Child abuse and neglect. Influences of qualitative research and clinical practice on child-care legislation and policy.

In an early paper, the authors presented the findings of a qualitative research study which applied the self-psychological and object relations theories to the social and interpersonal dynamics surrounding adolescent sexual offending. One of the findings of the study was that informal and formal social responses to detected offenders encouraged the rapid foreclosure of deviant, bad and dangerous social, interpersonal and sexual identity and therefore militated against therapeutic personality reconstruction. The current paper widens the scope of such observations to include the victim, as well as the offender, and examines the role of the therapist in mediating between intrapsychic and interpersonal priorities carried within the offense dynamics and socially and legally defined exigencies surrounding child abuse. The authors suggest that appropriate devolution of therapeutic agency can be devolved to patients through the concept of the twinship transference while at the same time attending to necessary psychiatric, medical, social and legal processes.

The role of the vasculature in regulating venous return and cardiac output: historical and graphical approach.

PURPOSE: To review the physiology of cardiac output regulation by the peripheral vasculature. This will enable the clinician to understand and manage the complex circulatory changes in various forms of shock, and in other common altered circulatory states encountered in anaesthetic practice. SOURCE: Articles were obtained from a Medline review (1966 to present; search terms: shock, venous return, cardiac output) and a hand search (Index Medicus). Other sources include review articles, personal files, and textbooks. PRINCIPAL FINDINGS: At steady state, cardiac output is equal to venous return (VR). Venous return depends on mean systemic pressure (PMS), which is the pressure in the peripheral vasculature driving blood flow to the heart, right atrial pressure (PRA), and the resistance to venous return (RV). When considering VR, PRA is the downstream pressure to VR, and not simply an indirect measure of the volume status. The pressure gradient for VR is, therefore, PMS-PRA, and in a system obeying Ohm's Law, [formula: see text] Shock and other altered circulatory states cause changes in both VR and cardiac function. The circulation can be conveniently described by a venous return and a cardiac output curve. By drawing these curves for each clinical situation, a clear understanding of the altered circulatory state is obtained, and treatment options can be clearly defined. CONCLUSION: The peripheral circulation controls cardiac output in many clinical conditions. Manipulation of the peripheral circulation is as important to the successful treatment of shock and other altered circulatory states, as is the manipulation of cardiac output.

Adolescent sexual offenders: a self-psychological perspective.

Following a request for assistance in formulating a treatment philosophy for adolescent sexual offenders, a qualitative study of seven adolescent offenders was designed with a view to elaborating pre-offense, and post-offense dynamics. The point of departure was the hypothesis that sexual offending had relation to object relations. It was further hypothesized that offenders' object relations and self-development had been disfigured in childhood and adolescent development. The developmental theories of Mahler, Stern, Winnicott, and Kohut were reviewed in order to shed light on the connection between disfigured self-development and sexual offending. Mahler's work suggested that anomalies during the separation-individuation process were heavily implicated. Winnicott's thinking on transitional functioning in potential space and his employment of the concepts of the true self and false self were especially useful. These bodies of work were assimilated to Kohut's theory of self development in which three nuclear sectors of the self, namely, the grandiose-exhibitionistic sector, the idealizing-voyeuristic sector, and the twinship-alterego sector, gradually coalesce and cohere through the moderating influence of parental empathy with the child's developmental tasks. Where such empathy is unforthcoming, or when the normal parental functions are obliterated by traumatic experiences of abuse, unmoderated needs for exhibitionism and voyeurism continue through childhood, adolescence, and adulthood. Victims of sexual offending were hypothesized to perform functions of restoration and preservation of a chronically weak and threatened self. The sample's interview transcripts were qualitatively analyzed and aggregated. Analysis suggested that, indeed, offenses appeared to have been motivated to preserve a weakened sense of self and that the thoughts and perceptions surrounding the offenses resonated with expressions of problematic separation from parental objects. In addition, it was noted that in the post-offense period, offenders had become subject to close supervision, or proctoring, from both formal and informal systems. In close supervision, offenders tended to rapidly crystallize a foreclosed, negative, deviant sexual identity in defense of unmoderated narcissism. Other observations were that intrafamilial offending was consistent with enmeshment in the family, adjudication and apparent treatment readiness, while extrafamilial offending was consistent with exclusion from the family, no adjudication and resistance to treatment.