BLOG POST ARCHIVES

beginning    January 2013 [LINK]

NOVEMBER 3, 2012       Mindfulness, Emotion Regulation, and Mental Health -- UPDATED Nov 7

Visitors to my site will know I have highlighted the research on how improved mindfulness skills, in particular the development of a non-judging relationship with internal experiences, can lead to improvements in mental health. Various suggestions have been made for what mechamisms are involved in this process, one being that Mindfulness assists Emotion Reguation, perhaps through some "top-down" process -- improving mindfulness might increase one's ability to control one's emotions -- [LINK]

Recent research, experimental and theoretical, provides further insight into these relationships. A recent paper, by Alberto Chiesa and colleagues from the Institute of Psychiatry, University of Bologna, Italy,  notes that current discrepancies between theoretical accounts of mindfulness' effects might derive from the many different descriptions and applications of mindfulness. Their review aims to discuss current descriptions of mindfulness and the relationship existing between mindfulness practice and most commonly investigated emotion regulation strategies. They discuss recent results from functional neuro-imaging studies investigating mindfulness training within the context of emotion regulation. They suggest that mindfulness training is associated with ‘top-down’ emotion regulation in short-term practitioners and with ‘bottom-up’ emotion regulation in long-term practitioners. Alternatively, they suggest, different instructions or mental conditions could influence the neural mechanisms of Mindfulness Training [LINK]  article available here [LINK]

In another article with a theoretical focus, which is freely available [LINK]  David Vago and David Silbersweig of the Department of Psychiatry, Brigham and Women’s Hospital, Boston, attempt to provide an integrative theoretical
framework and systems-based neurobiological model that explains the mechanisms by which mindfulness reduces biases related to self-processing and creates a sustainable healthy mind. Mindfulness is described through systematic mental training that develops meta-awareness (self-awareness), an ability to effectively modulate one’s behavior (self-regulation), and a positive relationship between self and other that transcends self-focused needs and increases prosocial characteristics (self-transcendence). This framework of self-awareness, -regulation, and -transcendence (S-ART) illustrates a method for becoming aware of the conditions that cause (and remove) distortions or biases. The development of S-ART through meditation is proposed to modulate self-specifying and narrative self-networks through an integrative fronto-parietal control network. Relevant perceptual, cognitive, emotional, and behavioral neuropsychological processes are highlighted as supporting mechanisms for S-ART, including intention and motivation, attention regulation, emotion regulation, extinction and reconsolidation, prosociality, non-attachment, and decentering. The S-ART framework and neurobiological model is based on our growing understanding of the mechanisms for neurocognition, empirical literature, and through dismantling the specific meditation practices thought to cultivate mindfulness.

I have now uploaded, and provided links to articles in the special section of The Journal of Traumatic Stress (Vol 25(3)) on Complex PTSD -- see my page here [LINK]

I shall be submittinng a brief commentary to this blog, but SPOILER ALERT -- see the articles by Daniel Weiss, and, in particular, with respect to the ACT study using covariance and omitting the inclusion of Emotion Regulation, please note the highlighted sections in this attached file -- [LINK] which I shall be including with further comments on a new page on my site

November 4, 2012       Childood Physical Abuse and Adult Mental Health -- Update

Carlos Bianco and colleagues at New York State Psychiatric Institute have recently completed a US national study [LINK] of the relationship between childhood physical abuse and adult mental heatlh. It is largely consistent with existing studies, and I quote the abstract below (iwith my emphases added):

This study characterizes adults who report being physically abused during childhood, and examines associations of reported type and frequency of abuse with adult mental health. Data were derived from the 2000–2001 and 2004–2005 National Epidemiologic Survey on Alcohol and Related Conditions, a large cross-sectional survey of a representative sample (N = 43,093) of the U.S. population. Weighted means, frequencies, and odds ratios of sociodemographic correlates and prevalence of psychiatric disorders were computed. Logistic regression models were used to examine the strength of associations between child physical abuse and adult psychiatric disorders adjusted for sociodemographic characteristics, other childhood adversities, and comorbid psychiatric disorders. Child physical abuse was reported by 8% of the sample and was frequently accompanied by other childhood adversities. Child physical abuse was associated with significantly increased adjusted odds ratios (AORs) of a broad range of DSM-IV psychiatric disorders (AOR = 1.16–2.28), especially attention-deficit hyperactivity disorder, posttraumatic stress disorder, and bipolar disorder. A dose-response relationship was observed between frequency of abuse and several adult psychiatric disorder groups; higher frequencies of assault were significantly associated with increasing adjusted odds. The long-lasting deleterious effects of child physical abuse underscore the urgency of developing public health policies aimed at early recognition and prevention.

The general picture remains: different types of abuse occur together, leading to similar mental disorders in adults; and the number of abuse episodes, more than their type, is what tends to determine the longterm impact.

November 12, 2012       Chronic Pain -- long term sequel to childhood abuse?    Updated December 4

As visitors to my site will know, I post articles / entries when I have received news of interesting recent research studies in the childhood abuse ==> adult mental suffering area. I'm reliant on the services of a number of journals automated services for this, and the service available from PubMed -- but things have been relatively quiet recently in "my" special area. However, I've just received a copy of a pre-press proof from a German author Winfried Hauser, Associate Professor, and Director of Psychomatic Medicine unit at Technische Universität München, Germany [LINK]

As Professor Hauser explains: Systematic reviews of case-control studies have demonstrated an association between self-reported sexual and physical abuse in childhood and (FMS) Fibromyalgia Syndrome  in adulthood. However, the case-control studies reviewed have not analysed whether the association of self-reported childhood maltreatments and FMS was attributable to depression. In this study, randomly selected age- and sex-matched controls from a representative survey of the general German population were used as controls. Childhood maltreatments were assessed by the German version of the Childhood Trauma Questionnaire CTQ and depression by the two-item depres-sion scale of the German version of the Patient Health Questionnaire PHQ-4. The scores of the five CTQ-subscales were compared between FMS-patients and controls using analysis of covariance adjusting for depressed mood. The researchers sample consisted of 153 FMS-patients (87.6% women; mean age 50.3 years) and 153 age- and sex matched participants of the general population. The comparison between FMS-patients and population controls, adjusted for depressed mood, demonstrated a significant group difference for emotional (p<0.001), and sexual abuse (p=0.01). Depressed mood fully accounted for group difference in physical abuse (p=0.01) and in emotional neglect (p<0.001). Depressed mood partially accounted for group difference in emo-tional abuse (p<0.001), but did not account for group difference in sexual abuse (p=0.10). The authors conclude that reports of FMS-patients some on childhood maltreatments were biased by depressed mood. However, the difference in self-reported childhood sexual abuse between adult FMS-patients and population controls was not attributable to depression.

For a discussion of how disruption of childhood attachments can influence pain syndromes, see these audiovisual materials by Maggie Phillips:    [LINK]

November 12 November, 2012 --       Suicidal Ideation and Victimization in Adolescents -- brief review

Today, a brief review from Medscape in their Continuing Medical Education series -- [LINK]

• Among youth who experienced peer victimization in the past year, the risk for suicidal ideation was 2.4 times greater vs children without this history.
• Among youth who were sexually assaulted in the past year, the risk for suicidal ideation was 3.4 times greater vs children without this history.
• Among youth who experienced maltreatment by a parent or caregiver, including physical abuse, emotional maltreatment, neglect, and/or custodial interference in the past year, the risk for suicidal ideation was 4.4 times greater vs children without this history.
• Effects of polyvictimization, or exposure to 7 or more individual types of victimization in the past year, were substantial, with youth exposed to many different forms of victimization almost 6 times more likely to report suicidal ideation.
• Therefore, polyvictimization was the strongest predictor of suicidal ideation.
• There was also a substantial association between suicidal ideation and living in a household with a stepparent or unmarried parent partner, which was not fully explained by victimization.

On the basis of these findings, the investigators concluded that recent victimization is important in increasing the risk for suicidal ideation in adolescents.

The investigators also suggest that exposure to many different forms of victimization likely reflects significant adversity across  multiple contexts of adolescents' lives, with victimization representing more of a life condition than a set of events for such youth.

To me, the finding that "substantial association between suicidal ideation and living in a household with a stepparent or unmarried parent partner" argues the need for parents and caregivers to be aware of these factors, relating to quality of attachment, and take proactive steps to improve attachment, rather than relying on "luck" or "time" alone to prevent difficulties arising (imho, speaking with the benefit of hindsight and personal experience).

November 24       Mindfulness training -- brief, but enduring effects

A recent study, published in Frontiers in Human Neuroscience  [LINK] has found that two months of training, consisting of as little as two hours per week (participants were also instructed to also meditate on their ownfor approximately 20 minutes per day)., could have enduring effects on neuropsychological functioing, as assessed by functional neuroimaging. "This is the first time that meditation training has been shown to affect emotional processing in the brain outside of a meditative state," study researcher Gaëlle Desbordes, of Massachusetts General Hospital and Boston University's Center for Computation Neuroscience and Neural Technology, said in a statement.

Researchers had study participants undergo one of three eight-week courses: one course was on mindful attention meditation, where they were trained to be more attentive and aware of their thinking, feeling and breathing; one course was on compassion meditation, where they were trained to feel compassion and kindness to other people and themselves; and one course just provided general health information as a control condition.

The researchers found that the people who took either of the meditation courses experienced decreased activity in the amydala in response to images that provoked negative emotions -- a sign that they were coping well with stress and were experiencing stability of their emotions. But people who only went through the health education class experienced an increase in the amygdala in response to images that provoked negative emotions.

Previously, Massachusetts General Hospital researchers found that eight weeks of meditation training was linked with more density of grey matter in the hippocampus of the brain (which plays a role in memory and learning), as well as parts of the brain linked with compassion and self-awareness. That research was published last year in the Journal of Psychiatry Research: Neuroimaging Holzel et al [LINK]

In a separate but related study, Dr. Murali Doraiswamy, of Duke University School of Medicine, has found that hippocampal size predicts antidepressant response, at least in those in later life  [LINK]. More details about the study than are available in the abstract are available here [LINK]

November 24       Prospective study of relationship between PTSD, anxiety and depression

It has long been known that PostTraumatic Stress Disorder (PTSD) can be co-morbid with a number of other disorders, particularly depression and anxiety. However, what the causative processes involved in these relationships has been much less clearly understood.  A new study by Angela Nickerson, of Australia's University of New South Wales, and colleagues from the United States, has begun to shed some light on those relationships, at least those occurring after sexual assault  [LINK]

In this study, participants were 126 women who had been sexually assaulted in the previous 4 weeks. It was found, using lower level mediation analyses, that changes in PTSD symptoms had a greater impact on changes in depression and anxiety than vice versa. Changes in PTSD symptoms contributed more to changes in scores on measures of depression and anxiety than changes in scores on measures of depression and anxiety contributed to changes in measures of PTSD when time since trauma was considered.

December 3       Childhood Abuse -- Internationally prevalent

MARIJE STOLTENBORGH of Leiden University, Netherlands, has produced another meta-analysis of published studies, this time looking at the international prevalence of childhood emotional abuse.  Those familiar with my site will know I have discussed prevalence there [LINK].

Ms Stoltenborgh previously published  an article reporting a meta-analysis of studies looking at the prevalene of childhood sexjual abuse in different countries [LINK].

In that article, Stoltenborgh reported a comprehensive meta-analysis that combined prevalence figures of childhood sexual abuse (CSA) reported in 217 publications published between 1980 and 2008, including 331 independent samples with a total of 9,911,748 participants. The overall estimated CSA prevalence was 127/1000 in self-report studies and 4/1000 in informant studies.

Self-reported CSA was more common among female (180/1000) than among male participants (76/1000). Lowest rates for both girls (113/1000) and boys (41/1000) were found in Asia, and highest rates were found for girls in Australia (215/1000) and for boys in Africa (193/1000). The results of the meta-analysis confirm that CSA is a global problem of considerable extent, but also show that methodological issues drastically influence the self-reported prevalence of CSA.

In the most recent paper, looking at childhood emotional abuse [LINK]  Stoltenborgh and colleagues present the resuts  of a comprehensive meta-analysis combining prevalence figures of child emotional abuse reported in 29 studies, including 46 independent samples with a total of 7,082,279 participants. The overall estimated prevalence was 3/1,000 for studies using informants and 363/1,000 for studies using self-report measures of child emotional abuse. Procedural factors again, as for studies of  CSA seem to exert a greater influence on the prevalence of childhood emotional abuse than sample characteristics and definitional issues, without fully explaining the vast variation of prevalence rates reported in individual studies.

The researchers  conclude that child emotional abuse is a universal problem affecting the lives of millions of children all over the world, which is in sharp contrast with the United Nation’s Convention on the Rights of the Child.

Going by self-reported prevalence rates, and as discussed on my website, there are good reasons to rely on these figures, CEM likely occurs at three times the rate of CSA and, again please refer to my website, CEM can have effects as severe, if not in some cases more severe, as CSA -- impacts, for individual clients and populations alike, likely to be under-estimated by many clinicians and policy makers and service planners.

December 3       Childhood abuse and late-life depression

Hannie Comijs and colleagues from the Department of Psychiatry, VU University Medical Center, Amsterdam, The Netherlands has recently had an article accepted for publication on childhood abuse and late-life depression [LINK]

From the article's abstract:

"BACKGROUND: Little is known about the role of childhood abuse in late-life depression. The aim of the study is therefore to study whether childhood abuse is associated with late-life depression according to its onset, and which clinical characteristics play a role in this association.

METHODS: Data were used from 378 depressed and 132 non-depressed persons, aged 60-93 years, from the Netherlands Study of Depression in Older persons (NESDO). Childhood abuse included psychological, physical and sexual abuse and emotional neglect.

RESULTS: 53% of the depressed older adults reported childhood abuse, compared to 16% of the non-depressed older adults (p<0.001). Using logistic regression analyses adjusted for age, sex and level of education, depression was strongest associated with physical abuse (Odds Ratio ((OR) 13.71; 95% Confidence Interval (CI) 3.25-57.91) and least with sexual abuse (OR 5.35; 95% CI 2.36-12.14). Childhood abuse was associated with early-onset (OR 13.73, 95% CI 7.31-25.80), middle age-onset (OR 5.36, 95% CI 2.90-9.90) and late-onset depression (OR 4.74, 95% CI 2.51-8.95). In the late-onset group childhood abuse was associated with an increased number of chronic diseases.

LIMITATIONS: Age of depression onset and childhood abuse were asked retrospectively, which may have biased the results.

CONCLUSIONS: Childhood abuse is strongly related to late-life depression and its comorbidities, even in the case of late-onset depression. This might suggest that psychological wellbeing can be maintained throughout middle age, but may be disturbed in later life."

On my website I have previously reviewed studies examining retrospective vs prospective studies, and the general conclusion is that retrospective studies yield results which can be generally relied on Thus I do not believe that the "limitation" mentioned is in fact one that warrants concern about the thrust of the study's results -- childhood abuse, especially physical abuse, is a significant precursor, and may be a significant contributing factor, to suffering depression in later life, even if one has managed to cope with the effects of such abuse earlier in life Further, and consistent with other studies reviewed on my website, such abuse early in life contributes to not only mental disorders but chronic physical illnesses as well.

A person doesn't just "get over it" if one has been abused early in life, whatever form the abuse took.

Elsewhere on my site I have reviewed (in my research proposal) evidence indicating that the effects of such abuse also significanty affect presentation during dementia.

December 3       Early life distress, brain changes, and internalizing problems

As a preface to the rest of this post, let me explain that by "internalizing problems" I mean such "internalizing symptoms" as depression, worry, fear, self-injury, and social withdrawal. This page discusses how internalizing symptoms present in Borderline Personality Disorder [LINK] though they are also common with a variety of other disorders. Behavioral and psychological problems are often described in terms of their degrees of internalizing versus externalizing presentation. The major distinction between these two presentations is related to whether the symptoms or behaviors are focused inward (i.e., toward to the self) or outward (i.e., toward others).

Researchers at the University of Wisconsin-Madison have recently published a paper Burghy et al [LINK] examining the relationship between early life stress (ELS) and problems in adolescents exhibiting internalizing symptoms.  ELS can refer to a number of experiences but in this study ELS referred to largely maternal experiences of environmental stressors  (as a methodological note, see Schrieber et al 2006 [LINK])  It is known that ELS and function of the hypothalamic-pituitary-adrenal axis predict later psychopathology. Animal studies and  cross-sectional human studies suggest that this process might operate through amygdala–ventromedial prefrontal cortex (vmPFC) circuitry implicated in the regulation of emotion. The Burghy et al study prospectively investigated the roles of ELS and childhood basal cortisol amounts in the development of adolescent resting-state functional connectivity (rs-FC), assessed by functional connectivity magnetic resonance imaging (fcMRI), in the amygdala-PFC circuit.  The study found, but in females only, that greater ELS predicted increased childhood cortisol levels, which predicted decreased amygdala-vmPFC rs-FC 14 years later. For females, adolescent amygdala-vmPFC functional connectivity was inversely correlated with concurrent anxiety symptoms but positively associated with depressive symptoms, suggesting differing pathways from childhood cortisol levels function through adolescent amygdala-vmPFC functional connectivity to anxiety and depression. These data highlight that, for females, the effects of ELS and early HPA-axis function may be detected much later in the intrinsic processing of emotion-related brain circuits.

I am at a loss, especially given my own experience of early stress, and exposure to maternal distress, as to why similar results were not found in males, and Burghy et al also don't offer any explanation for this difference. I have contacted the author of the article and he has not offered an explanation for this gender difference either.

December 20, 2012      Tragedy of numbers -- what's to be done?

My site is dedicated to understanding and helping others come to terms with the effects of childhood trauma, especially interpersonal trauma, and no clearer example of childhood trauma  on a large scale can be found in the events at Sandy Hook School, Newton, Connecticutt.  My profound sympathies go out to those affected by this tragedy.

I've been involved, and "observing" exchanges on the American PsyLaw list. It is very difficult for me, coming from a society with strict gun controls and relatively few weapons, to understand these events, to come to an emotional peace with these events, and I am not ashamed to say that I have cried, on more than one occasion, when observing and thinking about the events. For those not privy to the discussion on the list I'd like to quote a couple of important pieces of information. Firstly, about what factors are likely to be involved; secondly, a listing of available resources. But first, some observations on numbers. Wikipedia quotes the population of the United States as about 315 Milliion people, with some estimating the number of gun weapons as approximately 280 Million -- 89 guns for every 100 people, with (quoted on Letterman, in NZ at least -- we're a bit behind here) 70 shootings at schools since 1994. As one of the contributors to the PsyLaw list said: there are hundreds of thousands of people using guns in the United States, with only a few thousand gun-related casualties per year. Again,on Wikipedia this is estimated as below 70, 000 per year.  A contributor to the list from the UK is, like me, aghast at the events in Newtown, and has encouraged his colleagues on the list to support large scale gun controls -- this has NOT received support on the list, and I think it is beyond American culture, at this point in time, to accept such limitations. Perhaps after a further 70 shootings, or someone, like in the movies, sends his private militia in to fight a branch of the US Army?  Certainly, some groups probably have more guns avaiilable, per person, than many Army units.

I'm indebted to the members of the list, and especially Dr Andy Kane, Clinical, Consulting and Forensic Psychologist of Milwaukee, Wisconsin, for the final couple of items:

•     depression,
•     resentment,
•     tendency to blame others for their misfortunes,

•     social isolation,
•     fascination with violence,  
•     interest in weaponry

and

•     people who exhibit rage, either specific to some situation or in more generalized form,
•     and people who are bullied.

Research conducted with those who have committed offences indicates that spending time with "antisocial attitudes", and in this context I'd imagine those supportive of fascination with violence and interest in weaponry (especially guns), is also a significant risk factor. Of course, relying on any one of these factors, in isolation from consideration of the others, is likely to lead to a huge number of "false positives" -- wrongly concluding that someone is a risk when they are not.

This document discusses some possible means of addressing this problem    [LINK]

And here is a list of resources for parents of children aaffected by violence and disaster:  [LINK]

Incidentally, the practice known a "Critical Incident Stress Debriefing" is no longer advised-- outcome studies have shown it to have effects either neutral or iatrogenic -- causative of further problems -- "re-traumatization"  [LINK]  See also  [LINK]

December 20, 2012       Social Anxiety and Self-soothing

Recent research by Bruce and likely "senior author' Richard Heimberg, and fellow colleagues [LINK]  from Temple University, has replicated previous research showing high levels of childhood maltreatment amongst those adults suffering from Social Anxiety Disorder (SAD) and explored the impact of this history on response to pharmacotherapy. In this study it was found that all types of maltreatment except for sexual abuse and physical abuse were related to greater symptom severity. Emotional abuse and neglect were related to greater disability, and emotional abuse, emotional neglect, and physical abuse were related to decreased quality of life. Emotional abuse significantly predicted dropout from treatment. A time by emotional abuse statistical interaction suggests that for those who stayed the course, the impact of emotional abuse on severity of social anxiety weakened significantly over time. Emotional maltreatment was most strongly linked to dysfunction in SAD, despite a tendency in the anxiety literature to focus on the effects of sexual and physical abuse. Additionally, individuals reporting emotional abuse were more likely to dropout from pharmacotherapy, but those who stayed the course displayed similar outcomes to those without such a history. This is a valuable finding given the difficulty people with SAD have in taking part, initially, and early in life, in treatment, at times choosing to rely on "self-treatment".

In another study by Richard Heimberg, this time with colleagues from Louisiana State University,  [LINK] has examined "self-treatment" through substance use,a commonly occurring problem in this group. Most previous research has utilized existing theories of substance use (e.g. tension reduction-based theories) to understand SAD–SUD relations. However, these theories do not address why individuals with social anxiety, in particular, experience such high rates of substance-related problems. A possible explanation may lie in the nature of social anxiety itself, which is characterized not only by chronically elevated negative affective states, but by low positive affect, fear of scrutiny, and social avoidance. These aspects of social anxiety may work in concert to place these especially vulnerable individuals at risk for SUD. Buckner's paper presents a biopsychosocial model of SAD-SUD comorbidity that focuses on several specific facets of social anxiety that may be especially related to SUD risk. The utility of this model is evaluated via a review of the literature on the relations between SAD and substance-related behaviors. Unfortunately, this paper neglects to consider the integration of processes relating to childhood maltreatment into their model, although the processes examined: chronically elevated negative affective states,low positive affect, fear of scrutiny (perhaps allied to feelings of shame, common in survivors of childhood abuse), and social avoidance (note my previous allusions to Martin Dorahy's research on social disconnectedness in those with histories of childhood interpersonal trauma). Of course, one could always hypothesise the additive / interactive effects of these variables,but I would argue for the need to include childhood experiences, and temperament, factors into any "bio-psycho-social" model.

December 21, 2012       Childhood Maltreatment -- Victim to Offender

Tragically, some who are the victims of childhood maltreatment go on to develop offending behaviour themselves. This was noted over a decade ago, by Shields and Ciccheti (1998) [LINK] who noted that being the victim of physical violence was particularly predictive of "reactive aggression" and that the pathway to such offending was often through emotion dsyregulation.. Maltreated children also evidenced attention deficits, and subclinical or nonpathological dissociation was more likely among children who had experienced physical or sexual abuse. A history of abuse also predicted emotion dysregulation, affective lability/negativity, and socially inappropriate emotion expressions. This emotion dysregulation, fostered by poor attention modulation, was a mechanism of the effects of maltreatment on reactive aggression.

A recent study by Eva Kimonis (University of South Florida) and colleagues [LINK] has again looked at this relationship, this time focusing on  distinguishing between different types of juvenile psychopathy, and highlighting the role of emotion processing. In this more recent study, Kimonis et al divided a group of male serious juvenile offenders into two groups of primary and secondary variants of psychopathy depending on whether or not the individual suffered from anxiety.  Results indicated that the secondary, high-anxious variant was more likely to show a history of abuse and scored higher on measures of emotional and attentional problems.  On a picture version of the dot probe task, the low-anxious primary variant was not engaged by emotionally distressing pictures, whereas the high-anxious secondary variant was more attentive to such stimuli. Although the two groups differed as hypothesized from one another, neither differed significantly in their emotional processing from a nonpsychopathic control group of offending youth. These results are consistent with the possibility that the two variants of psychopathy, both of which were high on callous-unemotional (CU) traits (assessed using the Youth Psychopathic Traits Inventory), may have different etiological pathways, with the primary being more related to a deficit in the processing of distress cues in others and the secondary being more related to histories of abuse and emotional problems. Kimonis goes on to explore the research, and importantly (for the purposes of "Therapeutic Jurisprudence" -- which I shall be exploring in a new page on my website) and practice implications of their findings. For example, research suggests that cognitive-behavioral interventions may be most effective at treating internalizing problems (e.g., anger, anxiety, and depression) and related trauma histories that distinguish secondary variants. For the low-anxious primary variant, recent research suggests that deficits in attention to others’ distress cues can at least temporarily be corrected by focusing youths’ attention on the eye region. Also, increasing the salience of others’ distress cues has been found to attenuate laboratory-based aggression for youth scoring high on psychopathic traits. This group has also been shown to respond positively to rewards and this also can be capitalized on in treatment. For example, Hawes and Dadds (2005) [LINK] reported that clinic-referred boys (ages 4 to 9) with conduct problems and CU traits were less responsive to a parenting intervention than were boys with conduct problems who were low on CU traits. However, children with and without CU traits seemed to respond equally well to the first part of the intervention that focused on teaching parents methods of using positive reinforcement to encourage prosocial behavior. In contrast, only the group without CU traits showed added improvement with the second part of the intervention that focused on teaching parents more effective discipline strategies. In summary, several promising interventions have emerged for youth with CU traits. These efforts are likely to be enhanced if they consider the heterogeneity among high CU youth and appropriately tailor treatment to their individual needs.

A final observation can also be made -- we are moving more and more towards having evidence-based standards of care for adults suffering childhood trauma-related depressive, anxiety, substance-use, other psychiatric, and physical disorders. But, given my experience of practice and research issues in this area in New Zealand, we are VERY far behind where we need to be, where we, in my opinion, should be. Given the absence of a current research evidence base to local practice, people have died, through suicide, and through trauma-related physical disorders, long before they should have, after having suffered cruelly, emotionally and physically, from trauma-induced symptoms.