American Psychological Association practice guidelines for psychopharmacology: Ethical practice considerations for psychologists involving psychotropic use with children and adolescents.

OBJECTIVES: This study discusses the implications of the American Psychological Association's 2011 Practice Guidelines for Pharmacology as they apply to psychologists working with juvenile clients. Special considerations apply due to concerns about the developmental side effects that occur when psychotropic medications are prescribed to children and adolescents. METHODS OR DESIGN: This study provides recommendations for implementing each of the Practice Guidelines. Constructive criticism of the Practice Guidelines is also discussed with the aim of improving service delivery. RESULTS: This study provides specific recommendations for psychologists regarding obtaining adequate knowledge about psychopharmacology to inform clients or consult with physicians. Suggestions are made for continuing education requirements for psychologists who work with juveniles. CONCLUSIONS: Recommendations are made for psychologists working with juveniles to increase their knowledge of psychotropic medications for a more ethical and informed voice regarding the prescribing of such medications.

Attachment and selective attention: disorganization and emotional Stroop reaction time.

Although central to attachment theory, internal working models remain a useful heuristic in need of concretization. We compared the selective attention of organized and disorganized mothers using the emotional Stroop task. Both disorganized attachment and emotional Stroop response involve the coordination of strongly conflicting motivations under conditions of emotional arousal. Furthermore, much is known about the cognitive and neuromodulatory correlates of the Stroop that may inform attempts to substantiate the internal working model construct. We assessed 47 community mothers with the Adult Attachment Interview and the Working Model of the Child Interview in the third trimester of pregnancy. At 6 and 12 months postpartum, we assessed mothers with emotional Stroop tasks involving neutral, attachment, and emotion conditions. At 12 months, we observed their infants in the Strange Situation. Results showed that: disorganized attachment is related to relative Stroop reaction time, that is, unlike organized mothers, disorganized mothers respond to negative attachment/emotion stimuli more slowly than to neutral stimuli; relative speed of response is positively related to number of times the dyad was classified disorganized, and change in relative Stroop response time from 6 to 12 months is related to the match-mismatch status of mother and infant attachment classifications. We discuss implications in terms of automatic and controlled processing and, more specifically, cognitive threat tags, parallel distributed processing, and neuromodulation through norepinephrine and dopamine.

Reduction of disrupted caregiver behavior using modified interaction guidance.

The present study is a reanalysis of a preexisting study examining the usefulness of the Atypical Maternal Behavior Instrument for Assessment and Classification (AMBIANCE; Bronfman, Parsons, & Lyons-Ruth, 1999) measure as an indicator of efficacy in reducing disrupted caregiver behavior in two brief interventions. The current study examines the rate of change in the display of disrupted caregiver behavior over the course of an attachment-based intervention (Modified Interaction Guidance) in a group of 11 caregiver-infant dyads referred to a tertiary care clinic for feeding problems. The AMBIANCE was utilized as an indicator of change in disrupted behavior following an assessment feedback session and three intervention sessions. Results showed a significant decrease in the total display of disrupted caregiver behaviors, as well as a change in classification from disrupted to not-disrupted, after receiving both feedback from the assessment and the first treatment session. A qualitative analysis of the data further revealed different patterns of change between caregivers. These findings provide preliminary empirical support suggesting that a reduction of disrupted caregiver behavior can be observed relatively quickly after the commencement of the Modified Interaction Guidance intervention.

The two Bernard Berenson cousins: The interplay among immigration, culture, and narcissism.

The lives of two 19th century cousins, both of whom changed their names to Bernard Berenson, are considered from historical and psychodynamic perspectives, using a psychobiographical method. The Jewish cousins immigrated separately to Boston from Lithuania in 1875 and 1882. One cousin, later calling himself simply B.B., became a world-renowned art historian. The other Bernard became a misanthrope after feeling deeply humiliated by his cousin's family in Boston. Many biographies were written about the famous B.B. The only histories of his cousin Bernard were family stories, as he was the author's great-grandfather. The intersecting lives of these cousins are discussed. Both men faced the challenges of immigration as well as intense anti-Semitism and prejudice in each country in which they lived. These cultural and historical conditions interacted with the cousins' narcissistic vulnerabilities. Their lives demonstrate different manifestations of narcissistic suffering, with B.B's being more consistent with the construct of a "grandiose narcissist" and Bernard's being more consistent with that of a "closet narcissist." The life stories of these two cousins with the same name offers an intriguing instance of a complicated relationship among immigration, prejudice, and narcissism and case examples of the manifestation of how narcissistic suffering can influence lives.

On the relation between maternal state of mind and sensitivity in the prediction of infant attachment security.

Attachment theorists assume that maternal mental representations influence responsivity, which influences infant attachment security. However, primary studies do not support this mediation model. The authors tested mediation using 2 mother-infant samples and found no evidence of mediation. Therefore, the authors explored sensitivity as a moderator, studying the (a) interaction of mental representation and sensitivity as it predicts infant attachment security and (b) level of sensitivity in mothers whose infants' attachment security is either concordant or discordant with their own. The interactional analyses were not significant. But the match-mismatch data showed that when mother-infant attachment strategies were discordant, maternal sensitivity was more consistent with infant than maternal attachment strategy. These findings are congruent with an interpretation of sensitivity as a moderator that can block transmission of attachment strategy.

Improvements in 1-year cardiovascular clinical outcomes associated with a hospital-based discharge medication program.

BACKGROUND: Despite recent advances in the treatment and prevention of cardiovascular disease, a treatment gap for secondary prevention medications still exists. OBJECTIVE: To develop and implement a program ensuring appropriate prescription of aspirin, statins, beta-blockers, angiotensin-converting enzyme inhibitors, and warfarin at hospital discharge. DESIGN: A nonrandomized before-after study comparing patients hospitalized before (1996-1998) and after (1999-2002) implementation of a discharge medication program (DMP). Patients were followed for up to 1 year. SETTING: The 10 largest hospitals in the Utah-based Intermountain Health Care system. PATIENTS: In the pre-DMP and DMP time periods, 26,000 and 31,465 patients, respectively, were admitted to cardiovascular services (n = 57,465). MEASUREMENTS: Prescription of indicated medications at hospital discharge; postdischarge death or readmission. RESULTS: By 1 year, the rate of prescription of each medication increased significantly to more than 90% (P < 0.001); this rate was sustained. At 1 year, unadjusted absolute event rates for readmission and death, respectively, were 210 per 1000 person-years and 96 per 1000 person-years before DMP implementation and 191 per 1000 person-years and 70 per 1000 person-years afterward. Relative risk for death and readmission at 30 days decreased after DMP implementation; hazard ratios (HRs) for death and readmission were 0.81 (95% CI, 0.73 to 0.89) and 0.92 (CI, 0.87 to 0.99) (P < 0.001 and P = 0.017, respectively). At 1 year, risk for death continued to decrease (hazard ratio, 0.79 [CI, 0.75 to 0.84]; P < 0.001) while risk for readmission stabilized (hazard ratio, 0.94 [CI, 0.90 to 0.98]; P = 0.002), probably because survivors had more opportunities to be readmitted. LIMITATIONS: The study design was observational and nonrandomized, and the authors could not control for potential confounders or determine the extent to which secular trends accounted for the observed improvements. CONCLUSIONS: A relatively simple quality improvement program aimed at enhancing the prescription of appropriate discharge medications among cardiovascular patients is feasible and can be sustained within an integrated multihospital system. Such a program may be associated with improvements in cardiovascular readmission rates and mortality.

Cortisol concentrations in 12- to 18-month-old infants: stability over time, location, and stressor.

BACKGROUND: Sparse information on early development of hypothalamic pituitary adrenal (HPA) axis responsivity in human infants limits our understanding of stress hormone regulation and vulnerability to psychopathology. We considered whether infant cortisol stress response (CSR) is a suitable endocrine phenotype for developmental stress research. METHODS: We assessed stability of key CSR parameters across time, location, and stressor through saliva samples taken before and then 20 and 40 min following exposure to two stressors administered 1 week apart in 27 infants aged 12 to 18 months. Time-matched home samples were collected to control for circadian rhythm and to evaluate baseline stability. RESULTS: Baseline cortisol concentrations, peak percent change, and area under the curve (AUC) were stable across time and stressors. Following both stressors, half the infants exhibited peak cortisol concentrations at 20 min poststress; half peaked at 40 min poststress. For 56% of the infants, peak response time was inconsistent across stressors. CONCLUSIONS: In humans, baseline and CSR are stable by 12 to 18 months. Variation in CSR time course across stressors indicates that infant CSR should be sampled beyond 30 min. Results support using infant CSR, particularly as measured by AUC, as a valid endocrine phenotype for developmental stress research.

Do-not-resuscitate orders in the OR--suspend or enforce?

Retaining self-determination about medical care is a basic patient right. Advance directives (e.g., living wills, powers of attorney, health care proxies) are becoming more common in today's health care settings, including the OR. Perioperative personnel should be aware of and respect these documents and the patient's wishes--without compromising their own morals or ethics.

Successfully developing a cardiovascular research program in a community hospital.

Hoag Memorial Hospital, located in Newport Beach, Calif, is a not-for-profit community medical center. Within 2 years, our cardiovascular (CV) research program had enrolled more than 150 patients in 13 industry-sponsored clinical trials. This article highlights the best practices that have allowed us to create a foundation for success.

The maternal adversity, vulnerability and neurodevelopment project: theory and methodology.

OBJECTIVE: To describe the theory and methodology of the multi-wave, prospective Maternal Adversity, Vulnerability and Neurodevelopment (MAVAN) study. The goal of MAVAN is to examine the pre- and postnatal influences, and their interaction, in determining individual differences in mental health. METHOD: MAVAN is a community-based, birth cohort study of pregnant Canadian mothers and their offspring. Dyads are assessed longitudinally, with multiple assessments of both mother and child in home and laboratory across the child's development. Study measures, including assessments of cognitive and emotional function, are described. The study uses a candidate gene approach to examine gene-environment interdependence in specific developmental outcomes. Finally, the study includes measures of both brain-based phenotypes and metabolism to explore comorbidities associated with child obesity. One of the unique features of the MAVAN protocol is the extensive measures of the mother-child interaction. The relation between these measures will be discussed. RESULTS: Evidence from the MAVAN project shows interesting results about maternal care, families, and child outcomes. In our review, preliminary analyses showing the correlations between measures of maternal care are reported. As predicted, early evidence suggests that maternal care measures are positively correlated, over time. CONCLUSIONS: This review provides evidence for the feasibility and value of laboratory-based measures embedded within a longitudinal birth cohort study. Though retention of the samples has been a challenge of MAVAN, they are within a comparable range to other studies of this nature. Indeed, the trade-off of somewhat greater participant burden has allowed for a rich database. The results yielded from the MAVAN project will not only describe typical development but also possible targets for intervention. Understanding certain endophenotypes will shed light on the pathogenesis of various mental and physical disorders, as well as their interrelation.

Becoming the denigrated other: group relations perspectives on initial reactions to a bipolar disorder diagnosis.

The initial reactions to a bipolar disorder diagnosis of research participants in a small, qualitative study consisted of astonishment, dread of being "mad," and extremely negative associations. All had prior mental health diagnoses, including episodes of severe depression (all but one) and alcoholism (one). All participants reported mental health histories prediagnosis and most had spent years contending with mental health labels, medications, symptoms, and hospitalizations. In addition, most participants were highly educated health professionals, quite familiar with the behaviors that the medical system considered to comprise bipolar disorder. Their negative associations to the initial bipolar disorder diagnosis, therefore, appeared inconsistent with their mental health histories and professional knowledge. This article contextualizes these initial reactions of shock and distress and proposes interpretations of these findings from societal and psychodynamic group relations perspectives. The participants' initial negative reactions are conceptualized as involving the terror of being transported from the group of "normal" people into the group of "mad" or "crazy" people, i.e., people with mental illnesses, who may constitute a societal "denigrated other."

A picture is worth a thousand words: children's representations of family as indicators of early attachment.

To ascertain whether attachment representations at age 7 are related to early attachment behaviour, family drawings of 123 7-year-olds of known infant attachment status (25 avoidant, 80 secure, 18 resistant) were scored in four ways. Three of these were based in previous attachment research and one was based on a clinical method. The attachment-based coding schemes included specific markers for each attachment pattern (Kaplan & Main, 1985), global ratings (Fury, Carlson, & Sroufe, 1997) and efforts to classify each drawing as belonging to one of the three primary infant attachment groups (secure, avoidant, resistant). In the clinical scheme, children who had been resistant infants were distinguished from the others by use of overlapping and encapsulated figures. For the attachment based schemes, although individual markers were not successful in discriminating attachment groups, the more global approaches (aggregation of markers, global rating scales and judgments of attachment classification) succeeded in this task. In regression analyses controlling for concurrent child and parent measures, infant attachment did not make a significant contribution to predicting insecurity markers in drawings, although child current emotional functioning did. These findings linking attachment relationships with later representations of family relationships were in accord with the conception that avoidant attachment strategies de-emphasize intimate relationships, while resistant attachment strategies are preoccupied with close relationships. These links are most evident in global interpretive strategies rather than those that rely on specific markers.

Atypical maternal behavior, maternal representations, and infant disorganized attachment.

The data for 197 mother-infant pairs from two longitudinal studies were analyzed to assess relations between maternal attachment representations; atypical maternal behavior, coded with a new tool. Atypical Maternal Behavior Instrument for Assessment and Classification (AMBIANCE), and infant attachment. Both maternal and infant attachment were systematically related to atypical maternal behavior: mothers who were Unresolved on the Adult Attachment Interview and those whose infants were disorganized in the Strange Situation Procedure engaged in more atypical behaviors than those who were not Unresolved and whose infants showed organized patterns of attachment, respectively. Regression analyses indicated that when tested as a mediator, atypical maternal behavior as measured on the AMBIANCE did not reduce the association between maternal Unresolved status and infant disorganized attachment. This may, in part, reflect the fact that our low-risk sample did not include enough cases in the risk categories. These data provide preliminary empirical validation for the AMBIANCE and strengthen the evidence for links between atypical maternal behavior and disorganized attachment but indicate that in addition to maternal attachment representations, other factors must contribute to atypical maternal behavior.

Naïve observers' perceptions of family drawings by 7-year-olds with disorganized attachment histories.

Previous research has succeeded in distinguishing among drawings made by children with histories of organized attachment relationships (secure, avoidant, and resistant); however, drawings of children with histories of disorganized attachment have yet to be systematically investigated. The purpose of this study was to determine whether naïve observers would respond differentially to family drawings of 7-year-olds who were classified in infancy as disorganized vs. organized. Seventy-three undergraduate students from one university and 78 from a second viewed 50 family drawings of 7-year-olds (25 by children with organized infant attachment and 25 by children with disorganized infant attachment). Participants were asked to (1) circle the emotion that best described their reaction to the drawings and (2) rate the drawings on 6 bipolar scales. Drawings from children classified as disorganized in infancy evoked positive emotion labels less often and negative emotion labels more often than those children classified as organized. Furthermore, drawings from children classified as disorganized in infancy received higher ratings on scales for disorganization, carelessness, family chaos, bizarreness, uneasiness, and dysfunction. These data indicate that naive observers are relatively successful in distinguishing selected features of drawings by children with histories of disorganized vs. organized attachment.