form ofAlzheimer’s disease. This term is familiar to almost everyone in our society. It seems as if each decade is marked by a disease that everyone dreads—a diagnosis no one wants to hear because it feels like a death sentence. Cancer used to be such a diagnosis, then AIDS. But medical science has made remarkable strides with those diseases, and patients who now develop them have reason for hope and expectations of improvement. Alzheimer’s disease, on the other hand, remains incurable and almost untreatable, although, as you will see later, researchers are currently making enormous

concerned with the mental health of

elderly people.

progress toward understanding it and reversing, or at least slowing, its march.

What makes Alzheimer’s disease particularly frightening is that it means not only eventual physical death but also, as in Harry’s case, a slow psychological death—a progres�sive dementia, or deterioration of one’s memory and related cognitive faculties.There are

dozens of causes of dementia; however,Alzheimer’s disease is the most common one.

Although dementia is currently the most publicized psychological problem among the elderly, it is hardly the only one. Indeed, a variety of psychological disorders are tied closely to later life. As with childhood disorders, some of the disorders of old age are caused primarily by pressures that are particularly likely to appear at that time of life, others by unique traumatic experiences, and still others—like dementia—by biological abnormalities.

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001d Age and Stress

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Old age is usually defined in our society as the years past age 65. By this account, around

“old,” representing 12 percent of the total

36 million people in the United States are

population; this is an 11-fold increase since 1900 (Edelstein, Stoner, & Woodhead, 2008)

�

(see Fig. 15-1). Moreover, it is estimated that the U.S. population will consist of 65 million elderly people by the year 2030-20 percent of the population (Cherry, Galea, & Silva, 2007). Not only is the overall population of the elderly on the rise, but, furthermore, the number of people over 85 will double in the next 10 years. Older women outnumber older men by 3 to 2 (Etaugh, 2008).

64,925,000

(projected)

18 —

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Like childhood, old age brings special pressures, unique upsets, and major biological changes (Edelstein et al., 2008). People become more prone to illness and injury as they age, and they are likely to experience the stress of loss—the loss of spouses, friends, and adult children and the loss of former activities and roles (Etaugh, 2008). Many lose their sense of purpose after they retire. Even favored pets

35,000,000

and possessions may be lost.

�

25,544,000

The stresses of elderly people need not necessarily result in psychological problems (Edelstein et al., 2008; Cherry et al., 2007). In fact, some older persons use the changes that come with aging as opportunities for learning and growth. For others, however, the stresses of old age do lead to psychological difficulties (Aldwin, Spiro, & Park, 2006). Studies indicate that as many as half of elderly people would benefit from mental health services, yet fewer than 20 per�cent actually receive them. Geropsychology, the field of psychol�

10 –

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12,334,000

()

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5,791,00(

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ogy dedicated to the mental health of elderly people, has developed�almost entirely within the last 30 years, and at present fewer than 4�percent of all clinicians work primarily with elderly persons (Meyers,

�

3,120,000

2006; Dittman, 2005).

The psychological problems of elderly persons may be divided into two groups. One group consists of disorders that may be com�neon among people in all age groups but are often connected to the process of aging when they occur in an elderly person. These in-dude depressive, anxiety, and substance-related disorders. The other group consists of disorders of cognition, such as delirium and dementia, that

1900

1925

1980

2000

Year

Disorders of Aging and Cognition :1/ 469

�

result from brain abnormalities. As in Harry’s case, these brain abnormalities are most often tied to aging, but they also can sometimes occur in younger individuals. Elderly persons with one of these psychological problems often display other such problems. For example, many who suffer from dementia also experience depression and anxiety

(Apostolova & Cummings, 2008).

kkDepression in Later Life

Depression is one of the most common mental health problems of older adults. The features of depression are the same for elderly people as for younger people, including feelings of profound sadness and emptiness; low self-esteem, guilt, and pessimism; and loss of appetite and sleep disturbances. Depression is particularly common among those who have recently experienced a trauma, such as the loss of a spouse or close friend or the development of a serious physical illness (Edelstein et al., 2008; Etaugh, 2008).

–

[Oscar] was an 83-year-old married man with an episode of major depressive disorder He said that about one and one-half years prior to beginning treatment, his brother had died. In the following months, two friends whom he had known since childhood died.

. .

Following these losses, he … grew more

nd more pessimistic. Reluctantly, he acknowl�

edged, “I even thought about ending my life.”

.. .

During . . . treatment, [Oscar] discussed his relationship with his brother. He discussed how distraught he was to watch his brother’s physical deterioration from an extended ill�ness. He described the scene at his brother’s deathbed and the moment “when he took his final breath.” He experienced guilt over the failure to carry out his brother’s funeral

services in a manner he felt his brother would h

ve wanted

Later in therapy, he

also reviewed different facets of his past relationships with his two deceased friends. He

�

expressed sadness that the long years had ended

[Oscar’s] life had been organized

around visits to his brother’s home

nd outings with his friends

[While] his wife had

It 1.:TheieMförtfi

encouraged him to visit with other friends and family, it became harder

nd harder to do

s he became more depressed.

c:,

(Hinrichsen, 1999, p. 433)

&1937

470 ://CHAPTER 15

–

�

Overall, as many as 20 percent of people experience depression at some point dur�ing old age (Knight et al., 2006; Blazer, 2002).The rate is highest in older women. This rate among the elderly is about the same as that among younger adults—even lower, according to some studies. However, it climbs much higher among aged persons who

live in nursing homes (Carlson & Snowden, 2007).

Several studies suggest that depression raises an elderly person’s chances of devel�

oping significant medical problems (Edelstein et al., 2008; Alexopoulos, 2005). For example, older depressed people with high blood pressure are almost three times as likely to suffer a stroke as older nondepressed people with the same condition. Similarly, elderly people who are depressed recover more slowly and less completely from heart attacks, hip fractures, pneumonia, and other infections and illnesses. Small wonder that among the elderly, increases in clinical depression are tied to increases in the death rate

(Holwerda et al., 2007).

As you read in Chapter 8, elderly persons are also more likely to commit suicide than younger ones, and often their suicides are related to depression (Vannoy et al., 2007).The overall rate of suicide in the United States is 12 per 100,000 persons; among the elderly it is 19 per 100,000. Among 80- to-85-year-olds in particular, it is 27 per 100,000; among white American men over the age of 85, it is 65 per 100,000 (NCHS,

2006; CDC, 2001).

Like younger adults, older individuals who are depressed may be helped by cognitive-behavioral therapy, interpersonal therapy, antidepressant medications, or a combination of these approaches (Knight et al., 2006; Alexopoulos, 2005). Both indi�vidual and group therapy formats have been used. More than half of elderly patients with depression improve with these various treatments. At the same time, it is some�times difficult to use antidepressant drugs effectively and safely with older persons

„ ,

because the body breaks the drugs down differently in later life (Rubin, 2005; Sadavoy, 2004). Moreover, among elderly people, antidepressant drugs have a higher risk of

„

causing some cognitive impairment (Edelstein et al., 2008). Electroconvulsive therapy, applied with certain modifications, also has been used for elderly people who are se�verely depressed and unhelped by other approaches (Wang, 2007).

lereav6hiérit:cind Geridei

�

a Anxiety Disorders in Later Life

(F.taugl.; 20./..)8 U .S

Anxiety is also common among elderly people (Schuurmans et al., 2005). At any given� time, around 6 percent of elderly men and 11 percent of elderly women in the United �States experience at least one of the anxiety disorders (Gum et al., 2009). Surveys

‘405)

Disorders of Aging and Cognition : 471

indicate that generalized anxiety disorder is particularly common, experienced by up to 7 percent of all elderly persons (Holwerda et al., 2007).The prevalence of anxiety also increases throughout old age. For example, individuals over 85 years of age report higher rates of anxiety than those between 65 and 84 years. In fact, all of these numbers may be low, as anxiety in the elderly often goes unrecognized by physicians and thus may be under�

�

v )

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–

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reported ( Jeste, Blazer, & First, 2005).

�

There are many things about aging that may heighten the anxiety levels of certain individuals. Declining health, for ex-ample, has often been pointed to and in fact, older persons who experience significant medical illnesses or injuries report more anxiety than those who are healthy or injury-free (Nordhus & Nielsen, 2005). Researchers have not, however, been able to de�termine why certain individuals who experience such problems in old age become anxious while others who face similar circum�

�

V�

i 44 cf… ) — – .ì

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stances remain more or less calm.

Older adults with anxiety disorders have been treated with

“Am I the smart one and you’re the pretty one or is it

psychotherapy of various kinds, particularly cognitive therapy�(Knight et al., 2006; Mohlman et al., 2003). Many also re�

the other way around?”

ceive benzodiazepines or other antianxiety medications; those

with obsessive-compulsive disorder or panic disorder may be treated with serotonin�enhancing antidepressant drugs such as fluoxetine (Prozac), just as younger sufferers

are.

Again, however, all such drugs must be used cautiously with older people (Tamblyn et al., 2005).

0Substance Abuse in Later Life

Although alcohol abuse and other forms of substance abuse are significant problems for many older persons, the prevalence of such patterns actually appears to decline after age 60, perhaps because of declining health or reduced financial status (Becks & McCormick, 2008; Aldwin et al., 2006). The majority of older adults do not misuse alcohol or other substances despite the fact that aging can sometimes be a time of con�siderable stress. At the same time, accurate data about the rate of substance abuse among older adults are difficult to gather because many elderly persons do not suspect that they

have such a problem (Jeste et al., 2005).

Surveys find that 4 to 7 percent of older people, particularly men, have alcohol-related disorders in a given year (Knight et at, 2006). Men under 30 are four times as likely as men over 60 to display a behavioral problem associated with alcohol abuse, such as repeated falling, spells of dizziness or blacking out, secretive drinking, or social withdrawal. Older patients who are institutionalized, however, do display high rates of problem drinking. For example, alcohol problems among older persons admitted to general and mental hospitals range from 15 percent to 49 percent, and estimates of alcohol-related problems among patients in nursing homes range from 26 percent to

: Losing :a:

Spouse

�

60 percent (Klein & Jess, 2002; Gallagher-Thompson & Thompson,

1995).

Researchers often distinguish between older problem drinkers who have had alcohol-related problems for many years, perhaps since their 20s, and those who do not start the pattern until their 50s or 60s. The latter group typically begins abusive drink�ing as a reaction to the negative events of growing older, such as the death of a spouse or unwanted retirement (Onen et al., 2005). Alcohol abuse and dependence in elderly people are treated much as in younger adults (see Chapter 10), with such approaches as detoxification, Antabuse, Alcoholics Anonymous (AA), and cognitive-behavioral therapy

�

(Knight et al., 2006; Gurnack et al., 2002).

A leading kind of substance problem in the elderly is the misuse of prescription drugs (Beckman, Parker, & Thorslund, 2005). Most often it is unintentional. Elderly people buy 30 percent of all prescription drugs and 40 percent of all over-the-counter drugs.

WW; 2994, Wiii0.1i1

ol.:: 2C D4: C.61-16H0; 2():)3)

472 ://CHAPTER 15

In fact, older people receive twice as many prescriptions as younger persons; the aver�age elderly individual takes four prescription drugs and two over-the-counter drugs (Edelstein et al., 200$; Wilder-Smith, 2005). Thus their risk of confusing medications or skipping doses is high (Cooper et al., 2005). To help address this problem, physicians and pharmacists often try to simplify medications, educate older patients about their prescriptions, clarify directions, and teach them to watch for undesired effects (Rubin, 2005). On the other hand, physicians themselves are sometimes to blame in cases of prescription drug misuse, perhaps overprescribing medications for elderly patients or

unwisely mixing certain medicines (Spinewine et al., 2005; Wilder-Smith, 2005).

Yet another drug-related problem, apparently on the increase, is the misuse of powerful medications at nursing homes. Research suggests that antipsychotic drugs are currently being given to almost 30 percent of the total nursing home population in the United States, despite the fact that many such individuals do not display psychotic functioning (Lagnado, 2007). Apparently, these powerful and (for some elderly patients) dangerous drugs are often given to quiet and manage the patients.

�

Sleep and Sleep Disorders among the Old and Not S® Old

i,(psychosocial factors. Sleep depriva-tion for 100 hours or more leads to hallu-cinations, paranoia, and bizarre behavior. When people remain awake for over 200 hours, they frequently experience periods of “microsleep,” naps lasting two to three seconds. The body simply refuses to be en�

leep

is affected by both physical and

amount, quality, or timing of sleep. The parasomnias (nightmare disorder, sleep terror disorder, and sleepwalking disorder) involve abnormal events that occur during

2008; Asplund, 2005). In addition, some of the normal physical changes that occur as people age may heighten the chances of insomnia. As we age, for example, our body rhythms change, we naturally spend less time in deep sleep, our sleep is more readily interrupted, and we take longer to

sleep.

The most common of these disorders is insomnia, a dyssomnia in which people re-peatedly have great difficulty falling asleep or maintaining sleep (Taylor et al., 2008). More than 20 percent of the entire popu-lotion experience this pattern each year (APA, 2000). People with insomnia feel as though they are almost constantly awake. Often they are very sleepy during the day and have difficulty functioning effectively. The problem may be caused by factors such as anxiety or depression, medical ail-ments, pain, or medication effects (Andrea-sen & Black, 2006).

get back to sleep {Edelstein et al., 2008).

tirely deprived of sleep for long.

Another sleep disorder commonly found among the elderly is breathing-related sleep disorder, a respiratory problem in which persons are periodically deprived of oxygen to the brain while they sleep, so

that they frequently wake up. Sleep apnea, the most common form of this disorder, may occur in more than 10 percent of

the elderly population; it is less common in younger age groups (Wickwire et al, 2008; APA, 2000). Its victims, typically overweight persons who are heavy snor�ers, actually stop breathing for up to 30 seconds or more as they sleep. Hundreds of episodes may occur nightly, without the victim’s awareness.

To learn more about sleep, research-ers bring people into the laboratory and record their activities as they sleep, using various types of recording devices. One important discovery has been that eyes move rapidly about 25 percent of the time a person is asleep, a phenomenon known as rapid eye movement, or REM. REM sleep is often called “paradoxical sleep” because it resembles both deep sleep and wakefulness (Wickwire et al., 2008). De�

spite small movements and muscle twitches, the body is immobilized, almost paralyzed. At the same time, the eyes are darting back and forth, blood flow to the brain increases, and brain-wave activity is almost identical to that of an awake and alert person. Eighty percent of subjects who are awakened from REM sleep report that they

Sleep Disorders

among the Elderly

Insomnia is more common among older persons than younger ones (Knight et al., 2006). At least 50 percent of the popu-lotion over 65 years of age experience some measure of insomnia (Edelstein et al., 2008). Elderly people may be particularly prone to this problem because so many of them have medical ailments, experience pain, take medications, or grapple with depression and anxiety—each a known contributor to insomnia (Taylor et al.,

Sleep Disorders throughout

the Life Span

were dreaming.

As you have read, insomnia and breathing-related sleep disorder are particularly common among older people, although they are found in younger persons as

well. Other sleep disorders are just as common—in a few cases more common—

DSM-IV-TR identifies a number of sleep disorders. The dyssomnias (insomnia, hypersomnia, breathing-related sleep dis-order, narcolepsy, and circadian rhythm sleep disorder) involve disturbances in the

among the other age groups.

�

Disorders of Aging and Cognition :// 473

sychotic Disorders in Later Life

Elderly peop le have a higher rate of psychotic symptoms than younger persons (Broadway & Mintzer, 2007). Among aged people, these symptoms are usually the result of under�lying medical conditions such as delirium and dementia, the disorders of cognition that you will read about in the next section. However, some elderly persons suffer from

schizophrenia or delusional disorder

Actually, schizophrenia is less common in older persons than in younger ones. In fact, many persons with schizophrenia find that their symptoms lessen in later life (Meeks & Jeste, 20059). Improvement has sometimes occurred in people who have displayed schizophrenio. for 30 or more years, as we are reminded by the remarkable late-life improvement of 1994 Nobel Prize recipient John Nash, subject of the book and movie

A Beautifid Mind.

Another kind of psychotic disorder found among the elderly is delusional disorder, in which individuals develop beliefs that are false but not bizarre. This disorder is rare

• • •

�

experience nightmares from time to time, in

�

this disorder nightm

res become frequent

�

and cause such great distress that the indi�vidual must receive treatment. Such night�

, ,

�

mares often increase under

stress.

Persons with sleep terror disorder awaken suddenly during the first third of their evening sleep, screaming in extreme fear and agitation. They are in a state

of panic, are often incoherent, and have a heart rate to match. Sleep terrors most often appear in children and disappear

)

during adolescence.

People with a sleepwalking disorder— usually children—repeatedly leave their beds and walk around, without being conscious of the episode or remembering it later. The episodes occur in the first third

of the individuals’ nightly sleep. Those who are awakened while sleepwalking are confused for several moments. If allowed to continue sleepwalking, they eventually return to bed. Sleepwalkers usually man-age to avoid obstacles, climb stairs, and perform complex activities, in a seemingly emotionless state. Accidents do happen, however: tripping, bumping into furniture, and even falling out of windows have all been reported. Up to 5 percent of children experience this disorder, and as many as 40 percent have occasional sleepwalking episodes (Wickwire et al., 2008; APA, 2000). Sleepwalking usually disappears by age 15.

In contrast to insomnia, hypersomnia is a sleep disorder marked by a heightened need for sleep and excessive sleepiness. Sufferers may need extra hours of sleep each night and may need to sleep during

an argument or during an exciting part of

a football game.

People with circadian rhythm sleep disor-der experience excessive sleepiness or insom-nia as a result of a mismatch between their

the daytime as well (APA, 2000).

own sleep-woke p

ttern and the sleep-wake

Narcolepsy, a disorder marked by re-peated sudden bouts of REM sleep during waking hours, afflicts more than 135,000 people in the United States (NINDS, 2006). Although narcolepsy is a biological dis-order, the bouts of REM sleep are often triggered by strong emotions. Sufferers may suddenly fall into REM sleep in the midst of

schedule of most other people in their envi-ronment. Often the disorder takes the form of falling asleep late and awakening late. This clyssomnia can result from night-shift work, frequent changes in work shifts, or repeated

episodes of jet lag (Ohayon et al., 2002).

Nightmare disorder is the most common of the parasomnias. Although most people

�

474 ://CHAPTER 15

*defiriumeA rapidly developing cloud- ing of consciousness; the person has great

in most age groups—around 3 of every 10,000 persons—but its prevalence appears to increase in the elderly population (Chae & Kang, 2006). Older persons with a delusional disorder may develop deeply held suspicions of persecution; they believe that other persons—often family members, doctors, or friends—are conspiring against, cheating, spying on, or slandering them. They may become irritable, angry, or depressed or pur�sue legal action because of such ideas. It is not clear why this disorder increases among elderly people, but some clinicians suggest that the rise is related to the deficiencies in hearing, social isolation, greater stress, or heightened poverty experienced by many elderly persons.

attention,an

concentrating, focusing d following

an orderly

sequence of thought.

•dementiaeA syndrome marked by severe problems in memory and in at least one

other cognitive function.

eAlzheimer’s diseaseoThe most corn-mon form of dementia, usually occurring after

the age of 65.

Disorde.rs of Later Life

The problems of elderly people are often linked to the losses and other stresses and

changes that accomp

ny advancing age. As many as half of the elderly would

benefit from mental health services, yet fewer than 20 percent receive them. De�pression is a common mental health problem among this age group. Older people may also suffer from anxiety disorders. Between 4 and 6 percent exhibit alcohol-related problems in any given year, and many others misuse prescription drugs. In addition, some elderly persons display psychotic disorders such as schizophrenia or delusional disorder.

�

-”

1-.Disorders of Cognition

Most of us worry from time to time that we are losing our memory and other mental abilities.You rush out the door without your keys, you meet a familiar person and can�not remember her name, or your mind goes blank in the middle of an important test. Actually such mishaps are a common and quite normal feature of stress or of aging (Edelstein et al., 2008). As people move through middle age, these memory difficulties and lapses of attention increase, and they may occur regularly by the age of 60 or 70. Sometimes, however, people experience memory and other cognitive changes that are

far more extensive and problematic.

In Chapter 6 you saw that problems in memory and related cognitive processes can

–

occur without biological causes, in the form of dissociative disorders. More often, however, cognitive problems do have organic roots, par-ticularly when they appear late in life.The leading cognitive disorders among elderly persons are delirium and dementia.

4’t

Delirium

Delirium is a clouding of consciousness. As the person’s awareness�of the environment becomes less clear, he or she has great difficulty�concentrating focusing attention, and thinking in an organized way,

�

which leads to misinterpretations, illusions, and, on occasion, hal��lucinations (Trzepacz & Meagher, 2008; APA, 2000). Sufferers may�believe that it is morning in the middle of the night or that they are

�

home when actually they are in a hospital room.

�

This state of massive confusion typically develops over a short period of time usually hours or days. Delirium apparently affects more than 2 million people in the United States each year (Clary & Krishnan, 2001). It may occur in any age group, including children, but is most common in elderly persons. In fact, when elderly people enter a hospital to be treated for a general medical condition, 1 in

�

‘

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–

Disorders of Aging and Cognition :11 475

10 of them shows the symptoms of delirium (Trzepacz & Meagher, 2008; APA, 2000). At least another 10 percent develop delirium during their stay in the hospital (Inouye

et al., 2003, 1 999).

Fever, certain diseases and infections, poor nutrition, head injuries, strokes, and stress

(including the trauma of surgery) may all cause delirium (Wetterling, 2005). S toxication by certain substances, such as prescription drugs. Partly because oh face so many of these problems, they are more likely than younger ones to e delirium. If a clinician accurately identifies delirium, it can often be easy to cc treating the underlying infection, for example, or changing the patient’s drug tion (Sadavoy, 2004). However, the syndrome typically fails to be recognized it is (Hustey et al., 2003). One landmark study on a medical ward, for exam that admissio n doctors detected only 1 of 15 consecutive cases of delirium et al., 1987). Incorrect diagnoses of this kind may contribute

to a high death rate for older people with delirium (Trzepacz

& Meagher, 2008).

�

Dementia

People with dementia experience significant memory losses along with losses in other cognitive functions such as abstract thinking or language (APA, 2000). Those with certain forms of dementia may also undergo personality changes—they may begin to behave inappropriately, for example—and their symp�

�

toms may worsen steadily.

At any given time, between 3 and 9 percent of the world’s adult population are suffering from dementia (Bert et al., 2005). Its occurrence is closely related to age (see Fig. 15-2). Among people 65 years of age, the prevalence is around 1 to 2 percent, increasing to as much as 50 percent among those over

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–

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the age of 85 (Apostolova & Cummings, 2008).

Altogether, 5 million persons in the United States experience some

mentia (Geldrnacher, 2009). More than 70 forms have been identified. Like delirium, dementia is sometimes the result of nutritional or other problems that can be corrected. Most forms of dementia, however, are caused by brain diseases or injuries, such as Alzheimer’s disease or stroke, which are currently difficult or impossible to correct.

Alzheimer’s Disease Alzheimer’s disease is named after Alois Alzheimer, the German physician who formally identified it in 1907. Alzheimer first became aware of the syndrome in 1901 when a new patient, Auguste D., was placed under his care:

�

Age (Years)

On November 25, 1901, a

. . .

woman with no personal or family history of mental illness

was admitted to a psychiatric hospital in Frankfurt, Germ

ny, by her husband, who could

no longer ignore or hide quirks and lapses that had overtaken her in recent months. First,

there were unexplainable bursts of anger,

nd then a strange series of memory

problems.

She bec

me increasingly unable to locate things in her own h

me and began to make

surprising mistakes in the kitchen. By the time she arrived at Stadtische Irrenanstalt, the Frankfurt Hospital for the Mentally Ill and Epileptics, her condition was as severe as it w curious. The attending doctor, senior physician Alois Alzheimer, began the new file with

these notes.

. . .

She sits on the bed with a helpless expression.

L.t1,

“What is your name?”

7H!

Auguste.

,3[

rinl; (;(11

“Last name?”

Auguste.

“What is your husband’s name?”

476 ://CHAPTER 15

oneurofibrillary tangleseTwisted

Auguste, I think.

“How long have you been here?”

(She seems to be trying to remember.)

fibers that form within certain pbrain cells as people age. People with

Alzheimer’s disease have an excessive number of such tangles.

Three weeks.

It was her second day in the hospital. Dr. Alzheimer, a thirty-seven-year-old neuropa�

°senile plaqueseSphere-shaped depos-its of befa-amyloid protein that form in the spaces between certain brain cells and in certain blood vessels as people age. People with Alzheimer’s disease have an excessive number of such plaques.

thol

gist

nd clinician,

. . .

observed in his new patient a rem

rkable cluster of symptoms:

severe disorientation, reduced comprehension, aphasia (language impairment), paranoia,

ilucinations, and a short-term memory so incapacitated that when he spoke her full

name, Frau Auguste 0

, and asked her to write it down, the patient got only as

far as “Frau” before needing the doctor to repeat the rest.

He spoke her name again. She wrote “Augu” and again stopped.

When Alzheimer prompted her a third time, she was able to write her entire first name

and the initial “D” before finally giving up, telling the doctor, “I have lost myself.”

Her condition did not improve. It became apparent that there was nothing that anyone at this or any other hospital could do for Frau D. except to insure her safety and try to keep her as clean and comfortable as possible for the rest of her days. Over the next four and a half years, she became increasingly disoriented, delusional, and incoherent. She was

often hostile.

“Her gestures showed a complete helplessness,” Alzheimer later noted in a published�report. “She was disoriented as to time and place. From time to time she would state that

she did not understand anything, that she felt confused and t

tally lost

Often she

would scream for hours and hours in a horrible voice.”

By November 1904, three and a half years into her illness, Auguste D. was bedridden,

incontinent, and largely immobile

Notes from October 1905 indicate that she h

become permanently curled up in a fetal position with her knees drawn up to her chest,

muttering but unable to speak, and requiring assistance to be fed.

(Shenk, 2001, pp. 12-14)

Alzheimer’s disease is the most common form of dementia, accounting for as many

as two-thirds of all cases. Around 5 million people in the United States currently have this gradually progressive disease ( Julien, 2008; Hebert et al., 2003). It sometimes ap�pears in middle age, but in the vast majority of cases it occurs after the age of 65, and its prevalence increases markedly among people in their late 70s and early 80s (see

Fa’

Table 15-1).

DSM Checklist

Although some people with Alzheimer’s disease may survive for as many as 20 years, the time between onset and death is typically 8 to 10 years ( Julien, 2008; Soukup, 2006). It usually begins with mild memory problems, lapses of attention, and difficulties in language and communication (Apostolova & Cummings, 2008). As symptoms worsen, the person has trouble completing complicated tasks or remembering important ap�pointments. Eventually sufferers also have difficulty with simple tasks, distant memories are forgotten, and changes in personality often become very noticeable. For example, a

�

0 31 11

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1
1

man may become uncharacteristically aggressive.

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People with Alzheimer’s disease may at first deny that they have a problem, but they soon become anxious or depressed about their state of mind; many also become agitated. A woman from Virginia describes her memory loss as the disease progresses:

�

a’s:.. -:

Very often I wander around looking for something which I know is very pertinent, but then

after a while I forget about what it is I was looking fc

Once the idea is lost, every�

thing is lost and I have nothing to do but wander around trying to figure out what it was that was so important earlier.

Based a AM, 2C00

(Shenk, 2001, p. 43)

–

Disorders of Aging and Cognition :11 477

As the symptoms of dementia intensify, people with Alzheimer’s disease show less and less awareness of their limitations. They may withdraw from others during the late stages of the disorder, become more confused about time and place, wander, and show very poor judgment. Eventually they become fully dependent on other people. They may Jose almost all knowledge of the past and fail to recognize the faces of even close relatives. They also become increasingly uncomfortable at night and take frequent naps during the day (Edelstein et al., 2008; Tractenberg et al., 2005). During the late phases

110 –

`~ “!

~, –

–

�

of the disorder, the individuals require constant care.

Alzheimer’s victims usually remain in fairly good health until the later stages of the disease. As their mental functioning declines, however, they become less active and spend much of their time just sitting or lying in bed (Apostolova & Cummings, 2008). As a result, they are prone to develop illnesses such as pneumonia, which can result in death.Alzheimer’s disease is responsible for 71,000 deaths each year in the United States,

which makes it the seventh leading cause of death in the country (CDC, 2008).

r�

�

In most cases, Alzheimer’s disease can be diagnosed with certainty only after death ( Julien, 2008; APA, 2000), when structural changes in the person’s brain, such as ex-cessive neurofihrillary tangles and senile plaques, can be fully examined. Neurofibrillary tangles, twisted protein fibers found within the cells of the hippocampus and certain other brain areas, occur in all people as they age (see Figure 15-3), but people with Alzheimer’s disease form an extraordinary number of them. Senile plaques are sphere-shaped deposits of a small molecule known as the beta-amyloid protein that form in the spaces between cells in the hippocampus, cerebral cortex, and certain other brain regions, as well as in some nearby blood vessels. The formation of plaques is also a normal part of aging, but again it is exceptionally high in people with Alzheimer’s disease (Selkoe, 2002, 2000, 1992). It is not yet clear whether excessive numbers of tangles and plaques help cause Alzheimer’s disease or are merely reflections of other destructive processes that occur in the brains ofAlzheimer victims (Meyer-Luehmann et al., 2008; O’Connor et al., 2008).

,4;

‘

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Thalamus

Cerebral cortex

Large neurons shrink. Amyloid deposits develop in spaces between

cells.

Selected neurons

shrink or die.

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—

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Basal forebrain

Hypothalamus

Acetylcholine-secreting

Selected neurons die.

neurons shrink or die.

14d.:1

Amygdala

�

Amyloid deposits

cells.

in spaces between

Neurofibrillary tangles

–(

11r;_111Hh, ~I” ~_, 11 rS~~Jn~iln

ie f ~r~l;l~~ i+f f !q~re _ elo ~l l

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develop within neurons.

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Large neurons shrink or die. Amyloid deposits develop in spaces between cells. Neurofibrillary tangles develop within neurons.

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Looccuuss ceruleus

pli

Neurons die.

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•

480 ://CHAPTER 15

°vascular dementiaoDementia caused by a cerebrovascular accident, or stroke, which restricts blood flow to certain areas of the brain. Also known as multi�

infarct dementia.

2007).This finding has gained particular attention because in some animal studies zinc�has been observed to trigger a clumping of the beta-amyloid protein, similar to the

plaques found in the brains of Alzheimer’s patients (Turkington & Harris, 2009, 2001).

Yet another explanation suggests that the environmental toxin lead may contrib�

ute to the development of Alzheimer’s disease (Ritter, 2008). Lead was phased out of

gasoline products between 1976 and 1991, leading to an 80 percent drop of lead levels in people’s blood. However, many of today’s elderly population were exposed to high levels of lead in the 1960s and 1970s, regularly inhaling air pollution from vehicle exhausts—an exposure that might have damaged or destroyed many of their neurons. Several studies suggest that this previous absorption of lead and other pollutants may

indeed be having a negative effect on the current cognitive functioning of such indi�

viduals (Ritter, 2008; Schwartz & Stewart, 2007).

Finally, two other explanations for Alzheimer’s disease have been offered. One is the

antoinunune theory. On the basis of certain irregularities found in the immune systems of people with Alzheimer’s disease, several researchers have speculated that changes in aging brain cells may trigger an autoiinniune response (that is, a mistaken attack by the immune

system against itself) that leads to this disease (Zipp &Aktas,2006).The other explanation�is a viral theory. Because Alzheimer’s disease resembles Creutzfeldt-Jakob disease, another�form of dementia that is known to be caused by a slow-acting virus, some researchers

propose that a similar virus may cause Alzheimer’s disease (Doty, 2008; Prusiner, 1991). However, no such virus has been detected in the brains of Alzheimer’s victims.

Other Forms of Dementia A number of other disorders may also lead to dementia

2008). Vascular dementia, also known as multi-infarct

(Apostolova &

dementia, may follow a cerebrovascular accident, or stroke, during which blood flow to specific areas of the brain was cut off, thus damaging the areas. In many cases, the pa�tient may not even be aware of the stroke. Like Alzheimer’s disease, vascular dementia is progressive, but its symptoms begin suddenly rather than gradually. Moreover, cogni�tive functioning may continue to be normal in areas of the brain that have not been affected by the stroke, in contrast to the broad cognitive deficiencies usually displayed by Alzheimer’s patients. Vascular dementia accounts for 10 to 30 percent of all cases of dementia (Sadock & Sadock, 2007; Corey-Bloom, 2004). Some people have both

Alzheimer’s disease and vascular dementia.

Pick’s disease, a rare disorder that affects the frontal and temporal lobes, offers a clini�cal picture similar to Alzheimer’s disease, but the two diseases can be distinguished at autopsy. Creutzftldt-jakob disease, another source of dementia, has symptoms that often include spasms of the body. As you read earlier, this disease is caused by a slow-acting virus that may live in the body for years before the disease develops. Once launched, however, the disease has a rapid course. Huntington’s disease is an inherited

progressive

disease in which memory problems worsen over time, along

with personality changes and mood difficulties. Hunting�

victims have movement problems, too, such as severe

twitching and spasms. Parkinson’s disease, the slowly pro�

�

neurological disorder marked by tremors, rigidity,

and unsteadiness, can cause dementia, particularly in older

people or individuals whose cases are advanced. And, finally,�cases of dementia may also be caused by viral and bacterial

1*., in

a6:

Utfectious disorders such as HIV and AIDS, meningitis, and advanced syphilis; by brain seizure disorder; by drug abuse; or by toxins such as mercury or carbon monoxide.

—

Assessing and Predicting Dementia As you saw

most cases of Alzheimer’s disease

be diagnosed

with absolute certainty only after death, when an autopsy

performed. However, brain scans, which reveal struc�

tural abnormalities in the brain, now are used commonly

Disorders of Aging and Cognition :,// 481

as assessment tools and often provide clinicians with considerable confidence in their diagnoses of Alzheimer’s disease (Apostolova & Cummings, 2008; Julien, 2008). In ad�dition, several research teams are now trying to develop tools that can identify persons who are likely to develop dementia. One promising line of work comes from the labora�tory of brain researcher Lisa Mosconi and her colleagues (Mosconi et al., 2008; deLeon

Abnormality and the its

�

“You Are th4 e Music, while the Musk Lasts”

BY CLAYTON S. COLLINS

for a minute is miraculous. And for

half an hour, more so.”

. ..

Sacks [well-known neurologist

The key, says Sacks, is for pa�tients to learn to be well” again. Music can restore to them, he says, the identity that predates the illness. “There’s a health to music, a life to

l l

and author of the book Awakenings] danced to the Dead. For three solid hours.

At 60. And with “two broken knees.”

. . .

The power of music—. . . to “bring back” individuals rendered motionless and mute by neurological damage and disorders— is what’s driving Sacks these days. [He] is working on another case-study book, one that deals in part with the role of music as a stimulus to minds that

music.”

. . .

“Greg” was an amnesiac with a brain tumor and no coherent memo-ries of life since about 1969—but an encyclopedic memory of the years

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Pr’

0
1

that came before, and a re

I love of

-0=44,

have thrown up stiff sensory barriers

Grateful Dead tunes.

Ii–;7,\

[Note: The book, Musicophilia: Tales of

Sacks took Greg to that night’s [Grateful Dead] performance. “In the first half of the concert they were doing early music, and Greg was enchanted by everything,” Sacks recalls. “I mean, he was not an amnesiac. He was com�pletely oriented and organized and with it.” Between sets Sacks went b stage and introduced Greg to band member Micky Hart, who was im-pressed with Greg’s knowledge of the

group but quite surprised when Greg asked after Pigpen. When told the former band member had died 20 years before, “Greg was very upset,” Sacks recalls. “And then

Music and the Brain, is now published.

]

“One sees how robust music is neuro-logically,” Sacks says. “You can lose all sorts of particular powers but you don’t tend to lose music and identity.”

rs.

. . .

— , – – .-.4- Music and the r

Much of what he has encountered, particularly in working with patients at Beth Abraham Hospital, Bronx, N.Y.,

ck�

. . .

relates to music

�

demented people respond to music, babies respond to music, fetuses probably respond to music. Various animals respond to music,” Sacks says. “There is something about the animal nervous system

when one played some of the new music, which he had heard for the first time at the concert, he could sing along with it and remember it.”

It is an encouraging development

. . .

which seems to respond to music all

,” Sacks says, citing

30 seconds later he asked ‘How’s Pigpen?”

Children have been found to learn quickly lessons that are embedded in song. Sacks, the one-time quiet researcher, is invigorated by the possibilities. He wonders whether music could carry such information, to give his patient back a missing part of his life. To give Greg “some sense of what’s been hap-peeing in the last 20 years, where he has no autobiography of his own.”

the way down

. . .

During the second half, the band played its newer songs. And Greg’s world began to fall apart. He was bewildered and enthralled and frightened. Because

the music for him—and this is an extremely musical man, who understands the idiom of the Grateful Dead—was both familiar

the case of a patient with damage to the

frontal lobes of his brain.

“When he sings, one almost has the strange feeling that [music] has given him his frontal lobes back, given him back, temporally, some function that has been lost on an organic basis,” Sacks says, add-ing a quote from T. S. Eliot: “You are the

and unfamiliar

He said, This is like

the music of the future.

That would h

ye Sacks dancing in the

music, while the music lasts.”

Sacks tried to keep the new memories

The effects of music therapy may not always last. Sacks will take what he can get. “To organize a disorganized person

fresh. But the next day, Greg had no memory of the concert. It seemed as if all had been Lost. “But—and this is strange—

aisles.

Excerpted by permission from

Prolies, the magazine of Continental i

Airlines, February 1994.

�

482 :A/CHAPTER 15

et al., 2007). Using a special kind of PET scan, this research team examined activity in certain parts of the hippocampus in dozens of elderly research participants and then conducted follow-up studies of these individuals for up to 24 years. (The hippocampus plays a major role in long-term memory.) Eventually, 43 percent of the study’s participants developed either mild cognitive impair�ment (mild dementia) or Alzheimer’s disease itself.The researchers found that those who developed these cognitive impairments had indeed displayed lower hippocampus activity on their initial PET scans than the participants who remained healthy. Overall, the special PET scans, administered years before the onset of symp�toms, predicted mild cognitive impairment with an accuracy rate of 71 percent and Alzheimer’s disease with an accuracy rate of 83

percent.

As you will see shortly, the most effective interventions for Alzheimer’s disease and other kinds of dementia are those that help prevent these problems, or at least ones that are applied early. Clearly, then, it is essential to have tools that identify the disorders

�

as early as possible, preferably years before the onset of symptoms.

�

That is what

the research advances in assessment and diagnosis so exciting.

What Treatments Are Currently Available for Dementia? Treatments

for the cognitive features of Alzheimer’s

and

other

of dementia have

been at best modestly helpful. One common approach is the use of drugs that affect acetylcholine and glutamate, the neurotransmitters that play important roles in memory. Such drugs include tacrine (trade name Cognex), donepezil (Aricept), rivastigmine (Exelon), galantamine (Reminyl), and memantine (Namenda). Some Alzheimer’s patients who take these drugs improve slightly in short-term memory and reasoning ability, as well as in their use of language and their ability to cope under pressure (Apostolova & Cummings, 2008; Julien, 2008).Although the benefits of the drugs are limited and the risk of harmful

effects is sometimes high, these drugs have been approved by the Food and Drug Ad��ministration (FDA). Indeed, a skin patch for one of the drugs, rivastigmine, was approved�by the FDA in 2007 (Hitti, 2007). Clinicians believe that these drugs may be of greatest

t;M:QAx

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use to persons in the early stages of Alzheimer’s disease or to those with mild cognitive impairment. Another approach, taking vitamin E, either alone or in combination with one of these drugs, also seems to help slow down cognitive decline among people with mild dementia (Sano, 2003).A number of other possible drug treatments are being inves�

tigated currently.

The drugs discussed here are each prescribed after a person has developed mild cog�nitive impairment or Alzheimer’s disease. In contrast, several research teams are currently trying to develop an immunization for the disease (Bussiere et al., 2004). In a similar vein, a number of studies suggest that certain substances may help prevent or delay the onset of the disease. For example, one set of studies indicated that women who took estrogen, the female sex hormone, for years after menopause cut their risk of developing Alzheimer’s disease in half (Kawas et al., 1997), and other studies seemed to indicate that the use of nonsteroid anti-inflammatory drugs such as ibuprofen and naprosyn (drugs found in Advil, Motrin, Nuprin, and other pain relievers) may help reduce the risk ofAlzheimer’s

disease, although research findings on this possibility have been mixed ( Julien, 2008).

Cognitive treatments have been applied in cases of Alzheimer’s disease, with some

temporary success (Sadock & Sadock, 2007; Knight et al., 2006). In Japan, for example, a number of persons with the disease meet regularly in classes, performing simple cal�culations and reading aloud essays and novels. Proponents of this approach claim that it serves as a mental exercise that helps rehabilitate those parts of the brain linked to memory, reasoning, and judgment. In a similar vein, some research suggests that cogni�tive activities may actually help prevent or delay the onset of mild cognitive impair�ment or Alzheimer’s disease for certain individuals (Meyers, 2008). One study of 700 80-year-old individuals found that those research participants who had pursued cogni-tive activities over a five-year period (for example, writing letters, reading newspapers or books, or attending concerts or plays) were less likely to develop Alzheimer’s disease

4′.:3:414.i4.7.4_Al riPit-,14011:g

than mentally inactive participants (Wilson et al., 2007).

More Stimulation, Healthier Brain

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Behavioral interventions have also been applied to Alzheimer’s patients, with modest

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success. The approaches typically focus on changing everyday patient behaviors that are�stressful for the family, such as wandering at night, loss of bladder control, demands for

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attention, and inadequate personal care (Knight et al., 2006).The behavioral therapists use�a combination of role-playing exercises, modeling and practice to teach family members

(1, I I i.-i,. ,,-

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how and when to apply reinforcement in order to shape more positive behaviors.

484 :IICHAPTER 15

MTehedea

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HOME

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– – –

EXPLORE

�

Doctor, Do No Harm

BY LAURIE TARKAN, NEW YORK TIMES, JURE 24, 2008

�

Lamascola thought she was losing her 88-year�old mother to dementia. Instead, she was losing her to

overmedication.

�

Last fall her mother, Theresa Lamascola, of the Bronx, suf�fering from anxiety and confusion [along with dementia], was put on the antipsychotic drug Risperdal. When she had trouble

walking, her daughter took her to another doctor

Theresa Lamascola was moved to a nursing home to get these problems under control. But things only got worse. “My mother was screaming and out of it, drooling on herself and twitching,” said Ms. Lamascola, a pediatric nurse. The psychia�trist in the nursing home stopped the Risperdal, which can cause twitching and vocal tics, and prescribed a sedative and two other antipsychotics. “I knew the drugs were doing this to her,” her daughter said. “I told him to stop the medications and stay

away from Mom.” Not until yet another doctor took Mrs. L

mas�

cola off the drugs did she begin to improve.

�

The use of antipsychotic drugs to tamp down the agitation,

combative behavior

nd outbursts of dementia patients has

Used correctly, the drugs do have a role in treating some seri�ously demented patients, who may be incapacitated by para�noia or are self-destructive or violent. Taking the edge off the behavior can keep them safe and living at home, rather than in a nursing home. [But] if patients are prescribed an antipsychotic,

soared, especially in the elderly. S

les of newer antipsychotics

like Risperdal, Seroquel and Zyprexa totaled $13.1 billion in

2007, up from $4 billion in 2000

Part of this increase can

be traced to prescriptions in nursing homes. Researchers esti-mate that about a third of all nursing home patients have been

it should be a very low dose for the shortest period necessary,�said Dr. Dillip V. Jeste, a professor of psychiatry and neurosci�

given antipsychotic drugs

[The] Food and Drug Administra�

tion

has not approved marketing of these drugs for older

ence at the University of California, San Diego

people with dementia, but they are commonly prescribed to

[Thus, it was not totally surprising that Theresa Lamascola�improved dramatically when a physician finally took her off anti�

these patients “off label.”

…

[M]any doctors say misuse of the drugs is widespread. “These antipsychotics can be overused and abused,” said Dr. Johnny Matson, a professor of psychology at Louisiana State University. “And there’s a lot of abuse going on in a lot of these places.”… Nursing homes are short staffed, and insurers do not generally pay for the attentive medical care and hands-on psychosocial therapy that advocates recommend. It is much easier to use sedatives and antipsychotics, despite their side

psychotic drugs.] “It’s not clear whether it was getting her

.. .

medical issues finally under control or getting rid of the offend-ing medications,” [the physician] said. “But she had a miracu�

lous turnaround.”

Theresa Lamascola still has dementia, but ter put it, “I got my mother back.”

. . .

as her dough�

Originally published as “Doctors Say Medication Is Overused in Dementia,” Newlin* Times, National Section.

effeciA_

. .

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–

—

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Caregiving can take a heavy toll on the close relatives of people with dementia (Sadock & Sadock, 2007; Cummings, 2005). Almost 90 percent of all people with dementia are cared for by their relatives (Alzheimer’s Association, 2007; Kantrowitz & Springen, 2007) (see Figure 15-4). It is hard to take care of someone who is becoming increasingly lost, helpless, and medically ill. And it is very painful to witness mental and physical decline in someone you love. Many caregivers experience depression and anger, and their own physical and mental health often declines (Kantrowitz & Springen, 2007; Sherwood et al., 2005). Clinicians now recognize that one of the most important aspects

Disorders of Aging and Cognition 485

Other relative

Nonrelative

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of treating Alzheimer’s disease and other forms of dementia is to focus on the emotional�needs of the caregivers, including their needs for regular time out, for education about�the disease, and for psychotherapy (Knight et al., 2006; Gaugler et al., 2003). Some clini�

cians also provide caregiver support groups (Pillemer & Suitor, 2002).

In recent years, sociocultural approaches have begun to play an important role in treatment (Brooks, 2005; Hirshom, 2004; Kalb, 2000). A number of day-care facilities for patients with dementia have been developed, providing treatment programs and activi�ties for outpatients during the day and returning them to their homes and families at night. In addition, many assisted-living facilities have been built, in which individuals suffering from dementia live in cheerful apartments, receive needed supervision, and take part in various activities that bring more joy and stimulation to their lives. Studies suggest that such facilities often help slow the cognitive decline of residents and enhance

their enjoyment of life.

Given the progress now unfolding in the understanding and treatment of Alzheim�er’s disease and other forms of dementia, researchers are looking forward to advances in the coming years. The brain changes responsible for dementia are tremendously complex, but with so much research under way, most investigators believe that exciting breakthroughs are just over the horizon.

�

Disorders of Coorlition

Older people

likely than people of other age groups to experience de�

lirium, a clouding of consciousness in which a person has great difficulty concentrat�

ing, focusing attention, and following an orderly sequence of thought.

Dementia, a syndrome marked by severe memory loss and other cognitive dis�

turbances, also becomes incre

singly common in older age groups. It can be the

result of dozens of brain illnesses or injuries, most commonly Alzheimer’s disc

se or

vascular dementia. Alzheimer’s disease has been linked to an unusually high num�ber of neurofibrillary tangles and senile plaques in the brain. A number of causes have been proposed for this disease, including genetic factors; abnormal protein and neurotransmitter activily; high levels of zinc, lead, or various toxins; immune

system problems; and slow-acting infections.

Researchers are making progress at better assessing dementia and even at identifying persons who will eventually develop this problem. Drug, cognitive, and behavioral therapies have been applied to dementia, with limited success. Address�

ing the needs of caregivers is now also recognized

s a key part of treatment. In

addition, sociocultural approaches such as day-care facilities are on the rise.

�

486 ://CHAPTER 15

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*issues Affecting the Mental Health of the Elderly

Adiri6; ender’ and. R0c6

As the study and treatment of elderly people have progressed, three issues have raised concern among clinicians: the problems faced by elderly members of racial and ethnic minority groups, the inadequacies of Iong-term care, and the need for a health-mainte�nance approach to medical care in an aging world (Gallagher-Thompson & Thompson,

1995).

First, discrimination because of race and ethnicity has long been a problem in the United States (see Chapter 2), and many people suffer as a result, particularly those who are old (Utley et al., 2002). To be both old and a member of a minority group is considered a kind of “double jeopardy” by many observers. For older women in minority groups, the difficulties are sometimes termed “triple jeopardy,” as many more older women than older men live alone, are widowed, and are poor. Clinicians must take into account their older patients’ race, ethnicity, and gender as they try to diagnose and treat their mental

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health problems (Knight et al., 2006; Sadavoy et al., 2004).

Some elderly people in minority groups face language barriers that interfere with their medical and mental health care. Others may hold cultural beliefs that prevent them from seeking services. Moreover, many members of minority groups do not trust the majority establishment or do not know about medical and mental health services that are sensitive to their culture and their particular needs (Ayalon & Huyck, 2001). As a result, it is common for elderly members of racial and ethnic minority groups to rely

largely on family members or friends for remedies and health care.

Today, 10 to 20 percent of elderly people live with their children or other relatives, usually because of increasing health problems (Etaugh, 2008). In the United States, this living arrangement is more common for elderly people from ethnic minority groups than for elderly white Americans. Elderly Asian Americans are most likely to live with their children, African Americans and Hispanic Americans are less likely to do so, and white Americans are least likely (Etaugh, 2008; Armstrong 2001).

Second, many older people require long-term care, a general term that may refer

variously to services offered outside the family in a partially supervised apartment, in a senior housing complex for mildly impaired elderly persons, or in a nursing home where skilled medical and nursing care are available around the clock. The quality of care in such residences varies widely.

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Disorders of Aging and Cognition :fi 487

At any given time in the United States, only about 5 percent of the elderly popu�lation actually live in nursing homes, but as many as 30 percent eventually wind up being placed in such facilities (Edelstein et al., 2008). Thus many older adults live in fear of being “put away.” They fear having to move, losing independence, and living in a medical environment. Many also worry about the cost of long-term care facili�ties (Papastavrou et al., 2007). Around-the-clock nursing care is expensive, and nurs�ing home costs continue to rise. The health insurance plans available today do not adequately cover the costs of long-term placement (Newcomer et al., 2001). Worry over these issues can greatly harm the mental health of older adults, perhaps leading to

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depression and anxiety as well as family conflict.

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Finally, medical scientists suggest that the current generation of young adults should take a health- maintenance, or wellness promotion, approach to their own aging process (Mey�ers, 2008;Aldwin et al., 2006). In other words, they should do things that promote physi�cal and mental health—avoid smoking, eat well-balanced and healthful meals, exercise regularly, maintain positive social relationships, and take advantage of stress management and other mental health programs (Cherry et al., 2007; Peterson, 2006) .There is a grow— ing belief that older adults will adapt more readily to changes and negative events if their physical and psychological health is good.

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(Pciiiim i.c.,12005; 2004. ; 2031)

•••

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Issues is,fE-z…cting the Mental Health of the Elderly

In studying and treating the problems of old age, clinicians have become concerned about three issues: the problems of elderly members of racial and ethnic minority groups, inadequacies of long-term care, and the need for health maintenance by young adults.

PUTTING IT… together

Clinicians Discover the Elderly

Early in the twentieth century, mental health professionals focused little on the elderly. But like the problems of children, those of aging persons have now caught the attention of researchers and clinicians. Current work is bringing important changes in how we understand and treat the psychological problems of the elderly. No longer do clinicians simply accept depression or anxiety in elderly people as inevitable. No longer do they overlook the dangers of prescription drug misuse by the elderly.And no longer do they underestimate the dangers of delirium or the prevalence of dementia. Similarly, gero�

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psychologists have become more aware of the importance of addressing the health care

and financial needs of the elderly as keys to their psychological well-being.

C 4

As the elderly population grows ever larger, the special needs of people in this age group are becoming more visible. Thus the study and treatment of their psychological problems, like those of children, will probably continue at a rapid pace. Clinicians and

(

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public officials are not likely to underestimate their needs and importance again.

Particularly urgent is dementia and its devastating impact on the elderly and their families.The complexity of the brain makes dementia difficult to understand, diagnose, and treat. However, researchers announce exciting new discoveries almost daily. To date, this research has been largely biological, but dementia has such a powerful impact on patients and their families that today’s psychological and sociocultural investigations are also growing by leaps and bounds.

�

(CDC, 2007; Ash: 19991

488 ://CHAPTER 15

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•••

Need aging lead to depression and other psychological problems? What kinds of attitudes, preparations, and activities might help an individual enter old age with peace of mind and even positive anticipation?

pp. .468-474

growing problem of misuse of pre�

will eventually develop a devastating disease that currently has no known cure? pp. 480-482

scription drugs

mong the elderly?

pp. 471-472

3. Current research developments sug-gest that diagnosticians eventually may be able to identify victims of Alzheimer’s disease years before their memory begins to fail notice-ably. Would people be better off knowing or not knowing that they

4. If caregivers for elderly relatives

54 :0d,

often feel anxious, depressed, and overwhelmed, might those feelings be sensed by the elderly individuals, even those with dementia? How might this occur, and what impact might it have? pp. 484-485

What changes in medical prac-tice, patient education, or family

Fr’

interactions might address the

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geropsycoogy,p. delusional disorder, p. 473

tau protein, p. 479 acetylcholine, p. 479

Huntington’s disea

se, p. 480

Parkinson’s dise

se, p. 480

4delirium, p. 474

glutam

te, p. 479

hippocampus, p. 482�immunization, p. 483

1dementia, p. 475

lcium, p. 479

0 Alzheimer’s disease, p. 475

zinc, p. 479

estrogen, p. 483

(I: neurofibrill

ry tangles, p. 477

lead, p. 480

nonsteroid anti-inflammatory drugs, p. 483

.yi

7g senile plaques, p. 477

autoimmune theory, p. 480

y-care facilities, p. 485

beta-amyloid protein, p. 477

viral theory, p. 480

assisted-living facilities, p. 485 discrimination, p. 486

tri beta-amyloid pecursor protein, p. 478 presenilin, p. 478

!-] interIeukin-1, p. 478

vascular dementia, p. 480

Pick’s disease, p. 480

long-term care, p. 486

Creutzfeldt-Jakob dise

se, p. 480

health-maintenance approach, p. 487

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What is geropsychology? What kinds of special pressures and upsets are faced by elderly persons? pp. 468-469

4. Describe and explain the kinds of

8. Describe the clinical features and course of Alzheimer’s disease. What are its possible causes? pp. 475-480

substance abuse patterns that some-times emerge among the elderly. pp. 471-472

,4:

How common is depression among the elderly? What are the possible causes of this disorder in aged persons, and how is it treated? pp. 469-470

5. What kinds of psychotic disorders may be experienced by elderly persons? pp. 473-474

9. Can Alzheimer’s disease be predicted? What kinds of inter�

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ventions

re applied in cases of

4,-,;

6. What is delirium, and how does it differ from dementia? pp. 474-475

this and other forms of dementia? pp. 480-485

How prevalent

re anxiety dis�

7. How common is dementia among the elderly? What are some of the diseases and problems

10. What issues regarding aging have

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orders among the elderly? How do theorists explain the onset of these disorders in aged persons, and how do clinicians treat them?

ised particular concern among

clinicians? pp. 486-487

t may produce dementia?

pp. 475, 480

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on. 470-471

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Disorders of Aging and Cognition :// 489

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Search the Fundamentals of Abnormal Psychology Video Tool Kit

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Chapter 15 Video Cases

Pets and the Elderly: The Impact of Companionship

Living without Memory

‘

Suffering from Alzheimer’s Disease

A Video case discussions, study guides, and questions

/ Log on to the Corner Web Page

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ear Jodie:

There is a definite possibility that I will be killed in my attempt to get Reagan. It is for�this very reason that I am writing you this letter now. As you well know by now, 1 love you

TOPIC OVERVIEW

How Do Clinicians Influence the Criminal Justice System?

very much. The past seven months I have left you dozens of poems, letters and messages

Criminal Commitment and Insanity during

Commission of a Crime

in the faint hope you would develop an interest in me. . . . Jodie, I would abandon this idea of getting Reagan in a second if I could only win your heart and five out the rest of my life with you, whether it be in total obscurity or whatever. I will admit to you that the reason I’m going ahead with this attempt now is because I just cannot wait any longer to impress you. I’ve got to do something now to make you understand in no uncertain terms that i am doing all of this for your sake. By sacrificing my freedom and possibly my life I hope to change your mind about me. This letter is being written an hour before I leave for the Hilton Hotel. Jodie, I’m asking you

Criminal Commitment and

Incompetence to Stand Trial

How Does the Legal System Influence Mental Health Care? Civil Commitment

Protecting P

tients’ Rights

pie

se to look into your heart and at least give me the chance with this historical deed to g

your respect and love. I love you forever.

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John Hinckley

Clinical and Legal Fields Interact?

Malpractice Suits

Professional Boundaries

�

John W. Hinckley Jr. wrote this letter to actress Jodie Foster in March 1981. Soon after writing it, he stood waiting, pistol ready, outside the Washington Hilton Hotel. Moments later, President Ronald Reagan came out of the hotel, and the popping of pistol fire was heard.As Secret Service men pushed Reagan into the limousine, a policeman and the president’s press secretary fell to the pavement.The president had been shot, and by nightfall most of America had seen the face and heard the

Psychological Research of Legal Topics

Ethics and Mental Health Professionals

Mental Health, Business, and Economics

name of the disturbed young man from Colorado.

Bringing Mental Health Services

As you have seen throughout this book, the psychological dysfunctioning of an individual does not occur in isolation. It is influenced—sometimes caused—by societal and social pressures, and it affects the lives of relatives, friends, and acquain�tances. The case of John Hinckley demonstrates in powerful terms that individual dysfunction may, in some cases, also affect the well-being and rights of people the

to the Workplace

The Economics of Mental Health�The Person within the Profession

person does not know.

Putting It Together:

Operating within a Larger System

By the same token, clinical scientists and practitioners do not conduct their work in isolation. As they study and treat people with psychological problems, they are affecting and being affected by other institutions of society.We have seen, for example, how the government regulates the use of psychotropic medications; how clinicians helped carry out the government’s policy of deinstitutionalization; and how clinicians have called the psychological ordeal of Iraq combat veterans

and, before them,Vietnam veterans, to the attention of society.

In short,like their clients, clinical professionals operate within a complex social system, and in fact, it is the system that defines and regulates their professional responsibilities. Just as we must understand the social context in which abnormal behavior occurs in order to understand the behavior, so must we understand the

context in which this behavior is studied and treated.

Two social institutions have a particularly strong impact on the mental health profession—the legislative and judicial systems. These institutions—collectively,

492 ://CHAPTER 1 6

the legal field—have long been responsible for protecting both the public good and the rights of individuals. Sometimes the relationship between the legal field and the mental health field has been friendly, and they have worked together to protect the rights and meet the needs of troubled individuals and of society at large.At other times they have clashed, and one field has imposed

its will on the other.

This relationship has two distinct aspects. On the one hand, mental health professionals often play a role in the criminal justice system, as when they are called upon to help the courts assess the mental stability of people accused of crimes. They responded to this call in the Hinckley case, as you will see, and in thousands of other cases. This aspect of the relationship is sometimes termed psychology in law; that is, clinical practitioners and researchers oper�

‘ – –

–

ate within the legal system. On the other hand, there is another aspect to the relationship, called law in psychology. The legislative and judicial systems act upon the clinical field, regulating certain aspects of mental health care. The courts may, for example, force some individuals to enter treatment, even

against their will. In addition, the law protects the rights of patients.

The intersections between the mental health field and the legal and ju�

dicial systems are referred to as forensic psychology (McGrath & Torres,

�

2008; Packer, 2008). Forensic psychologists or psychiatrists (or related mental health professionals) may perform such varied activities as testifying in trials, researching the reliability of eyewitness testimony, or helping police profile the personality of a serial killer on the loose.

OPsychology in Law: How Do Clinicians influence the Criminal Justice System?

To arrive at just punishments, the courts need to know whether defendants are respon�sible for the crimes they commit and capable of defending themselves in court. If not, it would be inappropriate to find individuals guilty or punish them in the usual manner. The courts have decided that in some instances people who suffer from severe mental instability may not be responsible for their actions or may not be able to defend them�selves in court, and so should not be punished in the usual way. Although the courts make the final judgment as to mental instability, their decisions are guided to a large

degree by the opinions of mental health professionals.

When people accused of crimes are judged to be mentally unstable, they are usually sent to a mental institution for treatment, a process called criminal commitment. Actually there are several forms of criminal commitment. In one, individuals are judged mentally unstable at the time of their crimes and so innocent of wrongdoing. They may plead not guilty by reason of insanity (NGRI) and bring mental health professionals into court to support their claim. When people are found not guilty on this basis, they

°forhenlsic psyc il ologd yeTithheitrections

branch of

are committed for treatment until they improve enough to be released.

pbesytwceoenogpysyccohnological practice and

In a second form of criminal commitment, individuals are judged mentally unstable at the time of their trial and so are considered unable to understand the trial procedures and defend themselves in court. They are committed for treatment until they are corn-petent to stand trial. Once again, the testimony of mental health professionals helps

dicial system. Also researc an tfieeldjuof forensic schiatr

related to the

Gaiminal commitment®A legal pro-cess by which people accused of a crime are instead judged mentally unsta�ble and sent to a mental health facility for

treatment.

determine the defendant’s psychological functioning.

°not g silty by reason of insanity

stating that defendants (NG111)°A verdict

These judgments of mental instability have stirred many arguments. Some people consider the judgments to be loopholes in the legal system that allow criminals to escape proper punishment. Others argue that a legal system simply cannot be just unless it al-lows for extenuating circumstances, such as mental instability. The practice of criminal commitment differs from country to country. In this chapter you will see primarily how it operates in the United States. Although the specific principles and procedures of each country may differ, most countries grapple with the same issues and decisions that you will be reading about here.

are not guilty of committing a crime because they were insane at the time of the crime.

Law, Society, and the Mental Health Profession :1/ 493

Criminal Commitment and Insanity during

Commission of a Crime

olViNaghten testoA widely used legal

test for

that holds people to

be insane

at the

time they committed a

Consider once again the case of John Hinckley. Was he insane at the time he shot the president? If insane, should he be held responsible for his actions? On June 21, 1982, 15 months after he shot four men in the nation’s capital, a jury pronounced Hinckley not guilty by reason of insanity. Hinckley thus joined Richard Lawrence, a house painter who shot at Andrew Jackson in 1835, and John Schrank, a saloonkeeper who shot former president Teddy Roosevelt in 1912, as a would-be assassin who was found not guilty by

crime if, because of a mental disorder, they did not know the nature of the act or did not know right from wrong. Also known as M’Naghten rule.

°irresistible

�

test®A legal

test for

y that holds people to

reason of insanity.

crime if

be insane

at the

were driven to do so by an

ti me they committed a

It is important to recognize that “insanity” is a legal term (Hartocollis, 2008). That is, the definition of “insanity” used in criminal cases was written by legislators, not by clinicians. Defendants may have mental disorders but not necessarily qualify for a legal definition of insanity. Modern Western definitions of insanity can be traced to the mur-der case of Daniel M’Naghten in England in 1843. M’Naghten shot and killed Edward

uncontrolla

ble “fit of passion.

°Durham testoA

test for insanity

that holds people to be

insan

e at the

time they committed a crime if their act was the result of a mental disorder or defect.

Drummond, the secretary to British Prime Minister Robert Peel, while trying to shoot Peel. Because of M’Naghten’s apparent delusions of persecution, the jury found him to be not guilty by reason of insanity. The public was outraged by this decision, and their angry outcry forced the British law lords to define the insanity defense more clearly This legal definition, known as the M’Naghten test, or M’Naghten rule, stated that experiencing a mental disorder at the time of a crime does not by itself mean that the person was insane; the defendant also had to be unable to know right from wrong. The state

°American Law Institute testoA legal test for

be insan

e at the

crime if, because of a mental disorder, they did not know right from wrong or could not resist an uncontrollable impulse

to act.

that ho people to

time theeyy committed a

and federal courts in the United States adopted this test as well.

In the late nineteenth century some state and federal courts in the United States, dissatisfied with the M’Naghten rule, adopted a different test—the irresistible impulse test. This test emphasized the inability to control one’s actions. A person who com�mitted a crime during an uncontrollable “fit of passion” was considered insane and not

guilty under this test.

For years state and federal courts chose between the M’Naghten test and the irresist�

ible impulse test to determine the sanity of criminal defendants. For a while a third test, called the Durham test, also became popular, but it was soon replaced in most courts. This test, based on a decision handed down by the Supreme Court in 1954 in the case of Durham v. United States, stated simply that people are not criminally responsible if their

“unlawful act was the product of mental disease or mental defect.” This test was meant to offer more flexibility in court decisions, but it proved too flexible. Insanity defenses could point to such problems as alcoholism or other forms of substance dependence and conceivably even headaches or ulcers, which were listed as psychophysiological disorders in DSM-I.

In 1955 the American Law Institute (ALI) developed a test that combined aspects of the M’Naghten, irresistible impulse, and Durham tests. The American Law Institute test held that people are not criminally responsible if at the time of a crime they had a mental disorder or defect that prevented them from knowing right from wrong or from being able to control themselves and to follow the law. For a time the new test became the most widely accepted legal test of insanity.After the Hinckley verdict, however, there was a

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public uproar over the “liberal” ALI guidelines, and people called for tougher standards.

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Partly in response to this uproar, the American Psychiatric Association recom- mended in 1 983 that people should be found not guilty by reason of insanity only if they did not know right from wrong at the time of the crime; an inability to control themselves and to follow the law should no longer be sufficient grounds for a judgment of insanity. In short, the association was calling for a return to the M’Naghten test.This test now is used in all cases tried in federal courts and in about half of the state courts (Doherty, 2007).The more liberal ALI standard is still used in the remaining state courts, except in Idaho, Kansas, Montana, Nevada, and Utah, which have, more or less, done

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away with the insanity plea altogether (Greenberg & Felthous, 2007; Lohr, 2007).

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People suffering from severe mental disorders in which confusion is a major feature

1982

may not be able to tell right from wrong or to control their behavior. It is therefore not

494 ://CHAPTER 16

Physical assault—\

(38%)

Property crimes

(18%)

Murder

(15%)

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surprising that approximately two-thirds of defendants who are acquit-ted of a crime by reason of insanity qualify for a diagnosis of schizo-phrenia (Novak et al., 2007; Steadman et al., 1993). The vast majority of these acquitted defendants have a history of past hospitalization, arrest, or both. About half who successfully plead insanity are white, and 86 percent are male. Their mean age is 32 years. The crimes for which de-fendants are found not guilty by reason of insanity vary greatly. However, approximately 65 percent are violent crimes of some sort (APA, 2003; Steadman et al., 1993). Close to 15 percent of those acquitted are accused specifically of murder (see Fig. 16-1).

What Concerns Are Raised by the insanity Defense? De�

spite the changes in the insanity tests, criticism of the insanity defense�continues (Slovenko, 2009, 2004, 2002; Sales & Shuman, 2005). One

concern is the fundamental difference between the law and the science

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of human behavior (Dennison, 2007).The law assumes that individuals have free will and are generally responsible for their actions. Several models of human behavior, in contrast, assume that physical or psychological forces act to determine the individual’s behavior. Inevitably, then, legal definitions of insanity and responsibility will differ from those sug�

gested by clinical research.

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A second criticism points to the uncertainty of scientific knowledge about abnor�mal behavior. During a typical insanity defense trial, the testimony of defense clinicians conflicts with that of clinicians hired by the prosecution, and so the jury must weigh the claims of “experts” who disagree in their assessments (Koocher & Keith-Spiegel, 2008). Some people see this lack of professional agreement as evidence that clinical knowledge in some areas may be too incomplete to be allowed to influence important legal deci�sions. Others counter that the field has made great advances—for example, developing several psychological scales to help clinicians discriminate more consistently between

the sane and insane as defined by the M’Naghten standard (Rogers, 2008).

Even with helpful scales in hand, however, clinicians making judgments of legal insanity face a problem that is difficult to overcome: They must evaluate a defendant’s state of mind during an event that occurred weeks, months, or years earlier. Because mental states can and do change over time and across situations, clinicians can never be entirely certain that their assessments of mental instability at the time of the crime

are accurate.

Perhaps the most often heard criticism of the insanity defense is that it allows dan�gerous criminals to escape punishment. Granted, some people who successfully plead insanity are released from treatment facilities just months after their acquittal.Yet the number of such cases is quite small (MHA, 2007, 2004; Steadman et al., 1993). Accord�

ing to surveys, the public dramatically overestimates the percentage of defendants who plead insanity, guessing it to be 30 to 40 percent, when in fact it is less than 1 percent. Moreover, only a minority of these persons fake or exaggerate their psychological symp�toms (Resnick & Harris, 2002), and only one-quarter of defendants who plead insanity are actually found not guilty on this basis (APA, 2003; Callahan et al., 1991). In the end, less than 1 of every 400 defendants in the United States is found not guilty by reason of

insanity, and, in most such cases, the prosecution agrees that the verdict is appropriate.

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During most of -U.S. history, a successful insanity plea amounted to the equivalent of a long-term prison sentence. In fact, treatment in a mental hospital often resulted in a longer period of confinement than a verdict of guilty would have brought (Nwokike, 2005; Perlin, 2000). Because hospitalization resulted in little, if any, improvement, clini�cians were reluctant to predict that the offenders would not repeat their crimes. Today, however, offenders are being released from mental hospitals earlier and earlier. This trend is the result of the increasing effectiveness of drug therapy and other treatments in institutions, the growing reaction against extended institutionalization, and a greater emphasis on patients’ rights (Slovenko, 2009, 2004; Salekin & Rogers, 2001). In 1992, in the case of Poncho v. Louisiana, the U.S. Supreme Court clarified that the only accep

table

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tow, Society, and the Mental Health Profession :// 495

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Famous insanity Defense Cases

1977 In Michigan, Francine Hughes poured gasoline around the bed where her husband, Mickey, lay in a drunken stupor. Then she lit a match and set him on fire. At her trial she explained that he had beaten her repeatedly for 14 years and had threatened to kill her if she tried to leave him. The jury found her not guilty by rea-son of temporary insanity, making her into a symbol for many abused women across the nation.

performed crude lobotomies on them, and dismembered their bodies and stored the parts to be eaten. Despite a plea of not guilty by reason of insanity, the jury found him guilty as charged. He was beaten to death by another inmate in 1995.

people dead and wounding 3 others. Attorneys for Malvo, a teenager, argued that he had acted under the influence of the middle-aged Muhammad and that he should be found not guilty of the crimes by reason of insanity. The jury, however, found Malvo guilty of capital murder and sentenced him to life in prison.

1994 On June 23, 1993, 24-year-old Lorena Babbitt cut off her husband’s penis with a 12-inch kitchen knife while he slept. During her trial, defense attorneys argued that after years of abuse by John Bobbitt, his wife suffered a brief psychotic episode and was seized by an “irresistible impulse” to cut off his penis after he came home drunk and raped her. In 1994, the jury found her not guilty by reason of tempo-rary insanity. She was committed to a state mental hospital and released a few months later.

2006 On June 20, 2001, Andrea Yates,

36-year-old woman, drowned each of

her five children in the bathtub. Yates had

1978 David “Son of Sam” Berkowitz, a serial killer in New York City, explained that a barking dog had sent him demonic messages to kill. Although two psychiatrists assessed him as psychotic, he was found guilty of his crimes. Long after his trial,

he said that he had actually made up the delusions.

history of postpartum depression and

1979 Kenneth Bianchi, one of the pair known as the Hillside Strangler, entered a plea of not guilty by reason of insanity but was found guilty along with his cousin of

2003 For three weeks in October 2002, John Allen Muhammad and Lee Boyd Malvo went on a sniping spree in the Washington, DC, area, shooting 10

postpartum psychosis: She believed that she was the devil, that she had failed to be a good mother, and that her children were not developing correctly. Given such prob�lems and history, she pleaded not guilty by reason of insanity. In 2002, however, a Texas jury found her guilty and sentenced her to life in prison. This verdict was later overturned, and in 2006, after a new trial, Yates was found not guilty by reason of insanity and sent to a mental health facility for treatment.

sexually ass

ulting and murdering women

in the Los Angeles area in late 1977 and early 1978. He claimed that he had mul-tiple personality disorder.

�

1980 In December, Mark David Chapman murdered John Lennon. Chapman later explained that he had killed the rock music

legend because he believed Lennon to be

“ll-out.

” Pleading not guilty by reason

a se

of insanity, he described hearing the voice

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of God, considered himself his generation’s

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“catcher in the rye

novel), and compared himself to Moses. Chapman was convicted of murder.

” {from the J. D. Salinger

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1981 In an attempt to prove his love for actress Jodie Foster, John Hinckley Jr. tried to assassinate President Ronald Reagan. Hinckley was found not guilty by reason of insanity and was committed to St. Eliza�beths Hospital for the criminally insane in Washington, DC, where he remains today.

1992 Jeffrey Dahmer, a 31-year-old mass murderer in Milwaukee, was tried for the killings of 15 young men. Dahmer apparently drugged some of his victims,

�

496 ://CHAPTER 16

*guilty but mentally ilk®A verdict stating that defendants are guilty of committing a crime but are also suffer-ing from a mental illness that should be treated during their imprisonment.

basis for determining the release of hospitalized offenders is whether or not they are still “insane”; they cannot be kept indefinitely in mental hospitals solely because they are dangerous. Some states are able to maintain control over offenders even after their release from hospitals (Swartz et al., 2002). The states may insist on community treat-meat, monitor the patients closely, and rehospitalize them if

necessary.

What Other Verdicts Are Available? Over the past few decades, 14 states have

added another verdict option—guilty but mentally ill. Defendants who receive this verdict are found to have had a mental illness at the time of their crime, but the illness was not fully related to or responsible for the crime. The guilty-but-mentally-ill option enables jurors to convict a person they view as dangerous while also suggesting that the individual receive needed treatment. Defendants found to be guilty but mentally ill are given a prison term with the added recommendation that they also undergo treatment if

necessary.

After initial enthusiasm for this verdict option, legal and clinical theorists have

increasingly found it unsatisfactory (Melville & Naimark, 2002). According to research, it has not reduced the number of not-guilty-by-reason-of-insanity verdicts. Moreover, it often confuses jurors in both real and mock trials. And, perhaps most important, critics point out that appropriate mental health care is supposed to be available to all prisoners anyway, regardless of the verdict. They argue that the guilty-but-mentally-ill option differs from a guilty verdict in name only (Slovenko, 2009, 2004, 2002; Sadock &

Sadock, 2007).

Some states allow still another kind of defense, guilty with diminished capacity. Here a defendant’s mental dysfunctioning is viewed as an extenuating circumstance that the court should take into consideration in determining the precise crime of which he or she is guilty (Benitez & Chamberlain, 2008; Leong 2000). The defense lawyer

argues that because of mental dysfunctioning, the defendant could not have intended to commit a particular crime. The person can then be found guilty of a lesser crime—of manslaughter (unlawful killing without intent), say, instead of murder in the first degree (planned murder). The famous case of Dan White, who shot and killed Mayor George Moscone and City Supervisor Harvey Milk of San Francisco in 1978, illustrates the use of this verdict.

Defense attorney Douglas Schmidt argued that a patriotic, civic-minded man like Dan

White—high school athlete, decorated w

r veteran, former fireman, policeman, and city

supervisor—could not possibly have committed such an act unless something had snapped inside him. The brutal nature of the two final shots to each man’s head only proved that White had lost his wits. White was not fully responsible for his actions because he suffered from “diminished capacity.” Although White killed Mayor George Moscone and Supervi�sor Harvey Milk, he had not planned his actions. On the day of the shootings, White was

mentally incapable of planning to kill, or even of wanting to do such a thing.

Well known in forensic psychiatry circles, Martin Blinder, professor of law and psychia�try at the University of California’s Hastings Law School in San Francisco, brought a good measure of academic prestige to White’s defense. White had been, Blinder explained to

the jury, “g

rging himself on junk food: Twinkies, Coca-Cola

The more he consumed,

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the worse he’d feel and he’d respond to his ever-growing depression by consuming ever�more junk food.” Schmidt later asked Blinder if he could elaborate on this. “Perhaps if

it were not for the ingesti

n of this junk food,” Blinder resp

nded, “1 w

uld suspect th

these homicides would not have taken place.” From that moment on, Blinder became

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known as the author of the Twinkle defense

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n White was convicted only of voluntary manslaughter,

nd was sentenced to seven

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years, eight months. (He was released on parole January 6, 1984.) Psychiatric testimony convinced the jury that White did not wish to kill George Moscone or Harvey Milk.

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The angry crowd that resp

nded to the verdict by marching, shouting, trashing City

Hall, and burning police cars was in good part homosexual. Gay supervisor Harvey Milk

Law, Society, and the Menial Health Profession :1/ 497

�

had worked well for their cause, and his loss was a serious setback for human rights in

San Francisco. Yet it was n

niy members of the gay community who were appalled at

the outcome. Most San Franciscans shared their feelings of outr

ge.

(Coleman, 1984, pp. 65-70)

Because of possible miscarriages ofj ustice, many legal experts have argued against the “diminished capacity” defense. And, indeed, a number of states have eliminated it, includ�ing California shortly after the Dan White verdict (Gado, 2008; Slovenko, 2002, 1992).

What Are Sex-Offender Statutes? Since 1937, when Michigan passed the first

psychopath”

of states have placed sex offenders in a special legal

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category (Strutin, 2007; Zonana et al., 2004).These states believe that some of the indi��viduals who are repeatedly found guilty of sex crimes have a mental disorder, and so the

Th é•Affehncith

states categorize them as

mentally disordered sex offenders,

People classified in this way are convicted of a criminal offense and are thus judged to be responsible for their actions. Nevertheless, mentally disordered sex offenders are sent to a mental health facility instead of a prison. In part, such laws reflect a belief held by many legislators that such sex offenders are psychologically disturbed. On a practical level, the laws help protect sex offenders from the physical abuse that they often receive

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in prison society.

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Over the past two decades, however, most states have been changing or abolishing their mentally disordered sex offender laws, and at this point only a handful still have them (Sreenivasan et al., 2003). There are several reasons for this new trend. First, states typically have found the laws difficult to apply. Some of the laws, for example, require that the offender be found “sexually dangerous beyond a reasonable doubt”—a judg- ment that is often beyond the reach of the clinical field’s expertise. Similarly, the state laws may require that in order to be classified as mentally disordered sex offenders, in�dividuals must be good candidates for treatment, another judgment that is difficult for clinicians to make, especially for this population. Third, evidence exists that racial bias often affects the use of the mentally disordered sex offender classification (Sturgeon & Taylor, 1980). From a defendant’s perspective, this classification is considered an attrac�tive alternative to imprisonment—an alternative available to white Americans much

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498 :1/CHAPTER 16

ementat incompetenceeA st

to of

more often than to members of racial minority groups. White Americans are twice as�likely to be granted mentally disordered sex offender status as African Americans or

mental instability that leaves defendants unable to understand the legal charges and proceedings they are facing and unable to prepare an adequate defense with their attorney.

Hispanic Americans who have been convicted of similar crimes.

But perhaps the primary reason that mentally disordered sex offender laws have lost favor is that state legislatures and courts are now less concerned than they used to be about the rights and needs of sex offenders, given the growing number of sex crimes taking place across the country, particularly those in which children are victims. In fact, 17 states have instead passed sexually violent predator laws (or sexually dangerous persons laws).These new laws call for certain sex offenders who have been convicted of sex crimes and have served their sentence in prison to be removed from prison before their release and committed involuntarily to a mental hospital for treatment if a court judges them likely to engage in further “predatory acts of sexual violence” as a result of “mental abnormality” or “personality disorder” (Jackson & Richards, 2008). That is, in contrast to the mentally disordered sex offender laws, which call for sex offenders to receive treatment instead of imprisonment, the sexually violent predator laws require certain sex offenders to receive imprisonment and then, in addition, be committed for a period of involuntary treatment. The constitutionality of the sexually violent preda�tor laws was upheld by the Supreme Court in the 1997 case of Kansas v. Hendricks by a 5-to-4 margin. In California, one of the states with such a law, around 1 to 2 percent of convicted sex offenders have been committed to mental health treatment programs after serving their prison sentences (Sreenivasan et al., 2003).

Crimmal Commitment and Incompetence to Stand Trial

Regardless of their state of

the

defendants

be judged

mentally incompetent to stand trial. The competence requirement is meant to en�sure that defendants understand the charges they are facing and can work with their lawyers to prepare and conduct an adequate defense (Zapf & Roesch, 2009; Fitch, 2007).This minimum standard of competence was specified by the Supreme Court in

the case of Dusky v. United States (1960).

When the issue of competence is raised, most often by the defendant’s attorney, the judge orders a psychological evaluation, usually on an inpatient basis (see Table 16-1).As many as 40,000 competency evaluations are conducted in the United States each year (Zapf & Roesch, 2009, 2006; Roesch et al., 1999). Approximately 20 percent of defen�dants who receive such an evaluation are in fact found to be incompetent to stand trial. If the court decides that the defendant is incompetent, the individual is typically assigned to a mental health facility until competent to stand trial (Fitch, 2007; Perlin, 2003).

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Law, Society, and the Mental Health Profession :11 499

table

Multicultural Issues: Race and Forensic Psychology

disyturbedgwhitye Americans to be sent to prison as opposed to mental healt

disturbed people from r

cial minority groups are more

likely than

facilities.

Among defendants evaluated for competence to stand trial, those from racial minority groups are more likely than white American defendants to be referred for

inpatient evaluations.

Among defendants evaluated for competence to stand trial, those from racial

minority groups are more likely than white Americans to have the evaluation occur�in a strict-security inpatient setting, rather than in the noncorrectional mental health

system.

When nonwhite and white defendants are evaluated for competence to stand trial, the defendants from racial minority groups are more likely to be found incompetent

to stand trial.

1 o In New York State, 42 percent of all individuals ordered into involuntary outpatient

commitment are African Americ

n, 34 percent are white American, and 21 percent

are Hispanic American. In contrast, these three groups

comprise, respectively, 17

Haroules, 2007;

2004; Grekin

1994;

1989.

One famous case of incompetence to stand trial is that of Russell Weston, a man who entered the United States Capitol building in 1998 apparently seeking out then-House Majority Whip Tom DeLay, among others. Weston proceeded to shoot two police officers to death. In 1999, the defendant, who had stopped taking medications for his severe psychosis, was found incompetent to stand trial and sent to a psychiatric institution. In 2001, a judge ruled that he should be forced to take medications again, but even with such drugs Weston continued to have severe symptoms and to this day

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remains incompetent to stand trial for the 1998 shootings.

Many more cases of criminal commitment result from decisions of mental incom-petence than from verdicts of not guilty by reason of insanity (Zapf & Roesch, 2006). However, the majority of criminals currently institutionalized for psychological treat�ment in the United States are not from either of these two groups. Rather, they are convicted inmates whose psychological problems have led prison officials to decide they need treatment—either in mental health units within the prison or in mental hospitals

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(Senior et al., 2007; Way et al., 2005) (see Fig. 16-2).

It is possible that an innocent defendant, ruled incompetent to stand trial, could spend years in a mental health facility with no opportunity to dis-prove the criminal accusations. Some defendants have, in fact, served longer “sentences” in mental health facilities awaiting a ruling of competence than they would have served in prison had they been convicted. Such a possibility was reduced when the Supreme Court ruled, in the case ofJ ackson V. Indiana

L.] Prisoners

GGeenneral poo pull attii on

. .

52%

(1972), that an incompetent defendant cannot be indefinitely committed.�After a reasonable amount of time, he or she should either be found com��petent and tried, set free, or transferred to a mental health facility under civil

commitment procedures.

Until the early 1970s, most states required that mentally incompetent defendants be committed to maximum-security institutions for the “crimi-nally insane.” Under current law, however, the courts have greater flexibility. In fact, when the charges are relatively minor, such defendants are often treated on an outpatient basis, an arrangement called jail diversion because the disturbed individual is “diverted” from jail to the community for mental health care (Morrissey & Cuddeback, 2008).

11%

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Psychotic

Major

Personality

disorder

depressive

disorder

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How Do Clinicians Influence the Criminal Justice System?

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One way in which the mental health profession and the legislative and judicial systems interact is that clinicians often help assess the mental stability of people accused of crimes. Evaluations by clinicians may help judges and juries decide whether defendants are (1) responsible for crimes or (2) capable of defending

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themselves in court.

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If defendants are judged to have been mentally unstable

t the time they com�

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mitted a crime, they may be found not guilty by reason of insanity and placed in a treatment facility rather than a prison (criminal commitment). In federal courts and about half the state courts, insanity is judged in accordance with the M’Naghten

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test. Other states use the broader American Law Institute test.

The insanity defense has been criticized on several grounds, and some states

ve added an additional option, guilty but mentally ill. Another verdict option is

guilty with diminished capacity. In addition, a growing number of today’s sex of��fenders are being tried and judged under sexually violent predator laws rather than

the mentally disordered sex offender statutes of past times.

Regardless of their state of mind at the time of the crime, defendants may be found mentally incompetent to stand trial, that is, incapable of fully understanding the charges or legal proceedings that face them. If so, they are typically sent to a mental facility until they are competent to stand trial.

411.Law ‘on Psychology: How Does the Legal System nfluence Mental Iheallh, Carey

Just as clinical

and practice

influenced the legal system, so the legal system

has had a major impact on clinical practice. First, courts and legislatures have developed the process of civil commitment, which allows certain people to be forced into mental health treatment. Although many people who show signs of severe mental dis�turbance seek treatment voluntarily, a large number are not aware of their problems or are simply not interested in undergoing therapy. For such individuals, civil commitment

guidelines may be put into action.

Second, the legal system, on behalf of the state, has taken on the responsibility for protecting patients’ rights during treatment. This protection extends not only to patients who have been involuntarily committed but also to those who seek treatment volun�tarily, even on an outpatient basis.

C11/01 Commitment

Every year in the United States large numbers of people with mental disorders are in�voluntarily committed to treatment. Typically they are committed to mental institutions, but 27 states also have outpatient civil commitment laws that allow patients to be forced into community treatment programs (Haroules, 2007; Monahan et al., 2005). Civil commitments have long caused controversy and debate. In some ways the law provides greater protection for people suspected of being criminals than for people suspected of being psychotic (Strachan, 2008; Burton, 1990).

°civil commitmenteA legal process by which an individual can be forced to undergo mental health treatment.

by Commit? Generally our legal system permits involuntary commitment of in�dividuals when they are considered to be in need of treatment and dangerous to themselves or others. People may be dangerous to themselves if they are suicidal or if they act recklessly (for example, drinking a drain cleaner to prove that they are immune to its chemicals). They may be dangerous to others if they seek to harm them or if they unintentionally

Low, Society, and the Menial Health Profession :// 501

place others at risk.The state’s authority to commit disturbed individuals rests on its du�ties to protect the interests of the individual and of society: the principles of pawns patriae and police power (Swallow et al., 2005).

What Are the Procedures for Civil Commitment? Civil commitment laws vary from state to state (Bindman &Thornicroft, 2008). Some basic procedures, however, are common to most of these laws. Often family members begin commitment proceed�ings. In response to a son’s psychotic behavior and repeated assaults on other people, for example, his parents may try to persuade him to seek admission to a mental institution. If the son refuses, the parents may go to court and seek an involuntary commitment order. If the son is a minor, the process is simple. The Supreme Court has ruled that a hearing is not necessary in such cases, as long as a qualified mental health professional considers commitment necessary. If the son is an adult, however, the process is more involved.The court usually will order a mental examination and allow the person to contest the com�

mitment in court, often represented by a lawyer.

Although the Supreme Court has offered few guidelines concerning specific pro�cedures of civil commitment, one important decision, in the case of Addington v. Texas

�

(1979), outlined the minimum standard of proof needed for commitment. Here the Court ruled that before an individual can be committed, there must be “clear and convinc�ing” proof that he or she is mentally ill and has met the state’s criteria for involuntary commitment. The ruling does not suggest what criteria should be used. That matter is still left to each state. But, whatever the state’s criteria, clinicians must offer clear and convincing proof that the individual meets those criteria. When is proof clear and con�vincing, according to the Court? When it provides 75 percent certainty that the criteria

of commitment have been met. This is far less than the near-total certainty (“beyond a reasonable doubt”) required to convict people of committing a crime.

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502 ://CHAPTER 16

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against Therapists

a winter night in 2008, a 39-year�

been attacked in some form by a patient at

1 11l

old man named David Tarloff went

least once in private therapy, and an even larger percentage have been assaulted

in mental hospitals (Barron, 2008; Tryon, 1987; Bernstein, 1981). Similarly, a num�ber of therapists have been stalked or ha�

to the New York City office of psychiatrist Kent Shinbach with robbery on his mind. Tarloff had a long history of severe mental disorders, and apparently Dr. Shinbach had played a role in one his diagnoses and institutionalizations back in 1991. Upon his arrival, however, Tarloff first came upon psychologist Dr. Kathryn Faughey, whose office was near Dr. Shinbach’s. In

‘

�

rassed by patients (Hudson-Allez, 2006).

;-4

Patients have used a variety of weapons in their attacks, including such common objects as shoes, lamps, fire ex-tinguishers, and canes. Some have used guns or knives and have severely wounded or even killed a therapist, as we saw in the

the course of events, T

rloff slashed Dr.

Faughey to death with a meat cleaver and seriously wounded Dr. Shinbach, who tried

profession—a profession in which clients are invited to expose their innermost feel-ings and concerns. Such danger is particu-larly a possibility in cases in which clients

se of Dr. Faughey.

to come to the psychologist’s aid.

As you can imagine, many therapists who have been attacked continue to feel anxious and insecure in their work for a long time afterward. Some try to be more selective in accepting patients and to look for cues that signal impending violence. It is possible that such concerns represent a significant distraction from the task at hand when they are in session with clients.

As you have read, the vast majority of people with severe mental disorders are not violent and in fact are much more likely to be victims of violence than perpetrators. Nevertheless, periodic cases, like the tragic murder of Dr. Faughey, do occur, remind-ing psychotherapists that there is indeed some degree of danger attached to their

have displayed a history of violence.

According to surveys, more than 80 percent of therapists have on at least one occasion feared that a client might physi-tally attack them (Pope et al., 2006; Pope & Tabachnick, 1993). it is estimated that as many as 13 percent of therapists have

�

Emergency COMMIt `3ent Many situations require immediate action; no one can wait for commitment proceedings when a life is at stake. Consider, for example, an emer�gency room patient who is suicidal or hearing voices demanding hostile actions against others. He or she may need immediate treatment and round-the-clock supervision. If treatment could not be given in such situations without the patient’s full consent, the

consequences could be tragic.

Therefore, many states give clinicians the right to certify that certain patients need temporary commitment and medication. In past years, these states required certifica�tion by two physicians (not necessarily psychiatrists in some of the states). Today states may allow certification by other mental health professionals as well.The clinicians must declare that the state of mind of the patients makes them dangerous to themselves or others. By tradition, the certifications are often referred to as two physician certificates, or 2 PCs. The length of such emergency commitments varies from state to state, but three days is often the limit (Strachan, 2008). Should clinicians come to believe that a longer stay is necessary, formal commitment proceedings may be initiated during the period of emergency commitment.

Who (s Dangerous? In the past, people with mental disorders were actually less likely than others to

violent or dangerous acts.This low rate of violence was ap�

parently related to the fact that so many such individuals lived in institutions. As a result�of deinstitutionalization, however, hundreds of thousands of people with severe distur��bances now live in the community, and many of them receive little, if any, treatment.

Some of these individuals are indeed dangerous to themselves or others.

Although approximately 90 percent of people with mental disorders are in no way violent or dangerous (Pilgrim, 2003; Swanson et al., 1990), studies now suggest at least

Law, Soriek and the Mental Health Profession :1/ 503

a small relati unship between severe mental disorders and violent behavior (Norko & Baranoski, 2008). After re�viewing a number of studiesjohn Monahan (2008, 2001, 1

1993, 1992), a law and psychology professor, concluded+

that the rate of violent behavior among persons with->: =

severe mental disorders is at least somewhat higher than that of peop le without such disorders:

D Approximately 15 percent of patients in mental

hospitals have assaulted another person prior to admission.

) Around 25 percent of patients in mental hospitals�assault another person during hospitalization.

D Approximately 12 percent of all people with

schizop brenia, major depression, or bipolar dis�order have assaulted other people, compared with 2 percent of persons without a mental disorder.

1 [

D Approximately 4 percent of people who report

having been violent during the past year suffer�from schizophrenia, whereas 1 percent of non�

violent persons suffer from schizophrenia.

�

Monahan cautions that the findings do not suggest that people with severe mental disorders are generally dangerous. But they do indicate that a severe mental disorder may

be more of a risk factor for violence than mental health experts used to believe.

A judgment of dangerousness is often required for involuntary civil commitment.

But can mental health professionals accurately predict who will commit violent acts? Research suggests that psychiatrists and psychologists are wrong more often than right when they make long-term predictions of violence (Litwack et al, 2006; Eccleston & Ward, 2004) . Most often they overestimate the likelihood that a patient will eventually be violent. On the other hand, studies suggest that short-term predictions—that is, predic�tions of imminent violence—can be more accurate (Litwack et al, 2006). Researchers are now working, with some success, to develop new assessment techniques that use statistical approaches and are more objective in their predictions of dangerousness than the subjective judgments of clinicians (Scott et al., 2009; Norko & Baranoski, 2008).

�

What Are the Problems with Civil Commit- ent? Civil commitment has

been criticized on several grounds (Winick, 2008;

1982; Ennis & Emery, 1978).

First is the difficulty of assessing a person’s dangerousness. If judgments of dangerous�

ness are often inaccurate, how can one justify using them to deprive people of liberty? Second, the legal definitions of”mental illness” and “dangerousness” are vague.The terms may be defined so broadly that they could be applied to almost anyone an evaluator views as undesirable. Indeed, many civil libertarians worry about the use of involuntary commitment to control people, as occurred in the former Soviet Union and now seems to be taking place in China, where mental hospitals house people with unpopular politi�cal views (Charatan, 2001).A third problem is the sometimes questionable therapeutic value of civil commitment. Research suggests that many people committed involuntarily do not typically respond well to therapy (Winick, 2008). On the basis of these and other arguments, some clinicians suggest that involuntary commitment should be abolished

At.iSOcial:Risk

(Haroules, 2007; Szasz, 2007, 1977, 1963).

Trends in Civil Commitment The flexibility of the involuntary commitment laws probably reached a peak in 1962.That year, in the case of Robinson v. California, the Su�preme Court ruled that imprisoning people who suffered from drug addictions might violate the Constitution’s ban on cruel and unusual punishment, and it recommended involuntary civil commitment to a mental hospital as a more reasonable action. This

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504 :A/CHAPTER 16

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immediately following civil commitment procedures granted far fewer rights to “defen�

kepaing tii0111:00jé:4

dants” than the criminal courts did (Holstein, 1993). In addition, involuntarily commit�

ted patients found it particularly difficult to obtain release.

During the late 1960s and early 1970s, reporters, civil libertarians, and others spoke

out against the ease with which so many people were being unjustifiably committed to mental hospitals. As the public became more aware of these issues, state legislatures started to pass stricter standards for involuntary commitment (Pekkanen, 2007, 2002). Some states, for example, spelled out specific types of behavior that had to be observed before an assessment of dangerousness could be made. Rates of involuntary commit�

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then declined and release rates rose.

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Fewer people are institutionalized through civil commitment procedures today than in the past. In fact, some clinicians and states are concerned that commitment criteria are now too strict, and they are moving toward broadening the criteria once again (Large et al., 2008; Bloom, 2004). It is not yet clear whether this broadening will lead to a return to the vague commitment procedures of the past.

Protecting Patients’ Rights

Over the past two decades,

and state and federal laws have significantly

expanded the rights of patients with mental disorders, in particular the right to treatment and the right to refuse treatment.

How Os the Right to Treatment Protected? When people are committed to mental institutions and do not

treatment, the institutions become, in effect,

prisons for the unconvicted. To many patients in the late 1960s and the 1970s, large state mental institutions were just that.Thus some patients and their attorneys began to demand that the state honor their right to treatment. In the landmark case of Wyatt v. Stickney, a suit on behalf of institutionalized patients in Alabama in 1972, a federal court ruled that the state was constitutionally obligated to provide “adequate treatment” to all people who had been committed involuntarily. Because conditions in the state’s hospitals were so terrible, the judge laid out goals that state officials had to meet, including more therapists, better living conditions, more privacy, more social interactions and physical exercise, and a more proper use of physical restraint and medication. Other states have since adopted many of these standards.

�

Low Society, and the Mental Health Profession :1/ 505

Another important decision was handed down in 1975 by the Supreme Court in the case of O’Connor v. Donaldson. After being held in a Florida mental institution for more than 14 years, Kenneth Donaldson sued for release. He argued that he and his fellow patients were receiving poor treatment, were being largely ignored by the staff, and were allowed little personal freedom. The Supreme Court ruled in his favor, fined the hospital’s superintendent, and said that such institutions must review patients’ cases periodically. The justices also ruled that the state cannot continue to institutionalize people against their will if they are not dangerous and are capable of surviving on their

aright to oThe

right of

ppaattients, particullaarrllyy those who are invol�untarily committed, to receive adequate treatment.

°right to refuse treatmentoThe legal right of patients to refuse certain forms of

treatment.

own or with the willing help of responsible family members or friends.

To help protect the rights of patients, Congress passed the Protection and Advocacy for Mentally Ill Individuals Act in 1986. This law set up protection and advocacy systems

in all states and U.S. territories and gave public advocates who worked for patients the

power to investigate possible abuse and neglect and to correct those problems legally.

In recent years public advocates have argued that the right to treatment also should be extended to the tens of thousands of people with severe mental disorders who are repeatedly released from hospitals into ill-equipped communities. Many such people have no place to go and are unable to care for themselves, often winding up homeless or in prisons (Felix et al., 2008;Torrey, 2001).A number of advocates are now suing federal and state agencies throughout the country, demanding that they fulfill the promises of the community mental health movement (see Chapter 12).

How is the Right to Refuse Treatment Protected? During the past two de�cades the courts

decided that patients, particularly those in institutions, have

the right to refuse treatment (Rolon & Jones, 2008; Perlin, 2004, 2000). Most of the right-to-refuse-treatment rulings center on biological treatments (Rolon & Jones, 2008). These treatments are easier to impose on patients without their cooperation than psy�chotherapy, and they often seem more hazardous. For example, state rulings have con�sistently granted patients the right to refuse psychosmgery, the most irreversible form of physical treatment—and therefore the most dangerous.

Some states have also acknowledged a patient’s

right to refuse electroconvulsive therapy

�

(ECT), the treatment used in many cases of severe depression (see Chapter 7). However, the right-to-refuse issue is more complex with regard to ECT than to psychosurgery. ECT is very effective for many people with severe depression, yet it can cause great upset and can also be misused.Today many states grant patients—particularly voluntary patients—the right to refuse ECT. Usually a patient must be informed fully about the nature of the treatment and must give written consent to it.A number of states continue to permit ECT to be forced on committed patients (Baldwin

& Oxlad, 2000), whereas others require the consent of a close

•

–

relative or other third party in such cases.

In the past, patients did not have the right to refuse psycho-tropic medications. As you have read, however, many psychotropic drugs are very powerful, and some produce effects that are un�wanted and dangerous. As these harmful effects have become more apparent, some states have granted patients the right to refuse medication. Typically, these states require physicians to explain the purpose of the medication to patients and obtain their written_ consent. If a patient’s refusal is considered incom�

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petent or dangerous, the state may allow it to be overturned by�an independent psychiatrist, medical committee, or local court

& Jones, 2008). However, the refusing patient is sup- ported in this process by a lawyer or other patient advocate.

‘

What Other Rights Do Patients Have? Court deci�

protected still other patient rights over the past sev�

eral decades. Patients who perform work in mental institutions,�particularly private institutions, are now guaranteed at least a

506 ://CHAPTER 16

ID-4rNviir*-Kr-rerart-cmg3

minimum wage. In addition, a district court ruled in 1974 (and the Supreme Court con�firmed in 1999) that patients released from state mental hospitals have a right to aftercare and to an appropriate community residence, such as a group home. And in the 1975 case of Dixon v. Weinbergn; a district court ruled that people with psychological disorders should receive treatment in the least restrictive facility available. If an inpatient program at a com�munity mental health center is available, for example, then that is the facility to which they should be assigned, not a mental hospital (Hindman & Thornicroft, 2008).

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The “Rights’ Debate Certainly, people with psychological disorders have civil rights that must be protected at all times. However, many clinicians express concern that the patients’ rights rulings and laws may unintentionally deprive these patients of opportuni�ties for recovery. Consider the right to refuse medication. If medications can help a patient with a severe mental disorder to recover, doesn’t the patient have the right to that recov�ery? If confusion causes the patient to refuse medication, can clinicians in good conscience delay medication while legal channels are cleared? Psychologist Marilyn Whiteside raised similar concerns in her description of a 25-year-old patient with mental retardation:

�

He was 25 and severely retarded. And after his favorite attendant left, he bec

me self�

abusive. He be

t his fists against the side of his head until a football helmet had to be

ordered for his protection. Then he clawed at his fi

ce and gouged out one of his eyes.

The institution psychologists began a behavior program that had mildly

versive conse�

quences: they squirted worm water in his face each time he engaged in self-abuse. When that didn’t work, they requested permission to use an electric prod. The Human Rights Committee vetoed this “excessive and inhumane form of correction” because, after all,

the young man was retarded, not criminal.

Since nothing effective could be done that

bridged the rights and negated the dignity

of the developmentally disabled patient, he was verbally reprimanded for his behavior

nd allowed to push his thumb through his remaining eye. He is now blind, of course, but

he has his rights and presumably his dignity.

(Whiteside, 1983, p. 13)

�

Despite such legitimate concerns, keep in mind that the clinical field has not always done an effective job of protecting patients’ rights. Over the years, many patients have been overmedicated and received improper treatments. Furthermore, one must ask whether the field’s present state of knowledge justifies clinicians’ overriding of patients’ rights. Can clinicians confidently say that a given treatment will help a patient? Can they predict when a treatment will have harmful effects? Since clinicians themselves often disagree, it seems appropriate for patients, their advocates, and outside evaluators to play key roles in decision making.

�

How Does the Legal System Influence Mental Health Care?

Courts may be called upon to commit noncrimin

Is to ment

I hospitals for treatment,

a process called civil commitment. Society allows the involuntary commitment of�people who are considered to be in need of treatment and dangerous to themselves

or others. L

ws governing civil commitment procedures vary from state to state, but

a minimum standard of proof—clear and convincing evidence of the necessity of commitment—has been defined ley the Supreme Court.

Courts and legisl

tures significantly affect the mental health profession by speck

�

fying legal rights to which patients are entitled. The rights that have received the : most attention are the right to treatment and the right to refuse treatment.

Law, Society, and the Mental Health Profession 507

i;An What Other Ways Do the Clinical and Legal Fields Interact?

°malpractice suitoA lawsuit charging a therapist with improper conduct in the course of treatment.

Mental health and legal professionals may influence each other’s work in other ways as

During the past two decades, their paths have crossed in four key areas: malpractice

suits, professional boundaries, jury selection, and psychological research of legal topics.

Malpractice Suits

The number of malpractice suits against therapists has risen sharply in recent years. Claims have been made against clinicians in response to a patient’s attempted suicide, sexual activity with a patient, failure to obtain informed consent for a treatment, neg�ligent drug therapy, omission of drug therapy that would speed improvement, improper termination of treatment, and wrongful commitment (Koocher & Keith-Spiegel, 2008). Studies suggest that a malpractice suit, or the fear of one, can have significant effects on clinical decisions and practice, for better or for worse (Feldman et al., 2005; Beezhold, 2002).

Professional Boundaries

During the past

years the legislative and judicial systems have helped to change

the boundaries that separate one clinical profession from another. In particular, they have given more authority to psychologists and blurred the lines that once separated psychiatry from psychology. A growing number of states, for example, are ruling that psychologists can admit patients to the state’s hospitals, a power previously held only by

psychiatrists (Halloway, 2004).

In 1991, with the blessings of Congress, the Department of Defense (DOD) started to reconsider the biggest difference of all between the practices of psychiatrists

and psychologists—the authority to prescribe drugs, a role previously denied to psy�chologists. The DOD set up a trial training program for Army psychologists. Given the apparent success of this trial program, the American Psychological Association later recommended that all psychologists be allowed to attend a special educational program in prescription services and receive certification to prescribe medications if they pass (Poling et al. , 2008). New Mexico, Louisiana, and the L.T.S. territory of Guam now do in fact grant prescription privileges to psychologists who receive special pharmacological training.

Jury Selection

During the past 30 years, more and more lawyers have turned to clinicians for psycho�logical advice in conducting trials (Lieberman & Olson, 2008). A new breed of clinical specialists, known as “jury specialists,” has evolved. They advise lawyers about which jury candidates are likely to favor their side and which strategies are likely to win jurors’ support during trials. The jury specialists make their suggestions on the basis of surveys,

interviews, analyses of jurors’ backgrounds and attitudes, and laboratory enactments of

upcoming trials. However, it is not clear that a clinician’s advice is more valid than a lawyer’s instincts or that the judgments of either are particularly accurate.

A iud6iiithit of Mcilpitic*e

Psychological Research of Legal Topics

Psychologists have sometimes conducted studies and developed expertise on topics of great importance to the criminal justice system. In turn, these studies influence how the system carries out its work. Psychological investigations of two topics, eyewitness testimony and patterns of criminality, have gained particular attention.

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Eyewitness Testimony In criminal cases testimony by eyewitnesses is extremely in�fluential. It often determines whether a defendant will be found guilty or not guilty. But how

�

is eyewitness testimony? This question has become urgent, as a troubling

508 ://CHAPTER 16

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number ofprisoners (many on death row) have recently had their convictions overturned�after DNA evidence revealed that they could not have committed the crimes of which�they had been convicted. It turns out that 90 percent of such wrongful convictions were

based in large part on mistaken eyewitness testimony (Fisher & Reardon, 2007).

Most eyewitnesses undoubtedly try to tell the truth about what or who they saw. Yet research indicates that eyewitness testimony can be highly unreliable, partly because most crimes are unexpected and fleeting and therefore not the sort of events remem�bered well {Lindsay et al., 2007). During the crime, for example, lighting may be poor or other distractions may be present. Witnesses may have had other things on their minds, such as concern for their own safety or that of bystanders. Such concerns may greatly

impair later

memory.

Moreover, in laboratory studies researchers have found it easy to fool research par�ticipants who are trying to recall the details of an observed event simply by introduc�ing misinformation. After a suggestive description by the researcher, stop signs can be transformed into yield signs, white cars into blue ones, and Mickey Mouse into Minnie Mouse (Pickel, 2004; Loftus, 2003). In addition, laboratory studies indicate that persons who are highly suggestible have the poorest recall of observed events (Liebman et al.,

2002).

14TWATI?)n, fi.iiiias’irg.tzig.3

As for identifying actual perpetrators, research has found that accuracy is greatly in�fluenced by the method used in identification (Fisher & Reardon, 2007;Wells & Olsen, 2003). The traditional police lineup, for example, is not always a highly reliable tech�nique, and witnesses’ errors committed during lineups tend to stick (Wells, 2008; Haw & Fisher, 2004). Researchers have also learned that witnesses’ confidence is not neces�sarily related to accuracy (Ghetti et al., 2004). Witnesses who are “absolutely certain” may be no more correct in their recollections than those who are only “fairly sure.”Yet the degree of a witness’s confidence often influences whether jurors believe his or her

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testimony (Greene & Ellis, 2007).

Psychological investigations into eyewitnesses’ memory have not yet undone the judicial system’s reliance on those witnesses’ testimony. Nor should it. The distance between laboratory studies and real-life events is often great, and the implications of such research must be applied carefully Wagstaff et al., 2003). Still, eyewitness research has begun to make an impact. Studies of hypnosis and of its ability to create false memories, for example, have led most states to prohibit eyewitnesses from testifying about events if their recall of the events was initially helped by hypnosis (Knight, Meyer, & Goldstein, 2007).

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Patterns ®chf Cri• mi• nal°ity A growing number of television shows, movies, and books�suggest that clinicians often play a major role in criminal investigations by providing

Lan; Society, and the Mental Health Profession :1,/ 509

police with psychological profiles of perpetrators—”He’s probably white, in his 30s, has a history of animal torture, has few friends, and is subject to emotional outbursts.” The study of criminal behavior patterns and of profiling has increased in recent years; how�ever, it is not nearly as revealing or influential as the media and the arts would have us

believe (Turvey, 2008).

On the positive side, researchers have gathered information about the psychological features of various criminals, and they have indeed found that perpetrators of particular

Ili

�

Serial Murderers: Madness or Badness?

late 2001, a number of anthrax-i1.1,tainted letters were mailed to people

list of

killers who have fascinated

Akutagawa, 2004). Lack of conscience and an utter disregard for people and the rules of society—key features of antisocial personality disorder—are typical. Narcis�sistic thinking is quite common as well. The feeling of being special may even give the killer an unrealistic belief that he will not get caught (Kocsis, 2008; Wright et al., 2006). Often it is this sense of invincibility

throughout eastern parts of the United States, leading to 5 deaths and to severe illness in 13 other people. The FBI imme-diately mounted a massive investigation to find the person behind these killings, but the individual eluded them for almost seven years. Finally, in 2008 their investi-gation targeted a 62-year-old biodefense researcher named Bruce Ivins. With a mur-der indictment imminent, Ivins committed suicide by taking an overdose of medico-tions on July 29, 2008. It appeared that the FBI had finally found the perpetrator of

and horrified Americans over the years: Theodore Kaczynski (“Unabomber”), Ted Bundy, David Berkowitz (“Son of Sam”), John Wayne Gacy, Jeffrey Dahmer, Dennis

Rader (“BTK killer”), and more.

The FBI estimates that there are between 35 and 100 serial killers at large in the United States at any given time (Hickey, 2002). Each such killer follows his or her own pattern (Kocsis, 2008; Homant & Kennedy, 2006), but many of them appear to have certain characteristics in common. Most—but certainly not all—are white males between 25 and 34 years old, of average to high intelligence, generally clean-cut, smooth-talking, attractive, and

that leads to his capture.

these terrible deeds,

Sexual dysfunction and fantasy also seem to play a part (Wright et al., 2006; Arndt et al., 2004). Studies have found that vivid fantasies, often sexual and sa�distic, may help drive the killer’s behavior (Kocsis, 2008; Homant & Kennedy, 2006). Some clinicians also believe that the kill-ers may be frying to overcome general feelings of powerlessness by controlling, hurting, or eliminating those who are momentarily weaker (Fox & Levin, 2005, 1999). A number of the killers were abused as children—physically, sexually, and emotionally (Wright et al., 2006;

Given Ivins’s suicide, some questions remain about his crimes and even about his guilt or innocence. However, the FBI has concluded that this troubled man was indeed the anthrax killer. As such, he ap-pears to have been one of a growing

skillful m

nipulators (Kocsis, 2008; Fox &

Levin, 2005).

A number of serial killers seem to

display severe personality disorders (Homant & Kennedy, 2006; Whitman &

Hickey, 2002).

Despite such profiles and suspicions, clinical theorists do not yet understand why serial killers behave as they do. But most agree with Park Dietz, a highly regarded forensic expert, when he asserts, “It’s hard to imagine any circumstance under which they should be released to the public again” (Douglas, 1996, p. 349).

….•…

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510 ://CHAPTER 16

kinds of crimes—serial murder or serial sexual assault, for example—frequently share a number of traits and background features. But while such traits are often present, they are not always present, and so applying profile information to a par�ticular crime can be wrong. Increasingly police are consulting psychological profilers, and this practice appears to be helpful as long as the limitations of profiling are recognized (Turvey,

�

– I

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2008; Wright et al., 2006; Palermo et al., 2005).

A reminder of the limitations of profiling information comes from the case of the snipers who terrorized the Wash�ington, DC, area for three weeks in October 2002, shooting 10 people dead and seriously wounding 3 others (Turvey & McGrath, 2006). Most of the profiling done by FBI psycholo�gists had suggested that the sniper was acting alone; it turned out that the attacks were conducted by a pair: a middle-age man, John Allen Muhammad, and a teenage boy, Lee Boyd Malvo. Although profiles had suggested a young thrill-seeker, Muhammad was 41. Profilers had believed the attacker to be

white, but neither Muhammad nor Malvo was white. The pre�

�

diction of a male attacker was correct, but then again female serial killers are relatively rare (Scott, 2008).

s„

Other Clinicai-Legd. Interactions

Mental health and legal professionals also cross paths in four other areas. First,�malpractice suits against therapists have increased in recent years. Second, the�legislative and judicial systems help define professional boundaries. Third, lawyers

may seek the advice of mental he

Ith professionals regarding the selection of jurors

and case strategies. Fourth, psychologists may investigate legal phenomena such as eyewitness testimony and patterns of criminality.

Ethics and Mental Health Professionals

Discussions of the legal and mental health systems may sometimes give the impres�sion that clinicians as a group are uncaring and are considerate of patients’ rights and needs only when they are forced to be. This, of course, is not true. Most clinicians care greatly about their clients and try to help them while at the same time respecting their rights and dignity. In fact, clinicians do not rely exclusively on the legislative and court systems to ensure proper clinical practice. They also regulate themselves by continually developing and revising ethical guidelines for members of the clinical field. Many legal decisions do nothing more than place the power of the law behind these already exist�

ing professional guidelines.

Each profession within the mental health field has its own code of ethics (Koocher & Keith-Spiegel, 2008). The code of the American Psychological Association (2002, 1992) is typical. This code, highly respected by other mental health professionals and public officials, includes specific guidelines:

Mode of ethics®A body of principles and rules for ethical behavior, designed

to guide decisions and bers of

a profession.

ctions by mem�

1. Psychologists are permitted to offer advice in self-help books, on DVDs, on televi�

oconfidentiarThe principle that certain professionals noott divu llggee information they obtain froma clientt..

sion and radio programs, in newspapers and magazines, through mailed material, and in other places, provided they do so responsibly and professionally and base their advice on appropriate psychological literature and practices. Psychologists are bound by these same ethical requirements when they offer advice and ideas

law, Society, and the Mental Health Profession 511

online, whether on individual Web pages, blogs, electronic groups and bulletin boards, or chat rooms (Koocher & Keith-Spiegel, 2008). Internet-based profes�sional advice has proved difficult to regulate, however, because the number of such offerings keeps getting larger and so many advice-givers (at least one-third of them) do not appear to have any professional training or credentials (Heinlen et al., 2003).

2. Psychologists may not conduct fraudulent research, plagiarize the work of others, or publish false data. During the past 30 years cases of scientific fraud or miscon�duct have been discovered in all of the sciences, including psychology. These acts have led to misunderstandings of important issues, taken scientific research in the wrong direction, and damaged public trust. Unfortunately, the impressions created by false findings may continue to influence the thinking of both the public and other scientists for years.

3. Psychologists must acknowledge their limitations with regard to patients who are

disabled or whose gender, ethnicity, language, socioeconomic status, or sexual ori�entation differs from that of the therapist (Philogene, 2004). This guideline often requires psychotherapists to obtain additional training or supervision, consult with more knowledgeable colleagues, or refer clients to more appropriate professionals.

4. Psychologists who make evaluations and testify in legal cases must base their assess�

ments on sufficient information and substantiate their findings appropriately (Koocher & Keith-Spiegel, 2008; Costanzo et al., 2007). If an adequate examination of the individual in question is not possible, psychologists must make clear the limited nature of their testimony.

5. Psychologists may not take advantage of clients and students, sexually or otherwise.

This guideline relates to the widespread social problem of sexual harassment, as well as the problem of therapists who take sexual advantage of clients in therapy. The code specifically forbids a sexual relationship with a present or former ther�apy client for at least two years after the end of treatment—and even then such a relationship is permitted only in “the most unusual circumstances.” Furthermore, psychologists may not accept as clients people with whom they have previously

had a sexual relationship.

Research has clarified that clients may suffer great emotional damage from sexual involvement with their therapists (Koocher & Keith-Spiegel, 2008; Pope & Wedding, 2008). How many therapists actually have a sexual relationship with a client? On the basis of various surveys, reviewers have estimated that some form of sexual misconduct with patients may be engaged in by around 5 to 6 percent of today’s therapists, down from 10 percent more than a decade ago (Koocher & Keith-Spiegel, 2008; Pope & Wedding 2008).

Although the vast majority of therapists do not engage in sexual behavior of

any kind with clients, their ability to control private feelings is apparently another matter. In surveys, close to 90 percent of therapists reported having been sexually attracted to a client, at least on occasion (Pope &Vasquez, 2007; Pope et al., 2006). Although few of these therapists acted on their feelings, most of them felt guilty, anxious, or concerned about the attraction. Given such issues, it is not surprising that sexual ethics training is given high priority in many of today’s clinical training programs (Lamb et al., 2003).

6. Psychologists must adhere to the principle of confidentiality. All of the state and fed�eral courts have upheld laws protecting therapist confidentiality. For peace of mind and to ensure effective therapy, clients must be able to trust that their private exchanges with a therapist will not be repeated to others (Jain & Roberts, 2009; Green & Bloch, 2006). There are times, however, when the principle of confi�

dentiality must be compromised (Koocher & Keith-Spiegel, 2008). A therapist in training, for example, must discuss cases on a regular basis with a supervisor. Cli�ents, in turn, must be informed that such discussions are occurring.

51 2 ://CHAPTER 16

A second exception arises in cases of outpatients who are clearly dangerous.�The 1976 case of Tarase v. Regents of the University of Calfiornia, one of the most�important cases to affect client-therapist relationships, concerned an outpatient at a�University of California hospital. He had confided to his therapist that he wanted�to harm his former girlfriend, Tanya Tarasoff. Several days after ending therapy, the

former patient fulfilled his promise. He stabbed Tanya Tarasoff to

death.

Should confidentiality have been broken in this case? The therapist, in fact,�felt that it should. Campus police were notified, but the patient was released after�some questioning. In their suit against the hospital and therapist, the victim’s par��ents argued that the therapist should have also warned them and their daughter�that the patient intended to harm Ms. Tarasoff. The California Supreme Court

agreed: “The protective privilege ends where the public peril begins.”

The current code of ethics for psychologists thus declares that therapists have

a duty to protect—a responsibility to break confidentiality, even without the client’s consent when it is necessary “to protect the client or others from harm”

Since the Tarasoff ruling, California’s courts further have held that therapists must also protect people who are close to a client’s intended victim and thus in danger. A child, for example, is likely to be at risk when a client plans to assault the child’s mother. In addition, the California courts have ruled that therapists must act to protect people even when information about the dangerousness of a client is re�ceived from the client’s family, rather than from the client (Thomas, 2005). Many,

but not all, states have adopted the California court rulings or similar ones, and a

number have passed “duty to protect

ity for therapists and protect them from certain civil suits (Benjamin et al., 2009; Koocher & Keith-Spiegel, 2008).

” bills that clarify the rules of confidential�

�

;-‘,1..,Mental Health, Business, and Economics

The legislative and judicial systems are not the only social institutions with which men�

and economic fields are two other sectors that

tal health professionals interact.The

influence and are influenced by clinical practice and study.

Bringong Mental Health Services to the Workplace

It has been estimated that untreated psychological disorders

the United States

$105 billion in lost productivity each year (Armour, 2006). Collectively, such disorders are among the 10 leading categories of work-related disorders and injuries (Kessler & Stang, 2006; Kemp, 1994). In fact, almost 12 percent of all employees are said to experi�ence psychological problems that are serious enough to affect their work. Psychological problems contribute to 60 percent of all absenteeism from work, up to 90 percent of industrial accidents, and to 65 percent of work terminations. Alcohol abuse and other substance-related disorders are particularly damaging (Martin et al., 1994). The busi�ness world has often turned to clinical professionals to help prevent and correct such problems (Wang, 2007). Two common means of providing mental health care in the

iF.1-4.

16YAV.A-6 € II(‘~~~~

workplace are employee assistance programs and problem-solving seminars.

Employee assistance programs, mental health services made available by a place of business, are run either by mental health professionals who work directly for a company or by outside mental health agencies (Armour, 2006). Companies publicize such programs at the work site, educate workers about psychological dysfunctioning, and teach supervisors how to identify workers who are having psychological problems. Businesses believe that employee assistance programs save them money in the long run by preventing psychological problems from interfering with work performance and by reducing employee insurance claims, although these beliefs have not undergone exten�

Metddliiéolth:Parity

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sive testing (Wang 2007).

Stress-reduction and problem-solving seminars are workshops or group ses�

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sions in which mental health professionals teach employees techniques for coping,

Law, Satiety, and the Mental Health Profession :11 513

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solving problems, and handling and reducing stress (Russell, 2007; Daw, 2001). Programs of this kind are just as likely to be aimed at high-level executives as at assembly-line workers. Often employees are required to attend such workshops, which may run for several days, and are given time off from their jobs to do so.

The Economics of Mental Health

We have already seen how economic decisions by the government may influence the clinical field’s treatment of people with severe mental disorders. For example, the desire of the state and federal governments to reduce costs was an important consideration in the country’s deinstitutionalization movement, which contributed to the premature release of hospital patients into the community. Economic decisions by government

agencies may affect other kinds of clients and treatment programs as well.

As you read in Chapter 12, government funding for services to people with psycho�logical disorders has risen sharply over the past four decades, from $1 billion in 1963 to around $104 billion today (Mark et al., 2008, 2005; Redick et al., 1992). On the other hand, much of that money is spent on income support, housing subsidies, and other such expenses rather than directly on mental health services (Sperling, 2005). Govern-ment funding currently covers around two-thirds of all mental health services, leaving a mental health expense of tens of billions of dollars for individual patients and their

•duty to protectoThe principle that therapists must break confidentiality in order to protect a person who may be the intended victim of a client.

assistance program®

private insurance companies (Mark et al., 2008, 2005).

A mental health program offered by a business to its employees.

This large economic role of private insurance companies has had a major effect on the way clinicians go about their work. As you’ll remember from Chapter 1, to reduce their expenses, most of these companies have developed managed care programs, in which the insurance company decides such questions as which therapists clients may choose, the cost of sessions, and the number of sessions for which a client may be re-imbursed (Koocher & Keith-Spiegel, 2008). These and other insurance plans may also control expenses through the use of peer review systems, in which clinicians who work for the insurance company periodically review a client’s treatment program and recommend that insurance benefits be either continued or stopped. Typically, insurers require reports or session notes from the therapist, often including intimate personal

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teach embplloeymeseas nd reduce stress

solve pro

how to cope with and

*managed care programeAn insur�once program in which the insurance company decides the cost, method, pro-vider, and length of treatment.

information about the patient.

review system®A system by which clinicians paid by an insurance company may periodically review a patient’s progress and recommend the continuation or termination of benefits.

Many therapists and clients dislike managed care programs and peer reviews (Koocher & Keith-Spiegel, 2008; Mechanic, 2004).They believe that the reports required of thera- pists breach confidentiality, even when efforts are made to protect anonymity, and that

516 ://cHArrER 16

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“Look, you’re not the only one with problems.”

4�0

in which the field’s activities are conducted. Mental health researchers and clinicians are human beings, living within a society of human beings, working to serve human beings. The mixture of discovery, misdirection, promise, and frustration that you have encoun�tered throughout this book is thus to be expected. When you think about it, could the study and treatment of human behavior really proceed in any other way?

,9111 M

,[.:

Ethical, Economic, and Personal Factors

Each clinical profession has a code of ethics. The psychologists’ code includes prohibitions against engaging in fraudulent research and against taking advantage of clients and students, sexually or otherwise. It also establishes guidelines for re�specting patient confidentiality. The case of Tarasoff v, Regents of the University of

liforni

helped to determine the circumstances in which therapists have a duty to

protect the public from harm and must break patient confidentiality.

Clinical practice and study also intersect with the business and economic

worlds. Clinicians often help to address psychological problems in the workplace. In addition, private insurance companies have set up managed care programs whose

procedures influence and often reduce the length, nature, and qu

lily of therapy.

Fin

Ily, mental health activities are affected by the personal needs, values, and

goals of the human beings who provide clinical services. These factors inevitably affect the choice, direction, and even quality of their work.

�

N.A-§39-FrflrOtTIN*5 .

PUTTING IT… together

The BuSiiieSS:di:MentaiHedith

Operating within a Larger System

At one time clinical researchers and professionals conducted their work largely in isolation. Today, however, their activities have numerous ties to the legislative, judicial, economic, and other established systems. One reason for this growing interconnected�ness is that the clinical field has achieved a high level of respect and acceptance in our society. Clinicians now serve millions of people in many ways. They have much to say about almost every aspect of society, from education to ecology, and are widely looked to as sources of expertise. When a field achieves such prominence, it inevitably affects how other institutions are run. It also attracts public scrutiny, and various institutions begin to keep an eye on its activities.

�

(Itn

20 :3 4)

taw, Sodom and the Mental Health Profession :// 517

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HOME

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SEND

-•

EXPLORE

�

“Mad Pride

�

BY GABRIELLE GLASER, NEW YORK TIMES, MAY 11, 2008

n the YouTube video, Liz Spikol is smiling and animated, the light glinting off her large hoop earrings. Deadpan, she

{

holds up a diaper. It is not, she explains, a hygienic item for a giantess, but rather a prop to illustrate how much control people lose when they undergo electroconvulsive therapy, or ECT, as

she did 1 2 years ago.

– k

�

-er

)

In other videos and blog postings, Ms. Spikol, a 39-year-old writer in Philadelphia who has bipolar disorder, describes a period of psychosis so severe she jumped out of her mother’s

car and ran away like a scared dog.

In lectures across the country, Elyn Saks, a law professor and associate dean at the University of Southern California, recounts the florid visions she has experienced during her lifelong battle with schizophrenia—dancing ashtrays, houses that spoke to her—and hospitalizations where she was strapped down with leather restraints and force-fed medications.

�

ness such as schizophrenia and bipolar disorder, Ms. Saks and Ms. Spikol are speaking candidly and publicly about their demons. Their frank talk is part of a conversation about mental illness or as some prefer to put it, “extreme mental states”) that stretches from college campuses to community health centers,

�

‘-

•

�

from YouTube to online forums.

“Until now, the acceptance of mental illness has pretty much stopped at depression,” said Charles Barber, a lecturer in psy�chiatry at the Yale School of Medicine. “But a newer generation, fueled by the Internet and other sophisticated delivery systems, is saying, ‘We deserve to be heard, too.

Just as g

y-rights activists reclaimed the word queer as a

–

badge of honor rather than a slur, these advocates proudly call themselves mad; they say their conditions do not preclude them from productive lives. Mad pride events, organized by loosely connected groups in at least seven countries including Australia, South Africa and the United States, draw thousands of partici�

in which she couldn’t care for herself, or even shower. “I knew�I was crazy but also sane enough to know that I couldn’t make

myself sane,

” she says in the video

pants

. . .

_ Recent mad pride activities include a Mad Pride

Ms. Saks, the U.S.C. professor, who recently published a memoir, “The Center Cannot Hold: My Journey Through

Madness,” has come to accept her illness. She manages her symptoms with a regimen that includes psychoanalysis and medication. But stigma, she said, is never far away. She said she waited until she had tenure at U.S.C. before going public with

Cabaret in Vancouver, British Columbia; a Mad Pride March in Accra, Ghana; and a Bonkersfest in London that drew 3,000

participants

In recent years, groups have started antistigma

campaigns, and even the federal government embraces the mes��sage, with an ad campaign aimed at young adults to encourage

them to support friends with mental illness

her experience

Ms. Saks said she hopes to help others in

Ms. Spikol writes about her experiences with bipolar disor-der in The Philadelphia Weekly, and posts videos on her blog,

her position find tolerance, especially those with fewer resources. “I have the kind of life that anybody, mentally ill or not, would

the Trouble With Spikol

Thousands have watched her

want: a good place to live, nice friends, loved ones,” she said. “For an unlucky person,” Ms. Saks said, “I’m very lucky.”

joke about her weight gain and loss of libido, and her giggle-punctuated portrayal of ECT. But another video shows her face

Used by permission. A�

�

–

�

518 :IICHAPTER 16

11.-E10’vAT4’1611 i’l “.-“_- r,’1#f•=i

1.A

Today, when people with psychological problems seek help from a therapist, they are entering a complex system consisting of many interconnected parts. Just as their personal problems have grown within a social structure, so will their treatment be af�fected by the various parts of a larger system—the therapist’s values and needs, legal and economic forces, societal attitudes, and yet other forces. These many forces influence

,-, In Their Words

clinical research as well.

:::.ii .,.

The effects of this larger system on an individual’s psychological needs can be positive or negative, like a family’s impact on each of its members. When the system protects a client’s rights and confidentiality, for example, it is serving the client well. When economic, legal, or other societal forces limit treatment options, cut off treatment

,,.qli

Sigmund freyd, 1927

prematurely, or stigmatize a person, the system is adding to the person’s problems.

Because of the enormous growth and impact of the mental health profession in our society, it is important that we understand its strengths and weaknesses.As you have seen throughout this book, the field has gathered much knowledge, especially during the past several decades. What mental health professionals do not know and cannot do, how�ever, still outweigh what they do know and can do. Everyone who turns to the clinical field—directly or indirectly—must recognize that it is young and imperfect. Society is vastly curious about behavior and often in need of information and help. What we as a society must remember, however, is that the field is still putting it all together

�

riPITINI, ‘THOUGHTS

�

4’7 1. In some states, the defense must

declare that the person is mentally stable and unlikely to commit the

4. How might lingering anxiety affect the

prove that a defendant was not guilty by reason of insanity, while in other states is is the responsibility of the

behavior and effectiveness of clinicians

7..�4:

same crime

gain, even if the patient

who have been attacked? p. 502

shows significant improvement? pp. 493-496

5. Most psychiatrists do not want

prosecution to prove th

t a defendant

psychologists to be granted the authority to prescribe psychotropic medications. Surprisingly, many psychologists oppose the idea as well (Poling et al., 2008, 2007). Why might they take this position?

making this plea was not insane. Which burden of proof is more appropriate? pp. 493-496

3. How are people who have been

institutionalized viewed and treated by others today? Is the stigma of hospitalization a legitimate argu-ment against civil commitment?

pp. 500-504

After a patient has been criminally committed to an institution, why might a clinician be reluctant to

tr,*

p. 507

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KEY ‘TERMS

•••

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4 criminal commitment, p. 492

e0z7. not guilty by reason of insanity (NGR1),

sexually violent predator laws, p. 498 mental incompetence, p. 498

eyewitness testimony, p. 507

psychological profiles, p. 509

47; p. 492

civil commitment, p. 500

code of ethics, p. 510

24 M’Naghten test, p. 493

two physician certificate (2 PC), p. 502

confidentiality, p. 511

;

irresistible impulse test, p. 493

ngerousness, p. 503

duty to protect, p. 512

* .

0 Durham test, p. 493

right to treatment, p. 504

employee assistance programs, p. 512 stress-reduction and problem-solving

American Law Institute (ALI) test, p. 493 guilty but mentally ill, p. 496

right to refuse treatment, p. 505

malpractice lawsuit, p. 507

seminars, p. 512

:’pguilty with diminished capacity, p. 496

,,,

professional boundaries, p. 507

managed care program, p. 513 peer review system, p. 513

mentally disordered sex offenders,

jury selecti

n, p. 507

p. 497

. 41,.. 0 t •

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taw, Society, and the Mental Health Profession :1/ 519

�

1. Briefly explain the M’Naghten,

4. Wh

t are the reasons for civil corn�

practice of psychological profiling in criminal cases? pp. 507-510

irresistible impulse, Durham, and ALI tests of insanity. Which tests are used today to determine whether defen-dants are not guilty by reason of insanity? pp. 493-494

mitment, and how is it carried out? What criticisms have been made of civil commitment? pp. 500-504

8. What key issues are covered by the

5. What rights have court rulings and legislation guaranteed to patients with psychological disorders?

pp. 504-506

psychologist’s code of ethics? Under what conditions must therapists

break the principle of confidentiality? pp. 570-512

ye; 2. Explain the guilty-but-mentally-ill,

diminished-capacity, mentally-disordered-sex-offender, and sexually-violent-predator verdicts and laws. pp. 496-498

9. What kinds of programs for the

6. How do the legislative and judicial systems affect the professional bound�

prevention and treatment of psy�chological problems have been

”

aries of clinical practice? p. 507

est

blished in business settings?

.,ez 3. What are the reasons behind and the

7. What have clinical researchers

pp. 512-513

procedures for determining whether defendants are mentally incompetent to stand trial? pp. 498-499

learned about eyewitness memories and about patterns of criminality? How accurate and influential is the

1 0 . What trends have emerged in recent years in the funding and insurance of

ment

I he

Ith care? pp. 513-514

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“A” A Chapter 16 Video Cases

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Jeffrey Dahmer: Not Guilty by Reason of Insanity? Forcing People info Mental Health Treatment

When Treatment Leads to Execution

A Video case discussions, study guides, and questions

‘e”,1- Log on to the Corner Web Page

:1,,.1..”- � HYPERLINK http://www.worthpublishers.com/comer ��www.worthpublishers.com/comer�

A Chapter 16 outline, learning objectives, research exercises, study tools, and practice test questions

A Additional Chapter 16 case studies, Web links, and FAQs

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a crime if, because of a mental disorder, they did not know right from wrong or could not resist an uncontrollable impulse

Antigen A foreign invader of the bod y,

such as a bacterium or virus.

to act.

Antipsychotic drugs Drugs that help correct grossly confused or distorted

ABAB design A single-subject experimen-tal design in which behavior is measured during a baseline period, after a treatment has been applied, after baseline condi-tions have been reintroduced, and after

the treatment has been reintroduced. Also

Amnesia Loss of memory.

Amnestic disorders Organic disorders in which the primary symptom is memory

thinking, such as that found in psychotic

disorders.

Antisocial personality disorder A per�

loss.

sonality disorder marked by a general pat�tern of disregard for and violation of other

Amniocentesis A prenatal procedure used�to test the amniotic fluid that surrounds

people’s rights.

called a reversal design.

the fetus for the possibility of birth defects.

Anxiety The central nervous system’s

Abnormal psychology The scientific

Amphetamine A stimulant drug that is

physiological and emotional response to a

study of abnormal behavior in order to describe, predict, explain, and change

manufactured in the laboratory.

vague sense of threat or danger.

Arnygdala A structure in the brain that

Anxiety disorder A disorder in which

abnormal patterns of functioning.

plays a key role in emotion and memory.

anxiety is a central symptom.

Acetylcholine A neurotransmitter that has�been linked to depression and dementia.

Acute stress disorder An anxiety disorder�in which fear and related symptoms are�experienced soon after a traumatic event

Anaclitic depression A pattern of

Anxiety sensitivity A tendency of certain

depressed behavior found among very

persons to focus on their bodily sensations, assess them illogically, and interpret them

young

children that is caused by separation

from the mother.

as harmful.

Analog observation A method for observ�

Anxiolytics Drugs that

reduce anxiety.

Arbitrary inference An error in logic in which a person draws negative conclu�sions on the basis of little or even contrary

and last less than a month.

ing behavior in which people are observed in artificial settings such as clinicians’

Addiction Physical dependence on a

substance, marked by such features as tolerance, withdrawal symptoms during

offices or laboratories.

Analogue experiment A research method

evidence.

abstinence, or both.

in which the experimenter produces abnormal-like behavior in laboratory sub-jects and then conducts experiments on

Asperger’s disorder A pervasive devel�

Affect An experience of emotion or mood. Aftercare A program of posthospitalization

opmental disorder in which individuals display profound social impairment yet maintain a relatively high level of cogni�tive functioning and language skills. Also known as Asperger’s syndrome.

care and treatment in the community.

the subjects.

Agoraphobia An anxiety disorder in which a person is afraid to be in places or situa-tions from which escape might be difficult (or embarrassing) or help unavailable if

Anal stage In psychoanalytic theory, the

second 18 months of life, during which�the child’s focus of pleasure shifts to the

Assertiveness training A cognitive�

anus.

behavioral approach to increasing assertive

panic-like symptoms were to occur.

Anesthesia A lessening or loss of sensation

behavior that is socially desir

able.

Agranalocytosis A life-threatening reduc�

of touch or for pain.

Assessment The process of collecting and

Lion in white blood cells.This condition is sometimes produced by clozapine, one of

Anomie suicide Suicide committed by

interpreting relevant information about a

individuals whose social environment fails to provide stability, thus leaving them

client or subject.

the atypical antipsychotic drugs.

Asthma A medical problem marked by nar�rowing of the trachea and bronchi, which results in shortness of breath, wheezing, coughing, and a choking sensation.

Alcohol Any beverage containing ethyl

without a sense of beloncrino–

alcohol, including beer, wine, and liquor.

Anorexia nervosa A disorder marked by

Alcohol dehydrogenase An enzyme

the pursuit of extreme thinness and by an

that breaks down alcohol in the stomach

extreme loss of weight.

Asylum A type of institution first estab�

before it enters the blood.

Anoxia A complication of birth in which

lisped in the sixteenth century to provide care for persons with mental disorders.

Alcoholics Anonymous (AA) A self-help organization that provides support and guidance for persons with patterns of alto�

the baby is deprived of oxygen.

Antabuse (disulfiram) A drug that causes intense nausea, vomiting, increased heart rate, and dizziness when taken with aka-hol. It is often taken by people who are

Most became virtual prisons.

hol abuse or dependence.

Attention-deficit/hyperactivity disorder (ADHD) A disorder in which persons are unable to focus their attention, behave overactively and impulsively, or both.

Alcoholism A pattern of behavior in which�a person repeatedly abuses or develops a

trying to refrain from drinking alcohol.

dependence on alcohol.

Antagonist drugs Drugs that block or

Attribution An explanation of things we

Alogia A decrease in speech or speech con��tent; a symptom of schizophrenia. Also

change the effects of an addictive drug.

see going on around us that points to par�

Anterograde amnesia The inability to remember new information acquired after

titular causes.

known as poverty of speech.

Atypical antipsychotic drugs A new

Alprazolam A benzodiazepine drug shown to be effective in the treatment of anxiety

the event that triggered amnesia,

group of antipsychotic drugs that oper�ate in a biological manner that is different from the way traditional antipsychotic

Antianxiety drugs Psychotropic drugs

disorders. Marketed as Xemax.

that help reduce tension and anxiety. Also

Altruistic suicide Suicide committed by people who intentionally sacrifice their

called minor tranquilizers or anxiolytia.

drugs operate.

Antibipolar drugs Psychotropic drugs that help stabilize the moods of people suffer-ing from a bipolar mood disorder. Also

Auditory hallucination A hallucination in

lives for the well-being of society.

which a person hears sounds or voices that

Alzheimer’s disease The most common form of dementia, usually occurring after

are not actually present.

known as mood stabilizing drugs.

Augmentative communication sys�

the age of 65.

Antibodies Bodily chemicals that seek out

tem A method for teaching communi�cation skills to individuals with autism, mental retardation, or cerebral palsy by pointing to pictures, symbols, letters,

Amenorrhea The absence of menstrual

and destroy foreign invaders such as bacte�

cycles.

American Law Institute (ALI) test A legal test for insanity that holds people to be insane at the time of committing

ria or viruses.

Antidepressant drugs Psychotropic drugs that improve the mood of people with depression.

or words on a communication board or computer.

R. G-1

G-2 es’ °’ Glossary

Aura A warning sensation that may precede

Behavioral therapy A therapeutic

Bipolar II disorder A type of bipolar

a migraine headache.

approach that seeks to identify problem��causing behaviors and change them. Also

disorder in which a person experiences mildly manic (hypomanic) episodes and

Autistic disorder A pervasive devel�

opmental disorder marked by extreme unresponsiveness to others, poor commu-nication skills, and highly repetitive and rigid behavior. Also known as autism.

Autoerotic asphyxia A fatal lack of oxy��gen that persons may unintentionally�produce while hanging, suffocating or

known as behavior modification.

major depressive episodes.

Behaviors The responses an organism

Birth complications Problematic biologi�cal conditions during birth that can affect the physical and psychological well-being

makes to its environment.

Bender Visual-Motor Gestalt Test A

neuropsychological test in which a sub-ject is asked to copy a set of nine simple designs and later reproduce the designs

of the child.

Blind design An experiment in which sub-jects do not know whether they are in the experimental or the control condition.

strangling themselves during masturbation.

Automatic thoughts Numerous unpleasant thoughts that come into the mind, helping to cause or maintain depression, anxiety, or other forms of psychological dysfunction.

from memory.

Benzodiazepines The most common

Blunted affect A symptom of schizophre�

group of antianxiety drugs, including

nia in which a person shows less emotion

Valium and Xanax.

than most people.

Bereavement The process of working

Body dysmorphic disorder A somato�

Autonomic nervous system (ANS) The network of nerve fibers that connect the central nervous system to all the other

through the grief that one feels when a

form disorder marked by excessive worry that some aspect of one’s physical appear-ance is defective. Also known as dysruor�

loved one dies.

Beta-amyloid protein A small molecule

organs of the body.

that forms sphere-shaped deposits called senile plaques, linked to aging and to

phophobia.

Aversion therapy A treatment based on

Borderline personality disorder A per-sonality disorder in which an individual displays repeated instability in interper�sonal relationships, self-image, and mood, as well as extremely impulsive behavior.

Brain region A distinct area of the brain�formed by a large group of neurons.

the principles of classical conditioning in which people are repeatedly presented with shocks or another unpleasant stimu-lus while they are performing undesirable

Alzheimer’s disease.

Bilateral electroconvulsive therapy

behaviors such as taking a drug.

(ECT) A form of electroconvulsive therapy in which one electrode is applied to each side of the forehead and electrical

Avoidant personality disorder A per�

current is passed through

the brain.

sonality disorder in which an individual is consistently uncomfortable and restrained in social situations, overwhelmed by feel-ings of inadequacy, and extremely sensi�

Binge An episode of uncontrollable eating�during which a person eats a very large

Brain wave The fluctuations of electrical

potential that are produced by neurons in

quantity of food.

the brain.

Binge-eating disorder A type of eating

Breathing-related sleep disorder A sleep�disorder in which sleep is frequently dis�

tive to negative evaluation.

disorder in which a person displays a pat��tern of binge eating without accompany–

Avolition A symptom of schizophrenia

rupted by a breathing problem, causing

marked by apathy and an inability to start

ing compensatory behaviors,

excessive sleepiness or insomnia.

or complete a course of action.

Binge-eating/purging-type anorexia

Brief psychotic disorder Psychotic symp�toms that appear suddenly after a very stressful event or a period of emotional

Axon A. long fiber extending from the body of a neuron.

nervosa A type of anorexia nervosa in which people have eating binges but still lose excessive weight by forcing them-selves to vomit after meals or by abusing

turmoil and last anywhere from a few

hours to a month.

Baroreceptors Sensitive nerves in the

laxatives or diuretics.

Bulimia nervosa A disorder marked by

blood vessels that are responsible for sig-naling the brain that blood pressure is

Biofeedback training A treatment tech�

frequent eating binges that are followed by forced vomiting or other extreme com�

becoming too high.

nique in which a person is given informa-tion about physiological reactions as they occur and learns to control the responses

pensatory behaviors. Also known as binge-purge syndrome.

Baseline data An individual’s initial

response level on a test or scale.

voluntarily.

Basic irrational assumptions According

Biological challenge test A procedure

to Albert Ellis, the inaccurate and inappro-priate beliefs held by people with various

used to produce panic in subjects or cli-ents by having them exercise vigorously or perform other tasks in the presence of a

Cannabis drugs Drugs produced from

psychological problems.

the different varieties of the hemp plant,�Cannabis sativa. They cause a mixture of�hallucinogenic, depressant, and stimulant

Battery A series of tests, each of which

researcher or therapist.

measures a specific skill area.

Biological model The theoretical perspec��tive that points to biological processes as

effects.

B-cell A lymphocyte that produces anti�

Case manager A community therapist

bodies.

Behavioral medicine A field of treatment that combines psychological and physical interventions to treat or prevent medical

the key to human behavior.

who offers a full range of services for per-sons with schizophrenia or other severe disorders, including therapy, advice, medication, guidance, and protection of

Biological therapy The use of physical

and chemical procedures to help people

overcome psychological problems.

problems.

Biopsychosocial theories Explanations that attribute the cause of abnormality to an interaction of genetic, biological, developmental, emotional, behavioral,

patients’ rights.

Behavioral model A theoretical perspec��tive that emphasizes behavior and the

Case study A detailed account of a person’s

life and psychological problems.

ways in which it is learned.

Catatonia A pattern of extreme psychomo�for symptoms, found in some forms of schizophrenia, that may include catatonic

Behavioral self-control training

cognitive, social, and societal influences.

(BSCT) A cognitive-behavioral approach to treating alcohol abuse and dependence in which people are taught to keep track of their drinking behavior and to apply

Bipolar disorder A disorder marked by

alternating or intermixed periods of mania

stupor, rigidity, or posturing.

and depression.

Catatonic excitement A form of catato�nia in which a person moves excitedly, sometimes with wild waving of the arms and legs.

Bipolar I disorder A type of bipolar dis�

coping strategies in situations that typically trigger excessive drinking.

order in which a person experiences full manic and major depressive episodes.

Glossary :1 1

G-3

Catatonic stupor A symptom associated with schizophrenia in which a person becomes almost totally unresponsive to the environment, remaining motionless and

Client-centered therapy The human�

compelled to perform, always in an identi�

istic therapy developed by Carl Rogers in which clinicians try to help clients by being accepting, empathizing accurately,

cal manner.

Computerized axial tomography (CAT�scan) A composite image of the brain�created by compiling X-ray images taken

silent for long stretches of time.

and conveying genuineness.

Catatonic type of schizophrenia A type

Clinical interview A face-to-face encoun-ter in which clinicians ask questions of clients, weigh their responses and reac-tions, and learn about them and their

from many angles.

of schizophrenia dominated by severe psy�

Concordance A statistical measure of the frequency with which family members (often both members of a pair of twins) have the same particular characteristic.

Conditioned response (CR) A response previously associated with an uncondi�tioned stimulus that comes to be produced

chomotor disturbances.

Catharsis The reliving of past repressed

feelings in order to settle internal conflicts

psychological problems.

and overc.Dme problems.

Clinical psychologist A mental health

Caudate nuclei Structures in the brain,

professional who has earned a doctorate in

within the region known as the basal gan��glia, that help convert sensory information

clinical psychology.

Clinical psychology The study,

by a conditioned stimulus.

into thoughts and actions.

assessment, treatment, and prevention of

Conditioned stimulus (CS) A previously neutral stimulus that comes to be associ�ated with a nonneutral stimulus, and can then produce responses similar to those

Central nervous system The brain and

abnormal behavior.

spinal cord.

Clitoris The female sex organ located in

Cerebellum An area of the brain that

front of the urinary and vaginal openings. It becomes enlarged during sexual arousal.

coordinates movement in the body and perhaps helps control a person’s rapid

produced by the nonneutral stimulus.

Clozapine A commonly prescribed atypical

Conditioning A simple form of learning in which a given stimulus comes to produce

attention to things.

antipsychotic drug.

Cocaine An addictive stimulant taken from the coca plant; the most powerful natural

Checking compulsion A compulsion in

a given response.

which people feel compelled to check the

Conditions of worth According to client-centered theorists, the internal standards by which a person judges his or her own lovability and acceptability, determined

by the standards to which the person was

same things over and over.

stimulant known,

Child abuse The nonaccidental use of excessive physical or psychological force

Code of ethics A body of principles and rules for ethical behavior, designed to guide decisions and actions by members of

by an adult on a child, often aimed at

hurting or destroying the child.

a profession.

held as a child.

Chlorpromazine A phenothiazine drug

Cognition The capacity to think, rernem�

Conduct disorder A childhood disorder

commonly used for treating schizophrenia.

ber, and anticipate.

in which the child repeatedly violates the basic rights of others, displaying aggres�sion and sometimes destroying others’

Marketed as Thorazirle.

Cognitive behavior Thoughts and beliefs,

Chromosomes The structures located

many of which remain private.

within a cell that contain genes.

Cognitive-behavioral model A theoreti�

property, lying, or running away from

Chronic headaches Frequent intense aches in the head or neck that are not caused by

cal perspective that views cognitions as

home.

learned behaviors.

Confabulation A made-up description of�one’s experience to fill in a gap in one’s

another medical disorder.

Cognitive model A theoretical perspective

Circadian rhythms Internal “clocks” con-sisting of repeated biological fluctuations.

Circadian rhythm sleep disorder A sleep�disorder caused by a mismatch between�the sleep-wake cycle in a person’s envi��ronment and the person’s own circadian

that emphasizes the process and content of thinking as causes of psychological prob�

memory.

Confederate An experimenter’s accom�

lems.

plice, who helps create a particular impres��sion in a study while pretending to be just

Cognitive therapy A therapy developed

by Aaron Beck that helps people identify and change the maladaptive assumptions and ways of thinking that help cause their

another subject.

Confidentiality The principle that certain

sleep-wake cycle.

professionals will not divulge the informa�

Cirrhosis An irreversible condition, often caused by excessive drinking, in which the liver becomes scarred and begins to change in anatomy and functioning.

psychological disorders.

don they obtain from a client.

Cognitive triad The three forms of nega�

Confound In an experiment, a variable

rive thinking that theorist Aaron Beck says lead people to feel depressed.The triad consists of a negative view of one’s experi�

other than the independent variable that may also be acting on the dependent vari�

Civil commitment A legal process by

able.

which certain individuals can be forced to undergo mental health treatment.

ences, oneself, and the future.

Continuous amnesia An inability to recall�newly occurring events as well as certain

Coitus Sexual intercourse.

Clang A rhyme used by some persons

Community mental health center A

past events.

with schizophrenia as a guide to forming

community treatment facility that provides medication, psychotherapy, and, ideally, emergency care to patients and coordi-nates their treatment in the community.

Community mental health treatment A treatment approach that emphasizes corn�

Control group In an experiment, a group�of subjects who are not exposed to the

thoughts and statements.

Classical conditioning A process of learn-ing by temporal association in which two events that repeatedly occur close together in time become fused in a person’s mind

independent variable.

Conversion disorder A somatoform dis��order in which a psychosocial need or

and so produce the same response.

munity care.

conflict is converted into dramatic physical symptoms that affect voluntary motor or

Classification system A list of disorders,

Comorbidity The occurrence of two or

sensory function.

along with descriptions of symptoms and guidelines for making appropriate diag�

more disorders in the same person.

Convulsion A brain seizure.

Coronary arteries Blood vessels that sur�round the heart and are responsible for carrying oxygen to the heart muscle.

noses.

Compulsion A repetitive and rigid behav-for or mental act that persons feel they must perform in order to prevent or

Cleaning compulsion A common corn�

pulsion in -which people feel compelled to keep cleaning themselves, their clothing, and their homes.

reduce anxiety.

Coronary heart disease Illness of the

Compulsive ritual A detailed, often elabo-rate, set of actions that a person often feels

heart caused by a blockage of the coronary

arteries.

G-4 :2’1 Glossary

Correlation The degree to which events or�characteristics vary along with each other.

Culture-sensitive therapies Treatment

Delusion of reference A belief that

Correlational method A research proce�

approaches that seek to address the unique issues faced by members of various cultural

attaches special and personal meaning to the actions of others or to various objects

dure used to determine how much events or characteristics vary along with each

and ethnic groups.

or events.

Cyclothymic disorder A disorder marked

Dementia A syndrome marked by severe�problems in memory and at least one

other,

by numerous periods of hypomanic symp-toms and mild depressive symptoms.

Correlation coefficient (r) A statistical

other cognitive function.

term that indicates the direction and the�magnitude of a correlation, ranging from

Demonology The belief that abnormal

behavior results from supernatural causes

21.00 to 11.00.

Day center A program that offers hospital��like treatment during the day only. Also

such as evil spirits.

Corticosteroids A group of hormones

Dendrite An extension located at one end�of a neuron that receives impulses from

released by the adrenal glands at times of

called day hospital.

stress.

Death darer A person who is ambivalent about the wish to die even as he or she

other neurons.

Cortisol A hormone released by the adrenal

Denial An ego defense mechanism in

glands when a person is under stress.

attempts suicide.

which a person fails to acknowledge unac�ceptable thoughts, feelings, or actions.

Counseling psychology A mental health

Death ignorer A person who attempts

specialty similar to clinical psychology that requires completion of its own graduate

suicide without recognizing the finality of

Dependent personality disorder A per�

death.

sonality disorder characterized by a pattern of clinging and obedience, fear of separa�tion, and a persistent, excessive need to be

training program.

Death initiator A person who attempts

Countertransference A phenomenon of psychotherapy in which therapists’ own feelings, history, and values subtly influ-ence the way they interpret a patient’s

suicide believing that the process of death�is already under way and that he or she is

taken care of.

simply quickening the process.

Dependent variable The variable in an

Death seeker A person who clearly intends�to end his or her life at the time of a sui�

experiment that is expected to change as

problems.

the independent variable is manipulated.

Couple therapy A therapy format in which the therapist works with two people who share a long-term relationship. Also called marital therapy.

tide attempt.

Depersonalization disorder A disorder marked by a persistent and recurrent feel�

Declarative memory Memory of learned information such as names, dates, and other facts.

ing of being detached from one’s own mental processes or body; that is, one feels unreal and alien.

Covert desensitization Desensitization

Deep brain stimulation A treatment

that focuses on imagining confrontations�with the frightening objects or situations

procedure for depression in which a pace-maker powers electrodes that have been implanted in l3rodmann Area 25, thus

Depressant A substance that slows the

while in a state of relaxation.

activity of the central nervous system and�in sufficient dosages causes a reduction of

Covert sensitization A behavioral treat�

stimulating that brain area.

tension and inhibitions.

ment for eliminating unwanted behavior by pairing the behavior with unpleasant

Deinstitutionalization The discharge of large numbers of patients from long-term

Depression A low state marked by signifi�cant levels of sadness, lack of energy, low self-worth, guilt, or related symptoms.

Derailment A common thinking distur�bane in schizophrenia, involving rapid shifts from one topic of conversation to

mental images.

institutional care so that they might be

Crack A powerful, ready-to-smoke freebase

treated in community programs.

cocaine.

Cretinism A disorder marked by mental retardation and physical abnormalities; caused by low levels of iodine in the

Déjà vu The haunting sense of having pre��viously seen or experienced a new scene

or situation.

another. Also called loose associations.

Delirium A rapidly developing clouded

Desensitization See Systematic

mother’s diet during pregnancy.

state of consciousness in which a person has great difficulty concentrating, focusing attention, and keeping a straightforward

desensitization.

Creutzfeldt-Jakob disease A form of

Desire phase The phase of the sexual

dementia caused by a slow-acting virus that may live in the body for years before

stream of thought.

response cycle consisting of an urge to have sex, sexual fantasies, and sexual

the disease unfolds.

Delirium tremens (DTs) A dramatic

attraction to others.

Criminal commitment A legal process

withdrawal reaction experienced by some people who are alcohol-dependent; con-sists of mental confusion, clouded con-sciousness, and terrifying visual hallucina�

Detoxification Systematic and medically

by which persons accused of a crime are instead judged mentally unstable and sent to a mental health facility for treatment.

supervised withdrawal from a drug.

Deviance Variance from common patterns

of behavior.

Crisis intervention A treatment approach

dons. Also called alcohol withdrawal delirium.

Diagnosis A determination that a person’s

that tries to help people in a psychological crisis view their situation more accurately, make better decisions, act more construe�

Delusion A strange false belief firmly held

problems reflect a particular disorder.

despite evidence to the contrary.

Diagnostic and Statistical Manual of Mental Disorders (DSM) The classification

Delusional disorder A disorder consisting

tively, and overcome the crisis.

Critical incident stress debriefing Training in how to help victims of disasters or other horrifying events talk about their feelings and reactions to the

of persistent, nonbizarre delusions that are

system for mental disorders developed by the American Psychiatric

not part of a schizophrenic disorder.

Delusion of control The belief that one’s

Association.

impulses, feelings, thoughts, or actions are

Diathesis-stress view The view that a

being controlled by other people.

person must first have a predisposition to a�disorder and then be subjected to immedi�

traumatic incidents.

Delusion of grandeur The belief that one�is a great inventor, historical figure, or

Cross-tolerance Tolerance that a person

ate psychosocial stress in order to develop

develops for a substance as a result of reg�

other specially empowered person.

the disorder.

ularly using another substance similar to it.

Delusion of persecution The belief that one is being plotted or discriminated against, spied on, slandered, threatened, attacked, or deliberately victimized.

Diazepam A benzodiazepine drug, mar�

Culture A people’s common history, val�

keted as Valium.

ues, institutions, habits, skills, technology,

Dichotomous thinking Viewing problems�and solutions in rigid “either/or” terms.

and arts.

Read Comer: ch. 16 and watch the related presentations in the Module/Week 8 Reading & Study folder.

Review some of the famous Insanity Defense Cases in page 495 of your textbook. What is your explanation of the abnormal behavior (e.g., biological, emotional, spiritual)? What are some concerns about the Insanity Defense, what is your view, and why do you hold it?

Discussion should be at least two hundred to two hundred fifty words. Replies should be at least 100 words. Two replies are required.

Candice,

As far as my view concerning abnormal behavior is concerned, I believe it is closely related to all mentioned; biological, emotional and the spiritual. On the emotional side of things, feelings can become so severe, that it can cause one to demonstrate abnormal behavior. For instance, there are stress like disorder like post partum psychosis that effect usually new mothers which are brought on by the emotional pressures and new responsibilities. This disorder has been known for causing some to be abnormal in their behavior activity. In the biological sense, because we are genetically inclined, some people who are closely related to relatives that have suffered from abnormal behavior disorders are often at higher risk for developing abnormalities themselves. Now when it comes to the spiritual aspect, I believe that just like we fight against genetic disorders, we are also in spiritual battles, concerning generational curse. The bible speaks of in Romans 12:2 (NIV),“not conform any longer to the pattern of this world, but be transformed by the renewing of your mind”, and so by this we see that because of the fall we became subjected to sin which then produced abnormal behavior within many.

Roseanne,

I can see why the “not guilty by reason of insanity” verdicts are so controversial. Many of the famous insanity defense cases were highly publicized, hotly debated, and some of the verdicts were later overturned (Comer, 2011). It is difficult to know for sure if a person that committed a crime should be punished or should receive mental health treatment because they did not know what they did was wrong. I believe the abnormal behavior can be caused by any of the several different factors, depending on each individual case. However, I think for most people, this behavior is caused by a combination of factors. For example, I think most defendants involved in an Insanity Defense case have some kind of biological abnormality, such as a genetic tendency toward or a chemical imbalance in the brain accounting for a mental illness. Most defendants probably also have something else going on in their lives that caused them to be particularly vulnerable, such as emotional distress, family or marital stress, or spiritual depravity.

One of the concerns I have about the Insanity Defense is that I feel there is no way to have strict enough criteria to let off only those who truly need mental health treatment rather than a prison sentence, and at the same time, to not punish those who truly have a mental illness but no previous diagnosis or treatment history. I also agree with one of the criticisms described in our text, that it seems “clinical knowledge in some areas may be too incomplete to be allowed to influence important legal decisions” (Comer, 2011, p. 494). If several experts that are testifying disagree with one another about the defendant’s mental state, how can we know for sure which opinion is correct?”

Despite some of the concerns with the Insanity Defense, I think it is important to have that option in place because many people with a mental illness desperately need help and mental health treatment, not time in prison. I think prison would only hurt them or confuse them, but not rehabilitate them. I agree mostly with the M’Naghten rule, “that people should be found not guilty by reason of insanity only if they did not know right from wrong at the time of the crime” (Comer, 2011, p. 493). However, this is difficult to determine because a diagnosis alone does not mean an individual did not know what they were doing—a mental illness may play a part in the crime, but perhaps is not fully responsible (Hall, Lee, & Miraglia, 2011). In addition, because symptoms change over time, even if an individual has delusions and does not know right from wrong at the time of trial, that does not mean they did not know right from wrong at the time of the crime (Hall, Lee, & Miraglia, 2011).

Psalm 22:24 says, “For he has not despised or scorned the suffering of the afflicted one; he has not hidden his face from him but has listened to his cry for help”

(NIV). I think the justice system needs to continue to listen to the cries for help from those who are suffering from a mental illness. It is not easy, but we must do our best to determine which individuals knew what they did was wrong and which individuals need hospitalization or treatment.

Comer, R. J. (2011). Fundamentals of abnormal psychology, 6th ed. New York, NY: Worth Publishers.

Hall, D. L., Lee, L.-W. G., & Miraglia, R. P. (2011, Spring). The increasingly blurred line between “mad” and “bad”: treating personality disorders in the prison setting. Albany Law Review, 74(3), 1277+. Retrieved from http://go.galegroup.com .ezproxy.liberty.edu:2048/ps/i.do?id=GALE%7CA269432316&v=2.1&u=vic_liberty&it=r&p=ITOF&sw=w (accessed December 8, 2012).

My concern with the insanity defense is that there are by far too many cases tried in court that use defenses for insanity when the client is by no means insane. This defense appears to be the most popular amongst lawyers in high profile murder cases. I think that for people who try to use the plea of insanity defense, thorough clinical evaluation should already be done or have some signs of mental illness beforehand. I agree with the courts in the decision that, “in some instances people who suffer from severe mental instability, may not be responsible for their actions”, (comer, 2011, p.492). In such cases, these people who are otherwise already declared mentally unstable, a defense of such would be more believable in my opinion. I hold to this view because under such conditions when criminal commitment occurs, treatment will be adequately given and provided for those who need it, not for others who do not. One particular form of criminal commitment I also do not agree with is the fact that individuals are judged mentally unstable at the time of their cries and so innocent of wrong doing (comer, 2011, p.492). These types of laws make it very easy for those who are intentional cold blooded killers to get off free of being accused of any crime. And this type of negligence happens in everyday court. And so I ask you, where is the justice in that?

References

Comer, R. J. (2011). Fundamentals of Abnormal Psychology. New York, NY: Worth.

Abnormal Psychology

Chapter 15:

DISORDERS OF AGING AND COGNITION

Ronald J. Comer