Seminar on Thursday, 12th October 2017

Forensic Psychology, Psychiatry and Psychotherapy Perspectives in Public Children Law.

Seminar Presentation by Dr Mark Fernando

Ladies and Gentlemen:   (this is how the classical literature of talks and lectures usually begin on these subjects of:  Psychology, Psychiatry and Psychotherapy.)

So, Ladies and Gentlemen:  my first objective here is to begin by discussing the rather fashionable and popular topic at Universities both in the United Kingdom and in the USA. The topic is about creating  “Safe Spaces.

My initial intention here is to create a clearly defined:     “Safe Space,”   which is quintessential to all of our work and particularly so, regarding these very highly delicate and sensitive subject topics. 

By us affirming that we are able to discuss all the ideas that are going to be presented both within, this abstract concept and also in real world situations of  “Safe Spaces,”   my hope and my very sincere wish is, that we are going to take these ideas away with us,  when we need to professionally understand,  to analyse and to process,  very highly difficult and complicated situations,  with very frequently traumatised and damaged people that are requiring our assistance.  I would like to suggest that having  “Safe Spaces,”   is particularly significant and very important in conducting work about Public and Private Family and Children Law.  The development of the both the concept and the actual reality of “Safe Spaces,”  can thus give every reassurance and confidence to all potential vulnerable Clients who have been the Victims of any traumatic or violent episodes in their lives.

It can be emphasised that “Safe Spaces,” can also provide particularly vulnerable, sometimes traumatised and bruised people, with an axiom of humility that is devoid of super-egos and which is not arrogant at all, but a humble approach towards understanding their very practical problems. 

This to some extent, can set out my very basic conceptual terms of reference.  This is my own approach towards this entire subject field and this is what I try and do:   1. To be understanding and to empathise with the Victim.  Which may mean to be Therapeutic, to what extent is possible.   2. To Forensically analyse the given situation, with as very much accuracy as is possible to obtain.

I would like to mention that the meaning of the word “Forensic,” is being used here by me to define a wide range of Forensic Psychology, Psychiatry and Psychotherapy perspectives and circumstances.   All these perspectives and circumstances are relevant or related, to Family and Child Law.

Regarding the materials that I am including with this talk and as posted in the accompanying website, there are comparative examples from other countries, such as Iceland, Sweden, Australia, the USA, from mainland Europe and from some other regions of the world.   These examples are given for comparative use, to discover the views from other nations of the world also, regarding some of these same topics. 

I do need to warn you, that there are some aspects of the research and the materials that are included here, that you may find somewhat distressing, whilst you may also find some of the opinions and the views that are included here, controversial and that you may disagree with.

My attempts here and in this entire subject field, are to try and be Therapeutic whilst finding out what is True.   Truth and Truth -Telling is quintessential.  Honesty, Integrity, Veracity and the Reliability of Facts, if possible with Evidence, is what exactly is needed. I believe that this is also a contributory factor to a Healing process.  Whereas, Falsehoods, Dishonesty, Planted Memories and what is Untrue, can only lead to the further damage of the Victim that is involved. 

There are also very deep Moral, Ethical, Ontological, Epistemological and Philosophical implications regarding the need for seeking the Truth, rather than Fiction, for all the Cases involved.

In this talk, I am going to try and cover many different aspects and topics that are related to these subject fields, albeit rather briefly.

There are website hyperlinks that are included in the handout and on the seminar website given, that you may wish to read for more details.

About the social and clinical sciences theoretical position that I am taking, it is my own opinion, that it is practically possible to be both Forensic in perspective, whilst at the same time being Therapeutic and Healing, to whatever extent is possible.     

The following books give the main themes to be discussed in this talk:


The Forensic Interviewing of Children

1.1. From Barnahús – The Children´s House.”  Child Forensic Interviews:   Margrét Kristín Magnúsdóttir,  Psychologist and Forensic Interviewer.   Based on her forensic research and methodology from Iceland.

Click to access Barnahus,-an-overview.pdf

Click to access Child-Protection-Act-as-amended-2015.pdf

Click to access childrens-house-brocure.pdf

Click to access Child-Protection-in-Iceland-and-the-role-of-the-Government-Agency-for-Child-Protection.pdf

Click to access VidogborninokkarIslEn.pdf

1.2.  Child Interviews:  Forensic child interviews must be both formal and structured interviews.  The highly skilled techniques that are used to investigate whether a child has experienced or witnessed physical or sexual abuse and if so, to get disclosure. The correct and truthful experience of the child.

1.3. If a child discloses, then to assist the child in providing a sufficient narrative and detailed information: on the nature and the extent of the abuse, including details of those responsible and to take sufficient details of the event to allow for appropriate action to be taken.

1.4. The goal of the child forensic interview is to get maximum information, from the child,  whilst causing the minimum of stress and without the contamination of the evidence whatsoever.  Including ensuring that no false memories are planted by anyone involved, even inadvertently.

1.5.  The importance of  “child friendly” settings.  Ideally, a special well designed and suitable interview room.  The specialised interviewer needs to be a forensic psychologist, a forensic psychotherapist, or a similar professional.

1.6.  Expressions of emotions in a comfortable environment. The kind assessment of the child:  to discover whether the child is telling the truth.  Subjective interpretations regarding nonspecific accounts of abuse, can sometimes be sufficient.  The credibility of the child can be found out by both Forensic and Therapeutic Interviewing.  The goal and aim is discovering the truth, the facts from an objective standpoint.  Alternative explanations can be explored in obtaining corroborating details.  Whilst it is imperative to establish the child’s competency to tell the truth.

1.7.  Interview Stages and Introduction Rapport: – developmental assessment – competence assessment – ground rules.  Transitioning to a topic of concern.   Detail gathering and corroboration:  one event at a time.

Introduction:  Interviewer introduce him-/or herself and people present.  Explain the documentation (video/dvd recorded, notes taking).  Have child introduce him-/or herself; name, age, where they live, with whom, school, grade, their friends, etc.

1.8.  Rapport building:  Developmental assessment – age dependent (time, date, soft/hard, smaller/bigger) – body parts inventory.  Competence assessment – difference between truth and lies.  Ground rules – if I ask you the same question more than once – if you don’t know the answer – if you don’t understand the question – correct me if I’m wrong. Transitioning to the topic of concern: “Tell me why you are here today talking to me ?” open-ended invitation use, the child words followed by focused follow-up questions,  “… tell me all about that” “… tell me everything about that from the beginning to the end.”

1.9.  Gather details and corroboration, “did (this) happen one time or more than one time ?” focus on one event at a time, (last, first, most memorable, worst, etc.) who, what, where, how,… when (young children can’t answer that) five senses what was said how it started, how it ended.

Corroboration: computers, cameras, phones, force or coercion, bribes, clothing,  other things from the child’s narrative.

Once you have details on individual events… be sure to clarify details between different events,  ask any follow up questions necessary for you to understand what happened.  Ask the child if there is something you forgot to ask,  or something else they want to talk about in transition to closure.

1.10. Closure of the Interview:  maintain trust and rapport with the child,  a neutral topic (cool down). Does the interviewer put the child at ease?  Warm and friendly presence.  Strong presence that shows:  “you can tell me anything and I can handle it.“ “tell me …“ vs. “can you tell me …? “ “everything“ vs. “a little bit?“ Gentle persistence – knowing when to push for answers, as well as knowing when to stop. Pacing – allowing for silences.  Use of developmentally appropriate language. There is no such thing as a perfect interview!

Forensic Interviewing of Traumatised Children

2.1.  “Interviewing Traumatised Children”  Based on research by: Karen Gabriel.  LEGAL AID NSW CHILD REPESENTATION CONFERENCE, New South Wales, Australia.

On hope and opportunity for change for traumatised children:  Dr Bruce Perry says:  “The hallmarks of transforming therapeutic interaction are:  safety, predictability and nurturance.  Sometimes the most  ‘therapeutic’ interactions often come from people who have no training (or interest) in psychological or psychiatric labels, theories or treatment and adult expectations of the child that go with these.  In interacting with the child, respect, humour and flexibility,  can allow the child to be valued as what they are”.  Bruce.D Perry, MD, PHD in The Child Trauma Academy, “Understanding Traumatised and Maltreated Children: The Core Concepts.”

2.2. Planning the interview:  What information do you already have about the child/children’s experiences?  Who else can you talk to about the child?  Parents, carers, teachers, counsellors, caseworker, family GP/MD consultant.  Do you need to interview the child?  Will you interview the child on your own? Or with someone else? (counsellor, family GP/MD consultant). Place of interview: Privacy for the child. Child friendly interview room.  Prepare yourself: Life for traumatised children is often chaotic and you need to be a calm adult.  Allow sufficient time: you can’t rush the interview.  Build rapport, engage and get to know the child.  No set formula: playing with child dolls, drawing, talking.  Use developmentally appropriate language, recognise potential for impaired cognitive functioning.  Be clear about the purpose of your interview and explain to the child to some extent.  Monitor the child’s behaviour and provide appropriate boundaries and limits for unsafe behaviour.

 2.3.  The interview:  Know your limitations. You need to respect that some children will not want to talk to you.  Listen to and reassure the child. Seek further advice if you need to.  Be mindful of disclosure of new information from the child.

2.4.  Ending the interview:  Summarise for the child the main points of discussion.  Check with the child that you have understood.  Be clear about your future role?  What happens next?  Importantly, be truthful and make no false promises to the child.

3.1. Based upon:  “Training of police officers in Sweden -the development of interview behaviour.”  by Professor Ann-Christin Cederborg, Department of Child and Youth Studies, Stockholm University, Sweden.  Ann-Christin Cederborg’s reasons for this are due to police officers in Sweden that have been criticized by judges, prosecutors, psychologists and social workers,  for their undeveloped interview practice with children. Previous research findings mostly from Sweden,  but also from studies of forensic interviewing in other countries,  have influenced the Swedish Government’s ambition to financially support interview training of police officers. Police officers have also asked for further training in how to interview children.

3.2. In previous findings, police officers seldom used open questions when interviewing alleged child witnesses. Instead, they to a large extent, used option posing and suggestive questions. Even previously trained police officers in Sweden, relied heavily on option posing and suggestive questions. The need of a ”new” training program: The training program should enhance the quality of information provided by young victims. The new Swedish training program was inspired by NICHD protocol where the police officers are trained to structurally ask as many invitations as possible throughout the interview and the PEACE model specifically in terms of how to evaluate performances.

4.1.  In the United Kingdom,  a very helpful website for current guidelines regarding Forensic Child Law,  can be found at:

Guidance on Investigating Child Abuse and Safeguarding Children,  Second Edition,  2009  by The National Policing Improvement Agency.


This is the current UK Government publication that is very helpful regarding this subject field and the wider topics within this subject area.


These are February 2017  additions and revisions to the UK Government Policy Guidelines about these subject fields.


The United Kingdom College of Policing website also gives very highly detailed current guidance as to the interviewing of minors, as the Authorised Professional Practice, for all UK Police Forces.


These are also very helpful current 2017,  websites that are either UK Government websites,  or commissioned by the UK Government to publish on these subjects.

5.1.   Based on the research work about, “Child Interviewing in Scotland,”  by Deirdre Brown, Sonja Brubacher, Ann-Christin Cederborg, Coral Dando, Fiona Gabbert, John Halley, Carmit Katz, Michael Lamb, Amina Memon, Lindsay Malloy, Janice Murray, Annabelle Nicol, Robert O’Shea, Yael Orbach, Mel Pipe, Anne Ridley, Heather Stewart,  Scottish Institute for Policing Research, UK North East Scotland Child Protection Committee, Children’s Memory Research Project at Otago University, NZ,  and The National Institute of Child Health and Human Development, USA.

5.2.  Scottish Guidelines emphasise using open prompts. Open prompts (Invitations) – “Tell me what happened” – “Tell me more about that” – “Tell me everything about that” – “Then what happened” – “What happened next”.  Open prompts = research based recommendation – Open prompts elicit longer more detailed responses than closed and specific questions – Serve as evidence-in-chief – Information provided to open prompts is the most accurate (irrespective of age & delay) – Open prompts are non-suggestive – Difficult for defence to criticise the use of open prompts.

5.3.  Specific/focused questions are less accurate.  They cause contradictions.  Children try to answer questions they don’t understand.  Specific questions tap cued-recall memory. Children have difficulty with some concepts, e.g., – Behind/in front/over/under – Before/after – Times/dates/ages – Size/height/weight – Same/different – Neither/either – He/she/they.  For example:  “My dad puts fast petrol in the car so it goes bigger?” (4yo boy).

 5.4. Open Prompts (frequency):  Do you begin the main part of the interview by asking the child to provide a full account of what has happened?

Specific Questions (frequency):  Do you follow-up what is said by the child by asking specific what, when, where type questions? E.g., “where were you when you played this game?”

Specific questions (effectiveness):  If you do follow-up what is said by the child by asking specific questions, do you find this effective at finding out more about what happened?

5.5.  Interviews conducted between November 2003 & February 2011:   Interviews used as evidence in criminal and civil cases involving alleged abuse between April 2010 and April 2012.  37 interviews conducted with 25 children throughout Scotland Children aged 4 to 13 years 19 females & 6 males (2012).    The percentage of each ground rule used in the interviews:  Demonstrate ‘truth and lies’ “Don’t guess, say, ‘I don’t know’” “Correct me if I make a mistake” “If you don’t understand me say so” “It is important to tell the truth”.  Percentage Joint Investigative Interviews with children between November 2003 and February 2011 (N=37).  Ground rules remove pressure that the interviewee should provide answers if they are not sure about what happened.

5.6.   Recommendation regarding ‘practice interview’ before allegations are discussed – e.g., ‘brain training’.  Did interviewers use a practice interview? No practice interviews were conducted or recorded in the 37 interviews Joint Investigative Interviews with children between November 2003 and February 2011 (N=37).
Open-ended prompts Directives:  Option posing & yes/no Suggestive 8%,  39%,  36%,  17%.  The percentage of interviewer prompts and questions used in the substantive phase of the interviews (similar findings in other jurisdictions) Joint Investigative Interviews with children between November 2003 and February 2011 (N=37).
The percentage of interviewer prompts and questions used in the substantive phase of interviews with children (N=9). Preliminary field research (Tayside) (Nicol, La Rooy & Gabbert).

6.1.  The NICHD Protocol (2000),  Prof Michael Lamb Cambridge:

The NICHD Protocol (2000):   Using the same standardized approach with all children has advantages – It gives every child an equal opportunity to disclose or not disclose alleged abuse – Personal biases are minimized – Assists in efforts to maintain desirable interview standards over time – reduces skill fade – 3 x number of open prompts compared to non-protocol – Results in 75% to 88% disclosure rate (4 to 13 yo) – 50% increase in chance that charges are filed – 94% guilty verdicts (vs. 46% for non-protocol interviews) – Validated in over 40,000 interviews worldwide – Not currently used in Scotland.


NICHD Protocol     International Evidence-Based Investigative Interviewing of Children.  National Institutes of Health, USA:  National Institute of Child Health and Human Development.


Based on the research in:   “Allegation rates in forensic child abuse investigations: Comparing the Revised and Standard NICHD Protocols,” By Irit Hershkowitz,  University of Haifa, Israel,  Michael E. Lamb & Carmit Katz, University of Cambridge, United Kingdom.


(n=426):  4- to 13-year-old suspected victims of intra-familial abuse were interviewed using either the NICHD Investigative Interview Standard Protocol (SP) or a Revised version of this Protocol (RP) designed to both enhance rapport between children and interviewers and provide additional non-suggestive support to suspected victims who might be reluctant to make allegations. All allegations were corroborated by independent evidence documenting that the alleged abuse had indeed taken place. Analyses revealed that children were significantly more likely to make allegations of abuse when the RP rather than the SP was employed. These results suggest that supportive forensic interviewing may facilitate valid reports of abuse by young victims who might otherwise be unwilling to make allegations.


“The NICHD protocol: a review of an internationally-used evidence-based tool for training child forensic interviewers.”  David La Rooy, Sonja P. Brubacher, Anu Aromäki-Stratos, Mireille Cyr, Irit Hershkowitz, Julia Korkman, Trond Myklebust, Makiko Naka, Carlos E. Peixoto, Kim P. Roberts, Heather Stewart & Michael E. Lamb.

The Modified Stockholm Syndrome and the Modified Helsinki syndrome in Childrens Forensic Cases.


Stockholm syndrome (sometimes referred to as Helsinki syndrome)   is a condition that causes hostages to develop a psychological alliance with their captors as a survival strategy during captivity. These feelings, resulting from a bond formed between captor and captives during intimate time spent together, are generally considered irrational in light of the danger or risk endured by the victims. Generally speaking, Stockholm syndrome consists of strong emotional ties that develop between two persons where one person intermittently harasses, beats, threatens, abuses, or intimidates the other.


Formally named in 1973 when four hostages were taken during a bank robbery in Stockholm, Sweden.  Stockholm syndrome is also commonly known as “capture bonding”. The syndrome’s title was developed when the victims of the Stockholm bank robbery defended their captors after being released and would not agree to testify in court against them. Stockholm syndrome’s significance arises because it is based on a paradox, as captives’ sentiments for their captors are the opposite of the fear and disdain an onlooker may expect to see as a result of trauma.


There are four key components that generally lead to the development of Stockholm syndrome:

  • A hostage’s development of positive feelings towards their captor.

  • No previous hostage-captor relationship.

  • A refusal by hostages to cooperate with police forces and other government authorities.

  • A hostage’s belief in the humanity of their captor, for the reason that when a victim holds the same values as the aggressor, they cease to be perceived as a threat.

    The Modified Lima syndrome in Children’s Forensic Cases.

    9.1. Lima syndrome: A similar form of Stockholm syndrome called Lima syndrome has been proposed, in which abductors develop sympathy for their hostages. There are many reasons why Lima syndrome can develop in abductors.Sometimes when there are multiple abductors, one or more of them will start to disagree with what they are doing and influence one another.  An abductor may also have second thoughts or experience empathy towards their victims.

    9.2. Symptoms and behaviours for Lima syndrome:  Victims of the formal definition of Stockholm syndrome develop “positive feelings toward their captors and sympathy for their causes and goals, and negative feelings toward the police or authorities.”These symptoms often follow escaped victims back into their previously ordinary lives.  For Lima syndrome,  same affects abductors.

    9.3. Coping mechanisms for Stockholm and Lima syndromes:From a psychoanalytic lens, it can be argued that Stockholm syndrome arises strictly as a result of survival instincts. Strentz states, “the victim’s need to survive is stronger than his impulse to hate the person who has created the dilemma.” A positive emotional bond between captor and captive is a “defence mechanism of the ego under stress”. These sentimental feelings are not strictly for show, however. Since captives often fear that their affection will be perceived as fake, they eventually begin to believe that their positive sentiments are genuine.

    9.4.  Stockholm syndrome is not merely a condition developed in victims of kidnappings or hostage instances. It can also be applied to a wider variety of situations, afflicting victims of domestic or child abuse, human trafficking, and incest. Prisoners of war, political terrorism, cult members, concentration camp prisoners, slaves and prostitutes, can also fall prey to Stockholm syndrome.  Typically, Stockholm syndrome develops in captives when they engage in “face-to-face contact” with their captors, as well as when captors make captives doubt the likelihood of their survival by aggressively terrorizing them into “helpless, powerless, and submissive” states. This enables captors to appear to be nice people when captors perform acts of “kindness” upon, or fail to beat, abuse, or rape the victims.

    Battered person syndrome (BPS)

    10.1.Battered person syndrome (BPS) is a physical and psychological condition of a person who has suffered (usually persistent) emotional, physical or sexual abuse,  from another person. The condition was first researched extensively by Lenore E. Walker, who used Martin Seligman’s research about:  Learned Helplessness Theory,  to explain why some abused spouses and children stay in destructive relationships.

    10.2. When battered person syndrome (BPS) manifests as PTSD, it consists of the following symptoms: (a) re-experiencing the battering as if it were recurring even when it is not, (b) attempts to avoid the psychological impact of battering by avoiding activities, people, and emotions, (c) hyperarousal or hypervigilance, (d) disrupted interpersonal relationships, (e) body image distortion or other somatic concerns, and (f) sexuality and intimacy issues.


    Additionally, repeated cycles of violence and reconciliation can result in the following beliefs and attitudes:

    • The abused thinks that the violence was his or her fault.

    • The abused has an inability to place the responsibility for the violence elsewhere.

    • The abused fears for her/his life, and/or, the lives of loved ones whom the abuser might or has threatened to harm (e.g., children-in-common, close relatives or friends).

    • The abused has irrational beliefs about the abuser and about the power that the abuser holds over the victim/victims.

Post traumatic stress disorder (PTSD)


Post traumatic stress disorder (PTSD)  is a mental disorder that can develop after a person is exposed to a traumatic event, such as sexual assault, warfare and other traumatic situations.  These symptoms last for more than a month after the event. Young children are less likely to show distress but instead may express their memories through play.   A person with PTSD is at a higher risk for suicide or and intentional self-harm.


Most people who have experienced a traumatic event will not develop PTSD. People who experience interpersonal trauma, for example rape or child abuse, are more likely to develop PTSD, as compared to people who experience non-assault based trauma such as accidents and natural disasters. About half of people develop PTSD following rape. Children are less likely than adults to develop PTSD after trauma, especially if they are under ten years of age. Diagnosis is based on the presence of specific symptoms following a traumatic event.

The research by Dr Susan A. Clancy at Harvard Medical School, Harvard University shows,  a more complicated Child Forensic Psychology situation.  Dr. Clancy argues that there is no initial Post Traumatic Stress at the time of the Child experiencing the abuse or violence.  The concepts of the Modified Stockholm and the Modified Lima Syndrome can be noted from the research of Dr. Clancy.  Where the Child does not experience initial PTSD, but may have reverse feelings, particularly if the situation is within a family circumstance.

Dr Clancy’s  more complicated and much more intricate Child Forensic research describes that, whilst there may not be initial Post Traumatic Stress at the time of the Child experiencing the abuse or violence,  there can be effects that need Psychotherapy treatments at a future Adult stage of life, if these effects linger later in a person’s life.  She does discuss in her research very explicit details of research topics such as: 1. What was it like when it happened?  2. The truth about sexual abuse. 3. The politics of sexual abuse.  4. Why the trauma myth damages the victims. 5. How the trauma myth silences victims.

Munchausen’s Syndrome, the making up of falsehoods and Munchausen Syndrome by Proxy.


Munchausen’s syndrome is a psychological disorder where someone pretends to be ill, deliberately produces symptoms of illness in themselves or tells lies more generally.   This is a very serious disorder and can have very serious effects upon the victims of such accusations.

Munchausen’s syndrome is named after a German aristocrat, Baron Munchausen, who became famous for telling wild, unbelievable tales about his exploits.


Munchausen Syndrome by Proxy (MSBP) or Fabricated or induced illness (FII) can be a form of child abuse. It occurs when a parent or carer, usually the child’s biological mother, exaggerates or deliberately causes symptoms of illness in the child. Or others are accused by Proxy.

FII is also known as ‘Munchausen’s syndrome by proxy’.

The correct name for MSBP is now factitious disorder imposed on another (FDIA). If the person invents illness for themselves, this is factitious disorder imposed on self (FDIS).

Detailed current research that is helpful for Forensic Psychology, Psychiatry and Psychotherapy Perspectives in Public Children Law:

Introduction to the Special Issue on Adolescent and Young Adult Health: Why We Care, How Far We Have Come, and Where We Are Going  Katie A. Devine, PhD Maureen Monaghan, PhD, CDE Lisa A. Schwartz, PhD

Journal of Pediatric Psychology, Volume 42, Issue 9, 1 October 2017, Pages 903–909,

This special issue on adolescent and young adult (AYA) health comprises 15 original articles. The special issue recognizes the importance of AYA-focused research, highlights unique issues across the AYA period, and showcases cutting-edge research focused on AYAs. We describe the rationale for focusing on the AYA population, themes of the special issue, and future directions.

Pediatric Consultations: Negative-Word Use and Parent Satisfaction

Marco Gemmiti, PhD Selei Hamed, MD Johannes Wildhaber, PhD Cosette Pharisa, PhDPetra L. Klumb, PhD

Journal of Pediatric Psychology, jsx061,

Published:  21 March 2017

Objective: This study investigates the impact of pediatricians’ negative-word use on parents’ affective quality and satisfaction judgements during the medical encounter. Methods: In total, 68 medical consultations were videotaped and pediatricians’ communication transcribed for analysis. We used the Linguistic Inquiry and Word Count application to measure the amount of negative words used by the pediatrician. Parents rated their momentary mood as well as their satisfaction at the end of the encounter.

Results: Pediatricians’ negative-word use was negatively linked to parents’ affect quality, but not with the satisfaction ratings after the medical visit. Although there was no direct effect, our results revealed an indirect effect of pediatricians’ negative-word use on parents’ satisfaction via parents’ mood. Conclusions: The results point to the negative impact that words used during the medical encounter can have on individuals in need of care. Consequently, this is relevant for clinical training and practice.

Child Executive Control as a Moderator of the Longitudinal Association Between Sleep Problems and Subsequent Attention-Deficit/Hyperactivity Disorder Symptoms

Katherine M. Kidwell, MA Maren Hankey, MA Jennifer Mize Nelson, PhDKimberly Andrews Espy, PhD Timothy D. Nelson, PhD

Journal of Pediatric Psychology, jsx071,

Published:  06 April 2017

Executive function and self-regulation skills are the mental processes that enable us to plan, focus attention, remember instructions, and juggle multiple tasks successfully. Just as an air traffic control system at a busy airport safely manages the arrivals and departures of many aircraft on multiple runways, the brain needs this skill set to filter distractions, prioritize tasks, set and achieve goals, and control impulses.

Objective: To examine the longitudinal associations among sleep, executive control (EC), and attention-deficit/hyperactivity disorder (ADHD) symptoms in childhood. Methods: In this longitudinal study (N = 271), parents answered questions about sleep problems when children were 3 years old, children completed a comprehensive EC task battery at 4.5 years, and teachers completed standardized measures of child ADHD symptoms in 4th grade.

Results: Latent moderated structural equation models demonstrated that sleep problems at 3 years and EC deficits at 4.5 years were associated with ADHD symptoms in 4th grade. EC moderated the relationship between sleep problems and hyperactivity/impulsivity, such that children with both sleep problems and poor EC were particularly at risk for hyperactivity/impulsivity. Conclusions: Sleep problems and EC deficits early in development were associated with increased risk for ADHD symptoms in elementary school. Early assessment and intervention to promote healthy sleep and EC development may be helpful in ADHD prevention.

Clinical trial registration in fertility trials – a case for improvement? 
Cynthia M. Farquhar Marian G. Showell Emily A.E. Showell Penny BeethamNora Baak Selma Mourad Vanessa M.B. Jordan
Human Reproduction, Volume 32, Issue 9, 1 September 2017, Pages 1827–1834,
28 July 2017
What is the prevalence and source of prospectively and retrospectively registered and unregistered trials in fertility treatments?
Trial registration is low and does not appear to be changing over the 5 years studied.
Trial registration is associated with lower risk of bias than in unregistered trials.


The Cochrane Gynaecology and Fertility Group’s specialised register was searched on 5 November 2015 for randomised controlled trials (RCTs) published from January 2010 to December 2014.


Eligible trials included randomised women or men for fertility treatments, were published in full text, and written in English. Two reviewers independently assessed trial registration status for each trial, by searching the publication, trial registries, and by contacting the original authors.


Of 693 eligible RCTS, only 44% were registered trials. Of 309 registered trials, 21.7% were prospectively registered, 15.8% were registered within 6 months of first patient enrolment and 62.5% were retrospectively registered trials. Prospective trial registration by country varied from 0% to 100%. The highest frequency of prospective trial registration amongst the top 10 publishing countries was 31% in the Netherlands.

Image-Based Sexual Abuse   Clare McGlynn Erika Rackley

Oxford Journal of Legal Studies, Volume 37, Issue 3, 1 September 2017, Pages 534–561,     Published:    31 January 2017

Advances in technology have transformed and expanded the ways in which sexual violence can be perpetrated. One new manifestation of such violence is the non-consensual creation and/or distribution of private sexual images: what we conceptualise as ‘image-based sexual abuse’. This article delineates the scope of this new concept and identifies the individual and collective harms it engenders. We argue that the individual harms of physical and mental illness, together with the loss of dignity, privacy and sexual autonomy, combine to constitute a form of cultural harm that impacts directly on individuals, as well as on society as a whole. While recognising the limits of law, we conclude by considering the options for redress and the role of law, seeking to justify the deployment of the expressive and coercive powers of criminal and civil law as a means of encouraging cultural change.

The Provision of Healthcare to Young and Dependent Children: The Principles, Concepts, and Utility of the Children Act 1989

Jo Bridgeman

Medical Law Review, Volume 25, Issue 3, 1 August 2017, Pages 363–396,

Published:   14 June 2017

This article undertakes a thorough analysis of the case law concerned with the provision of healthcare to young and dependent children. It demonstrates how, despite the procedural changes introduced by the Children Act 1989 at an early stage in this body of case law, cases have continued to be brought to court by way of applications for the court to exercise its inherent jurisdiction or in wardship rather than using the orders introduced by the Act.

In determining these cases, the court is focused upon its protective duty to the vulnerable but proceedings appear to be adversarial contests between the claims of adults to know what is best for the child in which the medical view normally prevails. Through consideration of the principles and concepts of the Children Act of parental responsibility, working together, the welfare principle and placing the child at the centre of care, this article demonstrates their utility, as yet to be fully realised, in relation to the responsibilities of parents, professionals, public authorities, and the courts concerned with the provision of healthcare to young and dependent children.

Seeking Certainty? Judicial Approaches to the (Non-)Treatment of Minimally Conscious Patients   Richard Huxtable Giles Birchley

Medical Law Review, Volume 25, Issue 3, 1 August 2017, Pages 428–455,

Published:  18 April 2017

A modest, but growing, body of case law is developing around the (non-)treatment of patients in the minimally conscious state. We sought to explore the approaches that the courts take to these decisions. Using the results of a qualitative analysis, we identify five key features of the rulings to date. First, the judges appear keen to frame the cases in such a way that these are rightly matters for judicial determination. Secondly, the judges appraise the types and forms of expertise that enter the courtroom, seeming to prefer the ‘objective’ and ‘scientific’, and particularly the views of the doctors.

Thirdly, the judges appear alert to the reasonableness of the evidence (and, indeed, the parties) and will look favourably on parties who are willing to co-operate. But the judges will not simply endorse any consensus reached by the parties; rather, the judges will reach their own decisions. Those decisions must be taken in the best interests of the patient. Fourthly, the judges approach this assessment in different ways. A balancing exercise is not consistently undertaken and, even in those cases in which it is, the weight accorded to particular factors varies. As we discuss, the consistency and predictability of the law in this area is open to question. Finally, however, we cautiously suggest that some consistent messages do begin to emerge: the courts’ apparent preference for certainty in diagnosis and prognosis provide pointers for how cases might be decided.

The courts are much inclined to speak of the welfare principle as an absolute standard and an unproblematic concept which can act as a panacea for all ills affecting children. This is not altogether surprising since it is they who get to define its content in any given situation … [I]t becomes apparent that the process fails to establish coherent and consistent principles to govern matters which … are important issues of public policy.1

1. A Bainham, ‘Handicapped Girls and Judicial Parents’ (1987) 103 L Quart Rev 334, 339.

Bainham’s remarks were made in 1987 and were directed specifically towards the judges’ approaches to determining the welfare or ‘best interests’ of children. Despite three decades of judicial and legislative developments, his comment appears no less pertinent today, and not only to judges’ decisions about minors.2 In this article, we explore judicial decisions about the best interests of incapacitated adults, specifically those in the minimally conscious state (MCS). Patients with this disorder of consciousness have increasingly come before the courts for a decision about their treatment and, in particular, non-treatment. We explored all of the rulings up to July 2016 we could find in English law involving these patients, with a view to identifying the courts’ approaches to these cases. This is not an arid critical exercise. There are estimated to be 12,000–48,000 patients in the MCS in the UK;3 treatment might well continue for many of these patients but there will be some for whom non-treatment is being contemplated, so the messages emanating from the English courts might have import for a great many patients, as well as their loved ones, healthcare professionals and others who are providing them with care and treatment.4

Our current understanding of disorders of consciousness can be traced back to the intensive efforts of medical scientists in the 1950s.5 Various types of disorder are nowadays recognised, of which three need explanation here. In coma, the patient is unresponsive, his or her eyes are closed and movement is limited to reflexive responses.6 Having been recognised by the Ancient Greeks, systematic diagnosis of coma developed from the mid-19th century.7 The vegetative state (VS) was first recognised in 1940,8 with the term ‘persistent vegetative state’ (PVS) following in 1972, to refer to those who remained in this state for long periods.9 In PVS, patients spontaneously open their eyes in the course of normal sleep and waking cycles, but show no signs of awareness. They show signs of arousal, which may manifest in laughing, crying or violent movement (for example), but this is not in response to external stimuli, so is not consistently reproducible. Nowadays, guidance from the Royal College of Physicians stipulates that VS is to be described as ‘continuing’ (rather than ‘persistent’) if it lasts more than 4 weeks, and ‘permanent’ if it lasts more than 6 months following head injury or 12 months when arising from another cause.10

By the 1990s, queries about the prognostic value of a PVS diagnosis and gathering evidence of awareness in some patients diagnosed with PVS was prompting disquiet amongst some of those working in neurological rehabilitation.11 The ‘minimally conscious state’ (MCS) emerged as the definitive term to describe some of these patients in a 2002 diagnostic guideline.12 Patients in MCS show limited, but consistent and reproducible, signs of awareness. These signs may include visually tracking objects, bodily movements, vocalisations and speech, and diagnosis is generally made using the Sensory Modality Assessment and Rehabilitation Technique (SMART) and the Wessex Head Injury Matrix (WHIM) tools. Given their limited consciousness and awareness, patients in the VS or MCS require support from professional, as well as unpaid or familial, carers. As they are unable safely to eat or drink by conventional means, patients will be reliant on clinically-assisted nutrition and hydration (CANH) ie some form of tube feeding. Feeding tubes will sometimes become displaced or need to be replaced, necessitating decisions about whether or not re-insertion should occur. And sometimes those close to the patient will seek to have tube-feeding withdrawn.

The law obviously has a stake in such life-or-death decisions. Indeed, medical law has a longstanding interest in disorders of consciousness and the dilemmas associated with treating patients with such disorders. The New Jersey Supreme Court ruling in Quinlan in 1976, which concerned the (non-)treatment of a patient in the PVS, is arguably one of the key starting points in the development of this distinct field of law.13 In the past two decades, decisions like these have increasingly come before the English courts, with numerous high-profile rulings addressing the treatment that such patients should (not) receive. English law first took a position on the withdrawal or withholding of life-support from patients in the PVS in the Bland ruling in 1993.14 Breaking legal ground in this jurisdiction, the Lords decided that the withdrawal of CANH was permissible in the ‘best interests’ of Anthony Bland. The Lords signalled that future such cases would require judicial determination, a requirement that remains in place,15 despite the misgivings of some commentators.16Indeed, Bland remains the leading ruling in this area, notwithstanding the changes effected by the Mental Capacity Act 2005,17  which came into force in 2007.

Of course, Bland concerned a patient in the (P)VS. MCS was first mentioned in court in 2002, in A v H,18 in which a neurologist posited a diagnosis of MCS in a PVS patient, due to the presence of features incompatible with the diagnostic guidelines for PVS. A declaration approving the removal of CANH was nevertheless issued. This is not the only case to have come before the courts in which some of the criteria for diagnosing PVS have not been met, but the diagnosis was nevertheless accepted, and treatment withdrawn.19 However, MCS has since been confronted squarely,20and further cases can be anticipated because, since 2007, the withdrawal of CANH from these patients must also be decided in court.21

The courts’ decisions in this area are nowadays governed by the Mental Capacity Act 2005. According to this Act, incapacity involves the inability to make or communicate a particular decision due to ‘an impairment of, or a disturbance in the functioning of, the mind or brain’.22

Capacity is to be presumed,23 but this may be found lacking where the individual is unable ‘(a) to understand the information relevant to the decision, (b) to retain that information, (c) to use or weigh that information as part of the process of making the decision, or (d) to communicate his decision’.24 A patient who lacks capacity can seek to determine (or at least influence) his or her future treatment by making an advance decision to refuse treatment or by conferring a lasting power of attorney.25 Recipients of the latter are, however, required to make their decisions in the patient’s best interests—and this is the standard that generally governs if the patient has not conferred such a power or issued an advance decision. The Mental Capacity Act sets out a checklist of factors to consider when determining the best interests of incapacitated adults, which requires reference to ‘the person’s past and present wishes and feelings (and, in particular, any relevant written statement made by him when he had capacity)’, ‘the beliefs and values that would be likely to influence his decision if he had capacity’, and ‘the other factors that he would be likely to consider if he were able to do so’.26

Medical Law Review, Volume 25, Issue 3, 1 August 2017, Pages 526,
Published:  17 August 2017

S Huline-Dickens, A Clinician’s Brief Guide to Children’s Mental Health Law (Royal College of Psychiatrists, 2016).

A Kirkland, Vaccine Court: The Law and Politics of Injury (New York University Press, 2016).

J Laing, J McHale (eds), Principles of Medical Law 4th ed. (Oxford University Press, 2017).

Seeking Certainty? Judicial Approaches to the
(Non-)Treatment of Minimally Conscious Patients
Richard Huxtable Giles Birchley
Medical Law Review, Volume 25, Issue 3, 1 August 2017, Pages 428–455,

Gemma Turton, Evidential Uncertainty in Causation in Negligence
2016, Hardback,  245pp., £54.99, ISBN 9781509900329.
Review by Craig Purshouse
Medical Law Review, Volume 25, Issue 3, 1 August 2017, Pages 511–515,
Published:  10 March 2017.

Anyone who has glanced at the law reports recently will share Gemma Turton’s view that ‘the approaches of courts and academics to the doctrine of causation have become increasingly complicated and confused’ (p 1). Evidential Uncertainty in Causation in Negligence aims to rectify this and will, therefore, be of interest to readers of the Medical Law Review. After all, many of the leading appellate cases on causation have arisen in the clinical setting. Unlike in, say, a running-down case where a healthy person is left with a broken arm, the claimant in a clinical negligence case will usually already be ill before they have had any contact with a careless healthcare professional.

Psychiatric Injury Claims and Pregnancy: Re (a Minor) and Others v Calderdale & Huddersfield NHS Foundation Trust [2017] EWHC 824  Jaime Lindsey   Medical Law Review, fwx041,
Published:  12 September 2017
RE and others concerned a clinical negligence claim against the Defendant NHS Trust by a baby injured during childbirth, as well by her mother and grandmother for psychiatric injury found to have been caused by those events. This commentary focuses on the claim for psychiatric injury by the mother and grandmother, both of which succeeded on the basis that the childbirth was a sufficiently shocking and horrifying event. This commentary urges caution about this development based on how it represents law’s view of childbirth and the growth of claims that might result from any expansion of liability in this area.

Using and Disclosing Confidential Patient Information and the English Common Law: What are the Information Requirements of a Valid Consent?
Victoria Chico and  Mark J. Taylor
Medical Law Review, fwx038,
Published:  17 August 2017
The National Health Service in England and Wales is dependent upon the flow of confidential patient data. In the context of consent to the use of patient health data, insistence on the requirements of an ‘informed’ consent that are difficult to achieve will drive reliance on alternatives to consent. Here we argue that one can obtain a valid consent to the disclosure of confidential patient data, such that this disclosure would not amount to a breach of the common law duty of confidentiality, having provided less information than would typically be associated with an ‘informed consent’. This position protects consent as a practicable legal basis for disclosure from debilitating uncertainty or impracticability and, perhaps counter-intuitively, promotes patient autonomy.

While a considerable literature has been generated around the subject of consent, there has been relatively little discussion of the informational requirements of a valid consent from the perspective of the common law duty of confidentiality. This is perhaps surprising. It is no exaggeration to say that the future of the National Health Service, along with other health systems across the world, is dependent upon the flow of confidential data. Confidential patient data1 must flow not only to support the delivery of individual care. Confidential data must also—at times—flow to enable a health system to operate and to learn: to establish what works, what does not work, what could be done more effectively, efficiently, and safely.

In England and Wales, guidance on legal responsibilities associated with handling confidential patient data will often provide a summary at some point similar to that provided in the 2003 NHS Confidentiality: Code of Practice:

information that can identify individual patients, must not be used or disclosed for purposes other than healthcare without the individual’s explicit consent, some other legal basis, or where there is a robust public interest or legal justification to do so.

Department of Health Confidentiality: NHS Code of Practice (November 2003)

See also GMC Confidentiality (2009).

The healthcare that is imagined in this guidance is the patient’s own. Identifiable patient data may flow to support a patient’s own care based on an implied consent. Any further use of identifiable patient data requires an explicit consent or some other legal justification. This responsibility to obtain explicit patient consent, or alternative legal justification, is attributed to the common law duty of confidentiality. Of course, the law of confidence sits within a broader complex of responsibilities4 but it is true to say that it is principally the common law duty, interpreted in the context of the Human Rights Act 1998 that is understood to drive the responsibility to obtain patient consent for the disclosure of confidential data.

The relative paucity of legal discussion of the informational requirements of a valid consent might be attributable to many of the leading cases on breach of confidence focusing on justifications other than consent. Furthermore, there may be an assumption that the law here simply mimics the requirements of a valid consent in other areas. However, because the legal informational requirements of a valid consent are not uniform across different areas of law, there needs to be some discussion of the most appropriate approach to informing a consent in the law of confidence. The value of doing so can be illustrated with reference to current and upcoming issues. In October 2016, the Association for Clinical Genetic Science (ACGS) and the Public Health Genomics (PHG) Foundation collaborated in delivery of an evidence session for the National Data Guardian (NDG). The session sought to engage the assistance of the NDG in addressing a challenge encountered within the field of genomic medicine. The challenge relates to inconsistent understanding of the legality of sharing health (including genetic) data about one person to aid the interpretation of clinical significance of gene test results returned to another. As noted above, traditionally consent has only been implied to disclosure for purposes relating to an individual’s own care.

Disclosure of identifiable data to a clinician with no responsibility for an individual’s care, in order to inform the care provided to another, falls outside that traditional understanding.

To assess the nature and scale of any challenge to bringing such disclosure within the scope of a valid consent one must understand the information requirements. Of course, that is not all that one would need to understand. One would also, for example, need to be clear on the requirements regarding the voluntariness of a consent, what might constitute valid communication, whether there are substantive constraints upon permissible breadth, etc. However, amongst these issues is the question of what information an individual would need to be provided with in order for any consent given to be valid. There is currently no clarity regarding the information provision requirements for a valid consent relevant to an action for breach of a duty of confidentiality.

Reason and Paradox in Medical and Family Law: Shaping Children’s Bodies

Brian D. Earp Jennifer Hendry Michael Thomson

Medical Law Review, fwx027,

Published:  24 May 2017

A correction has been published: Medical Law Review, fwx034,

Keywords: Children, Genital cutting, Religion, Shaping surgeries, Systems theory,

Topic: child male circumcision genitalia judgment parent religion statutes and laws genital system self-mutilation by cutting. Legal outcomes often depend on the adjudication of what may appear to be straightforward distinctions. In this article, we consider two such distinctions that appear in medical and family law deliberations: the distinction between religion and culture and between therapeutic and non-therapeutic. These distinctions can impact what constitutes ‘reasonable parenting’ or a child’s ‘best interests’ and thus the limitations that may be placed on parental actions. Such distinctions are often imagined to be asocial facts, there for the judge to discover.

We challenge this view, however, by examining the controversial case of B and G [2015]. In this case, Sir James Munby stated that the cutting of both male and female children’s genitals for non-therapeutic reasons constituted ‘significant harm’ for the purposes of the Children Act 1989. He went on to conclude, however, that while it can never be reasonable parenting to inflict any form of non-therapeutic genital cutting on a female child, such cutting on male children was currently tolerated. We argue that the distinctions between religion/culture and therapeutic/non-therapeutic upon which Munby LJ relied in making this judgement cannot in fact ground categorically differential legal treatment of female and male children. We analyse these distinctions from a systems theoretical perspective—specifically with reference to local paradoxes—to call into question the current legal position. Our analysis suggests that conventional distinctions drawn between religion/culture and the therapeutic/non-therapeutic in other legal contexts require much greater scrutiny than they are usually afforded.

Catherine Stanton and Hannah Quirk (eds), Criminalising Contagion. Legal and Ethical Challenges of Disease Transmission and the Criminal Law, Cambridge University Press, 2016, Hardback,  241pp., £64.99, ISBN 9781107091825.  Glenys Williams

Medical Law Review, fwx042,

Published:  28 September 2017

This outstanding book is a must read for all those interested in this topic, and indeed beyond, as it raises issues fundamental to society as a whole, in the light of emerging diseases such as, for example, Ebola, SARS, and various new strains of influenza (p xiii).1 While its focus is mainly on criminalising contagion in the context of HIV/AIDS, it also extends to a chapter on leprosy,2and another on the possibility of criminalising non-sexually transmitted diseases (STDs).3 The different aspects of the topic covered in the book are impressive, and range from a novel approach to what it is to be human in relation to the notion of harm,4 to the viewpoint of a front line sexual health adviser5…

Medical Law Review, Vol. 25, No. 1, pp. 47–72  doi:10.1093/medlaw/fww029  Advance Access Publication: December 8, 2016

LIMINALITY AND THE LIMITS OF LAW IN HEALTH RESEARCH REGULATION: WHAT ARE WE MISSING IN THE SPACES INBETWEEN?  GRAEME LAURIE,  School of Law, University of Edinburgh, Old College, South Bridge, Edinburgh, EH8 9YL, UK,   This article fundamentally challenges the way in which law currently regulates human health research. It invokes the anthropological concept of liminality—the quality of in-between-ness—to suggest deeper ways of understanding ongoing challenges in delivering acceptable and effective regulation of research involving human participants. In stark contrast to the structural regulatory spaces constructed by law, the metaphor of the liminal space is explored to explain what is lost through our failure to see health research regulation as an inherently human experiential process, involving potentially profound transformative events for participants and researchers alike.

The implications for the future of health research regulation are then examined. In particular, the analysis calls into question key features of the current regulatory paradigm, and demands that we reconsider our own demands of law in this context. The argument is made that health research is a liminal process and that we fail to treat it as such. This requires a rethink of corollary regulation also in processual terms. Ultimately, the charge is to undertake a radical reimagining of regulatory space to accommodate and promote liminal regulatory spaces. KEYWORDS: Health research, Liminality, Regulation, Confidentiality, Consent.   I. INTRODUCTION: UNDERSTANDING REGULATORY SPACE IN HEALTH RESEARCH  The metaphor of the ‘regulatory space’1 is now commonly invoked to describe the metaphysical environment occupied by institutional actors and bounded by law. It delineates a sphere of influence and control over many human endeavours in a diverse range of contexts. This is equally true in the realm of health research regulation, where we have witnessed a burgeoning of legal and quasi-legal interventions in recent decades, nationally and internationally, and sadly too often driven by public scandals or moral panics.

To take the British and European context as an example, the UK was the first country anywhere to regulate the creation, storage, and use of human embryos through the introduction of the Human Fertilisation and Embryology (HFE) Act 19902 in the wake of the birth of the first so-called test-tube baby. This now represents the most comprehensive licensing and inspectorate regime in the world under the auspices of the HFE Authority. Importantly, it has also served as something of a template for regulatory regimes that followed. For example, the UK instituted the labyrinthine Human Tissue Act 2004 with its associated licensing Authority as a direct result of the Bristol and Alder Hey organ retention scandals that arose from suboptimal (or non-existent) consent practices relating to forensic and research uses of deceased children’s tissues. This regulatory endeavour replaced one legislative instrument of four sections with a new law 25 times its length.3 Arising in parallel have been European and other supranational influences.

Child Marriage – Acceptance By Association  Arthur van Coller

International Journal of Law, Policy and the Family, ebx011,

Published:  25 September 2017

The practice commonly referred to as ‘child marriage’ constitutes a human rights violation against a vulnerable person. Child marriage results in lifelong deleterious consequences for countless children. The child is placed in an environment whereby the parent/child relationship is prematurely terminated for an inappropriate purpose. This practice is an affront to childhood, marriage, and the family and should not be confused with adult marriage. This article argues that the effective elimination of child marriage requires, in part, that the practice be correctly named and defined and therefore that use of the term ‘marriage’ in ‘child marriage’ is misleading and inappropriate. A new term ‘paedogamy’ is proposed to accurately describe this practice. A definition of paedogamy is also presented to incorporate all the elements thereof and to reflect the inherent harmful nature of the practice.

Chapters from Forensic Child and Adolescent Mental Health   Chapter 3 – Assessment of Young Offenders

from Section 2 – Assessment and Needs of Young Offenders:  By Prathiba ChitsabesanLorraine Khan  Edited by Susan BaileyPaul TarbuckUniversity of Central Lancashire, PrestonPrathiba Chitsabesan

Young people who end up in the youth justice system have well-documented multiple vulnerabilities affecting their life chances (Centre for Mental Health, 2010), including a higher level of mental health need. Politicians and professionals have begun to recognise the importance of meeting the needs of offenders, as long-term costs to society become increasingly apparent. Studies to date suggest that one of the most common reasons for unmet need is lack of appropriate and timely assessment (Kroll et al., 2002; Harrington and Bailey, 2005; Centre for Mental Health, 2010).

A recent review by the Office of the Children’s Commissioner (Hughes et al., 2012) raised concerns about the significant number of young people within the secure estate who demonstrated symptoms indicating potential neurodisability that were undetected. However, assessment can be complicated by a number of factors including the non-clear-cut nature of emerging poor mental health in comparison to presentations in adults (Vikram et al., 2007), the minimisation of symptoms by young offenders and the disinclination of young people to engage with mental health services due to fear of stigma. Initial assessment is a key factor in the successful treatment of mental or physical health needs for young offenders. Early identification of mental health needs may also reduce the later risk of mental disorders and their related health costs (Knapp et al., 2011). Timely assessment may inform risk assessment processes as well as increasing engagement in offencerelated interventions. Learning disabilities and language disorders are also more common in this group of young people and are likely to affect many aspects of their life and functioning. However, identification of mental disorders in young children and adolescents can be complex.

A normal childhood may be hard to define and can be influenced by a number of different variables, including gender and culture. It is therefore unclear whether childhood psychopathology should be defined by categorical disorders or symptoms. Additionally, the developmental trajectory of psychopathology from childhood into adulthood is complex, as different pathways can lead to the same adult outcomes and vice versa. While a detailed assessment of every offender’s mental health would be helpful, it would be costly to implement given the number of young people in contact with the justice system and the pressures on the police and the courts to deliver justice expediently. Instead a two-tiered approach providing a universal screen to all juvenile offenders but a more detailed assessment of those highlighted in the initial screen is likely to be more cost-effective. There has been much confusion in the juvenile justice system between the terms ‘screening’ and ‘assessment’, and often the terms are used interchangeably. Grisso et al. (2005) attempt a clearer defi- nition. They argue that screening is a briefer process that helps to identify current needs or symptoms and should be applied to all offenders in the juvenile justice system at the point of entry. It helps to differentiate young people into two main categories: those at higher risk and requiring more detailed assessment, and those whose needs are more minor. Screening tools should ideally demonstrate good reliability and validity.

Reliability ensures that the screening tool produces consistent results irrespective of the person administering it, while validity ensures that the screening tool measures what it’s supposed to. Assessment involves a more comprehensive evaluation of symptoms identified in the initial screening process and facilitates a response which is more pertinent to the needs of that particular individual. For example, a young person may require a full physical examination, a more thorough mental health.  The high rate of psychopathology in juvenile offenders may be the consequence of shared risk factors in the development of both antisocial behaviour and psychiatric disorders. The lives of these young people are often characterised by attachment difficulties, trauma, familial psychopathology and disadvantage (Loeber and Farrington, 2000; McCabe et al., 2002). Unsurprisingly rates of disruptive disorders such as conduct disorder are particularly high, ranging from 24% to 73% (Teplin et al., 2002; Vreugdenhil et al., 2004). Conduct disorder is also associated with high comorbidity for other psychiatric disorders, including Attention Deficit Hyperactivity Disorder (ADHD) and substance misuse. While studies consistently show high rates of psychiatric disorders among young offenders, prevalence rates are diverse due to differences in methodology between studies.

This includes differences in sampling techniques and assessment tools, as well as variations in sample sizes (see Table 3.1). The North West Juvenile Project (NWJP) attempted to address some of the limitations of previous studies by including a large random sample of offenders detained at Cook County Juvenile Temporary Detention Center (Teplin et al., 2002; Abram et al., 2003). Juvenile offenders (1172 males) were assessed using the Diagnosis Interview Schedule for Children–Version 2.3 (DISC-2.3). Excluding conduct disorder, 60% of offenders met the diagnostic criteria for one or more disorders. Affective (16%) and anxiety disorders (21%) were common, while 51% had a substance misuse disorder (Table 3.1). ADHD was found in 11% of young offenders. Comorbidity was frequent, with 17% of male offenders presenting with three or more types of disorders. Overlap between substance misuse disorders and ADHD or conduct disorder was particularly common (31%). Research findings have consistently shown that juvenile offenders are characterised by high comorbidity, contributing to complexity in both their assessment and treatment. Rates of comorbidity are especially high among offenders misusing substances (Domalanta et al., 2003). Within the remit of this chapter we have not explored substance misuse by juvenile offenders, as this is covered comprehensively elsewhere (please refer to Chapter 13 by Theodosiou).

The NWJP study also explored rates of trauma and Post-Traumatic Stress Disorder (PTSD) and found that the majority of young male offenders had experienced at least one trauma in their lifetime (93%), while 11% met the criteria for PTSD. However, rates of PTSD were found to be much higher in a study of 370 male juvenile offenders in custody in Russia (Ruchkin et al., 2002). Most offenders reported some post-traumatic stress symptoms, with 25% meeting full DSM-IV criteria. Higher PTSD scores were found to be related to higher scores of violence exposure. Autistic Spectrum Disorder (ASD) is used to describe a group of disorders, including autism and Asperger’s Syndrome. It is a lifelong condition affecting communication, relationships with others and how young people make sense of the world around them. Males are more likely to be affected by autism than females. Knowledge of the prevalence rate of ASD in the youth justice system is generally poor (please refer to Chapter 15 by Gralton and Baird). There is some concern that young people who experience autism may be over-represented among offending populations (Cashin and Newman, 2009). Howlin (1997) suggested that certain features of ASD could predispose some young people to offend in particular ways.

These include their social naivety which could lead to suggestibility and a tendency to be influenced by others, antisocial behaviour stemming from poor understanding or misinterpretation of social cues, and crimes reflecting obsessions. In response to these concerns, the National Autistic Society has developed information and guidance on autism for professionals working within the criminal justice system (The National Autistic Society, 2008). Self-harm is also under-investigated by many studies as research tools evaluating mental disorders primarily focus on psychiatric diagnoses. Studies have shown that self-harm is more prevalent among offenders as certain risk factors for self-harm are more common among this group (please refer to Chapter 10 by Trainor, Rothwell and Hales). Predictors of an increased risk include previous attempts, prolonged low mood, ADHD, having a bad temper (impulsive aggression) and substance use frequency (Putnins, 2005). The literature similarly demonstrates that suicide rates are much higher in the offender population compared with non-antisocial peers. This may be partially explained by their tendency to use violent methods, for example hanging and stabbing, rather than taking an overdose.

Lifetime risk of suicide attempts was found to be high at 12% (Wasserman et al., 2002) Studies suggest that risk factors for suicidal behaviour may be different for juvenile offenders compared with the wider population. Ruchkin et al. (2003) found that ADHD, but not depression, independently predicted suicidal behaviour. However, findings from studies are inconsistent and more research in this area is essential as suicide risk is a significant problem in this population. There have also been few longitudinal studies that have explored how mental health needs change over time, particularly for offenders as they move between custody and community settings. Kroll et al. (2002) followed a sample of 97 male juvenile offenders admitted to secure care using the Salford Needs Assessment Schedule for Adolescents (SNASA) (Kroll et al., 1999). Three months after admission, rates of depression, PTSD and anxiety disorders had increased. One explanation for the increase in mental health needs may be the use of alcohol and drugs by young offenders in the community to manage their mental health symptoms. These symptoms become increasingly apparent following admission to custody due to reduced access to these substances. The offenders were reassessed two years later when many offenders had been released back into the community (Harrington et al., 2005).

Rates of substance abuse increased to 31% on discharge compared with 21% following initial admission. Anxiety disorder including PTSD was also more common at followup in young people who remained in custody, although this may be partially attributed to the association with violent crime as high rates of PTSD have been found in violent offenders (Ruchkin et al., 2002). Mental Health Screening Mental health screening can focus on diagnostic labels or symptoms; it can focus on broader problem areas affecting a child’s well-being; or alternatively it can map risk and protective factors associated with mental health and emotional well-being. Ideally screening tools should have both high sensitivity (measure of true positives) and specificity (measure of true negatives), although this is difficult to achieve in practice. Instead, many screening tools often have low sensitivity (high false positives), but high specificity (low false negatives). Consequently, many young people may screen positive who have some mental health symptoms but who are below threshold to meet the criteria for a mental health diagnosis. However, this is essential to ensure that offenders with possible mental disorders are not missed. Internationally, there have been a number of mental health screening tools developed for use within the youth justice system. Any tool selected should be feasible for use and therefore administered relatively easily and quickly by juvenile justice staff.

Chapter 5,  in:  Forensic Child and Adolescent Mental Health,  

The Influence of Neurodevelopmental Impairment on Youth Crime,

By Nathan Hughes , Huw Williams and Prathiba Chitsabesan

Edited by Susan BaileyPaul TarbuckUniversity of Central Lancashire, Preston.

Publisher: Cambridge University Press   pp 68-82.

University of Cambridge,  October 2017.

Childhood neurodevelopmental impairments are physical, mental or sensory functional deficits caused by disruption in the development of the central nervous system – which consists of the brain, the spinal cord and a related set of neurons – or peripheral nervous system – which sends sensory information to the brain and controls the functioning of organs and muscles (Patel et al., 2011). Such disruptions are often the result of a complex mix of influences, including: genetics; pre-birth or birth trauma; illness or injury in childhood; or nutritional, educational or emotional deprivation; and might result in one or more of a wide range of physical, mental or sensory functional difficulties.

Common impairments include cognitive deficits; specific learning difficulties; communication difficulties; and emotional and behavioural problems (Patel et al., 2011; APA, 2013).

Such symptoms can occur in combination, as evidenced in a wide range of clinically defined disorders or conditions, including (though not restricted to): Attention Deficit Hyperactivity Disorder (ADHD);Autistic Spectrum Disorder (ASD); learning (or intellectual) disability; communication disorders; Foetal Alcohol Syndrome Disorders (FASDs) and Traumatic Brain Injury (TBI) (Patel et al., 2011; APA, 2013).

The particular symptoms associated with each of these conditions are briefly outlined in Table 5.1. While these descriptions utilise clinical definitions, it is important to acknowledge that the clinical presentation of many of these conditions can change over time. For example, social communication disorders may become more evident during periods of transition, such as in starting secondary school (NICE, 2011), while overt hyperactivity symptoms in young people with ADHD frequently diminish in adolescence (Schmidt and Petermann, 2009). Impairments associated with many of these conditions are frequently on a spectrum, with many young people presenting with subclinical levels of need that do not meet diagnostic criteria or threshold for individual disorders, though still significantly affected by multiple symptoms and complex expressions of impairment.

Similarly, given overlap in cause and expression, young people may experience various conditions in parallel. As such, a particular label or ‘disorder’ may not always adequately express the functional needs and difficulties experienced by a young person.

The Prevalence of Neurodevelopmental Impairment among Young People in Custody

A recent review of evidence across a range of international contexts reveals a consistently high incidence rate of neurodevelopmental impairment among incarcerated young people. Following an extensive, structured literature review of research, we have compared the rates of specific neurodevelopmental disorders and conditions amongst young people in custodial institutions to equivalent rates established in studies of young people in the general population (Hughes et al., 2012). In doing so, we demonstrate a disproportionate prevalence of a range of conditions amongst young people in custody.

Neurodevelopmental Condition

Prevalence Rates amongst Young People in the General Population*(%)

Prevalence Rates amongst Young People in Custody* (%)

Attention Deficit Hyperactivity Disorder



Autistic Spectrum Disorder



Intellectual (or Learning) Disability



Communication Disorders



Foetal Alcohol Syndrome Disorder



Traumatic Brain Injury



* References are provided and studies summarised by Hughes et al. (2012).

These data clearly require careful interpretation given the methodological and analytical challenges in combining and comparing such a diverse range of research. Varying classifications or definitions of specific neurodevelopmental disorders are apparent, creating difficulties in the interpretation and direct comparison of findings. This variability is reflected in the numerous measures, tools and methods used to assess prevalence rates of specific disorders, which include: analyses of records of previous clinical diagnoses; self-report surveys of specific symptoms; qualitative interviews with young people and the use of validated instruments or clinical tests. These varied approaches can potentially lead to very different assessments of levels of prevalence (Fazel et al., 2008). Comparisons are also made difficult by the variation in samples and populations on which individual studies are focused. This includes variation in the age range considered, which is typically dependent on the age of young people within a particular custodial setting.

Child and Adolescent Mental Health

© Association for Child and Adolescent Mental Health

Vol. 22 Issue 3

Edited by: Jane Barlow, Kapil Sayal, Paul Harnett, Bernadka Dubicka and Nick Midgley

Impact Factor: 1.597

ISI Journal Citation Reports © Ranking: 2016: 61/121 (Pediatrics); 67/121 (Psychology Clinical); 75/139 (Psychiatry (Social Science)); 98/142 (Psychiatry)

Online ISSN: 1475-3588

Associated Title(s): Journal of Child Psychology and Psychiatry.

Maltreatment and trauma – the impact on development and implications for child mental health services.

There is now a broad consensus that maltreatment in childhood is one of the strongest predictors of poor mental health across the lifespan. Whether physical, emotional or sexual abuse, emotional or physical neglect, early experiences of maltreatment have been demonstrated to impact on a wide range of domains, including attachment relationships, academic achievement, physical development and key areas of neurobiological development. To give just one example, a study by McCrory et al. (2011), using functional MRI scans to investigate the impact of physical abuse and domestic violence on children, found changes in brain structure and functioning comparable to soldiers with post-traumatic stress disorder exposed to combat. It is no surprise, then, that a high proportion of both children and adults accessing mental health services have histories of maltreatment and trauma, although for young people this access is sometimes limited by the fact that children with histories of maltreatment do not always fit easily into existing psychiatric diagnostic systems (deJong, 2010).

Despite the importance of understanding the impact of maltreatment and trauma, and of developing more effective models of prevention and treatment, there are still major gaps in our knowledge. The nine articles in this virtual issue all offer responses to some of those identified gaps, whether in relation to understanding the impact of maltreatment, challenges concerning definitions and measurement, or regarding the development of effective interventions.

To set the stage, Fisher (2015) offers a valuable overview of the needs of looked after and adopted children, a group of children who often have histories of maltreatment and trauma, and whose long-term outcomes are generally much poorer than the general population. Fisher carefully reviews the impact of maltreatment on different domains of children’s well-being, whilst also recognising the importance of not seeing these children as a homogenous group. He identifies some important gaps in our knowledge, such as the relative lack of data on the long-term outcomes for adopted and fostered children; and he points out that many of the children in care show remarkable resilience in the face of adversity, reminding us that it is essential for us to understand what contributes to such resilience.

Other papers in this virtual issue focus on specific aspects of maltreatment, or consider its impact on particular aspects of children’s development. For instance, Mothes et al. (2015) take a close look at the impact of different forms of childhood maltreatment on executive functioning in adolescence, demonstrating the consequences of such experiences for domains such as cognitive flexibility and verbal processing speed; whilst Al-Krenawi and Graham (2012) focus specifically on the impact of political violence on the psychosocial development of adolescents. Their study, examining young people in the West Bank and Gaza Strip, documents the associations between exposure to high levels of political violence and a range of poor outcomes, including mental health problems (such as depression and PTSD), levels of aggression and social functioning. They also identify some of the features that appear to protect adolescents against this impact, including economic status and parental education levels.

Whilst developmental studies of this sort are crucial, many are hampered by issues related to assessment and measurement. The study by Leigh, Yule and Smith (2016) provides a careful review of the various measurement tools for assessing PTSD in children and young people, balancing psychometric properties with clinical utility. They highlight the important role of assessing trauma exposure across child mental health services, and identify specific self-report measures, which are easy to use, and have good psychometric properties. However they also make the case for the value of semi-structured interviews as part of the process of diagnosis and treatment planning, even if such instruments can be time-consuming to use; and recognise the risk that assessment and diagnosis may vary significantly depending on how maltreatment is investigated. Woolgar and Baldock (2015) compare community and expert assessments of attachment disorders in looked after and adopted children, and argue that there is a significant risk of over-diagnosis of attachment disorders in community services, leading to a heightened risk that more common disorders, such as conduct disorder and neurodevelopmental disorders, may go un-diagnosed, and hence un-treated.

Likewise, Pinto and Maia (2014), compare two sources of childhood adversity – official records and self-report – and explore degrees of discrepancy between these different sources of knowledge, as well as examining each of them as predictors of psychopathology in youths aged 14-23. Interestingly, despite the clear limitations of self-report, data from that source was strongly associated with psychopathology, with self-reported childhood sexual abuse having an independent association with increased risk for later depression. These issues related to measurement, assessment and diagnosis ultimately matter because they are likely to have implications for preventative and treatment services. Fisher’s (2015) review paper notes that rigorous research about interventions specifically targeted at looked after and adopted children is limited, making the need for research in this field even more of a priority. Saxe et al. (2012) outline preliminary evidence for a systems-oriented treatment model called Trauma Systems Therapy (TST) for young people with traumatized children.

They highlight the importance of family engagement, given the high levels of premature treatment dropout from child mental health treatments in general, but in particular from those focused on the impact of trauma. Likewise, Toth and Gravener (2012) provide a valuable review of relational interventions for maltreated children, with a particular focused on Child-Parent Psychotherapy (CPP), a model of working informed by attachment theory that has been found to be efficacious. Like Saxe et al., Toth and Gravener highlight that one of the greatest challenges is translating treatments from university-based laboratory settings to community settings. This gap is documented in the study by Czincz and Romano (2013), in which the majority of psychologists working in community-based services reported that they had never received any training in specific evidence-based treatment approaches for children and adolescents who had experienced childhood sexual abuse, such as trauma-focused cognitive behaviour therapy (TF-CBT). Whilst this study underlines the need for on-going training and education for those working in community services, Toth and Gravener (2012) highlight the importance of enduring commitment across systems if interventions with a laboratory-based evidence-base are going to be meaningfully translated into clinical practice.

Taken together, the papers in this virtual issue highlight many of the challenges faced by those trying to understand the impact of early maltreatment and trauma on the lives of children, as well as the difficulties facing those who are involved with assessment and diagnosis. But they also highlight the important progress made in this field, as academics and clinicians work together to both increase our understanding, but more importantly intervene effectively to improve the outcomes of those lives effected by the impact of early maltreatment and trauma.

The impact of political violence on psychosocial functioning of individuals and families: the case of palestinian adolescents

By Alean Al-Krenawi and John R. Graham

Childhood sexual abuse: community-based treatment practices and predictors of use of evidence-based practices,  By Jennifer Czincz and Elisa Romano

Review: Adoption, fostering, and the needs of looked-after and adopted children

By Philip A. Fisher

Measurement Issues: Measurement of posttraumatic stress disorder in children and young people – lessons from research and practice,

By Eleanor Leigh, William Yule and Patrick Smith.

Childhood maltreatment and executive functions in adolescents,

By Luiza Mothes, Christian Haag Kristensen, Rodrigo Grassi-Oliveira, Rochele Paz Fonseca, Irani Iracema de Lima Argimon and Tatiana Quarti Irigaray.

Psychopathology among youths who were victims of documented childhood maltreatment,

By Ricardo J. Pinto and Ângela C. Maia.

Innovations in Practice: Preliminary evidence for effective family engagement in treatment for child traumatic stress– trauma systems therapy approach to preventing dropout,  By Glenn N. Saxe, B. Heidi Ellis, Jason Fogler and Carryl P. Navalta.

Review: Bridging research and practice: relational interventions for maltreated children,  By Sheree L. Toth and Julie Gravener.

Attachment disorders versus more common problems in looked after and adopted children: comparing community and expert assessments   By  Matt Woolgar and Emma Baldock


deJong, M., (2010). Some reflections on the use of psychiatric diagnosis in the looked after or “in care” child population. Clinical Child Psychology and Psychiatry, 15, 4: 589-599. DOI:

McCrory, E., De Brito, S., Sebastian, C., Mechelli, A., Bird, G., Kelly, P. & Viding, E. (2011). Heightened neural reactivity to threat in child victims of family violence.

Current Biology, 21 (23): R947-R948  DOI:10.1016/j.cub.2011.10.015

Measurement Issues: Measurement of posttraumatic stress disorder in children and young people – lessons from research and practice

By  Eleanor Leigh, William Yule and Patrick Smith

Version of Record online: 17 OCT 2015

DOI: 10.1111/camh.12124

© 2015 Association for Child and Adolescent Mental Health

Issue:  Child and Adolescent Mental Health

Volume 21, Issue 2, pages 124–135, May 2016


Many young people are exposed to traumatic events and a significant minority of these individuals will go on to experience posttraumatic stress disorder (PTSD). Valid and reliable measurement tools for assessing PTSD are essential and can aid screening, clinical diagnosis, treatment planning and outcome monitoring.


This article outlines the range of instruments available for these aspects of measurement, including assessment of PTSD in very young children, with a focus on those scales with good clinical utility and sound psychometric properties.


This is a particularly challenging time for clinicians working with children and young people with PTSD: all instruments will need to be revised and updated in order to better reflect the recent revisions to the diagnostic criteria for PTSD with the publication of the DSM-5 and no doubt the anticipated ICD-11. Despite this, measurement tools can still play a vital role in assessing PTSD in children and young people.

Attachment disorders versus more common problems in looked after and adopted children: comparing community and expert assessments

Authors  Matt Woolgar,  Emma Baldock  First published: 22 January 2014

DOI: 10.1111/camh.12052.

Background:   Attachment disorders in adopted and fostered children may be overdiagnosed and could obscure more common disorders.

Methods:   A case note review of 100 referrals to a specialist adoption and fostering service compared community referrals with the specialist assessments of attachment disorders.

Results:  Attachment disorders were identified four times more often in community referrals versus the specialist service, but this only partly explained the significant under-identification of more common disorders in the community, especially for neurodevelopmental factors and conduct disorder by up to 10-fold.

Conclusions:  The relevant practice parameters are discussed and implications for service models for adopted and fostered children reviewed.

1.Ferdinando Salamino, Elisa Gusmini, A shift in narratives: From ‘attachment’ to ‘belonging’ in therapeutic work with adoptive families. A single case study, European Journal of Psychotherapy & Counselling, 2017, 19, 1, 22 CrossRef

  1. Emma Gore Langton, Adopted and permanently placed children in education: from rainbows to reality,Educational Psychology in Practice, 2017, 33, 1, 16 CrossRef

  2. Neil W. Boris, Kimberly Renk, Beyond Reactive Attachment Disorder,Child and Adolescent Psychiatric Clinics of North America, 2017, 26, 3, 455 CrossRef

  3. Susan Dickerson Mayes, Susan L. Calhoun, Daniel A. Waschbusch, Rosanna P. Breaux, Raman Baweja, Reactive attachment/disinhibited social engagement disorders: Callous-unemotional traits and comorbid disorders, Research in Developmental Disabilities, 2017, 63, 28 CrossRef

1.Brian Allen, A RADical Idea: A Call to Eliminate “Attachment Disorder” and “Attachment Therapy” From the Clinical Lexicon, Evidence-Based Practice in Child and Adolescent Mental Health, 2016, 1, 1, 60 CrossRef

  1. Rebecca Anthony, Sarah Meakings, Julie Doughty, Heather Ottaway, Sally Holland, Katherine H. Shelton, Factors affecting adoption in Wales: Predictors of variation in time between entry to care and adoptive placement,Children and Youth Services Review, 2016, 67, 184 CrossRef

  2. Charles H. Zeanah, Tessa Chesher, Neil W. Boris, Heather J. Walter, Oscar G. Bukstein, Christopher Bellonci, R. Scott Benson, Regina Bussing, Allan Chrisman, John Hamilton, Munya Hayek, Helene Keable, Carol Rockhill, Matthew Siegel, Saundra Stock, Practice Parameter for the Assessment and Treatment of Children and Adolescents With Reactive Attachment Disorder and Disinhibited Social Engagement Disorder,Journal of the American Academy of Child & Adolescent Psychiatry, 2016, 55, 11, 990 CrossRef

1.Jocelyn E Finlay, Günther Fink, Dana Charles McCoy, L Carolina Tavárez, Jeanne Chai, Goodarz Danaei, Majid Ezzati, Wafaie Fawzi, Mary C Smith Fawzi, Stunting risk of orphans by caregiver and living arrangement in low-income and middle-income countries, Journal of Epidemiology and Community Health, 2016, 70, 8, 784 CrossRef

  1. Carmen Pinto, Matt Woolgar, Introduction: Looked-after children,Child and Adolescent Mental Health, 2015, 20, 4, e1 Wiley Online Library

  2. John Simmonds, The potential for use of the Development and Well-Being Assessment (DAWBA) in adoption support assessments,Adoption & Fostering, 2015, 39, 4, 330 CrossRef

Psychopathology among youths who were victims of documented childhood maltreatment

Authors:  Ricardo J. Pinto,  Ângela C. Maia

First published: 11 February 2013

DOI: 10.1111/camh.12020.


There is an established relationship between childhood maltreatment and later psychopathology, but most studies have used self-reports and only consider a small number of experiences. The main aim of this study was to examine predictors of psychopathology by comparing two sources (official records vs. self-reports) of ten different childhood adversities among youths who were identified by Child Protective Services (CPS). We also used a comparison group that was not identified by CPS. This study also compared, in terms of psychopathology, three groups of respondents (under-report; agreement; and over-report) based on the discrepancy between the two sources of childhood adversity.

Method:   The sample included 136 youths, ages 14–23 years, identified by CPS prior to age 12 as being maltreated and who lived with their family for at least 5 years. The comparison group included 80 youths.

Results:   The identified youths were not different from the comparison group in global psychopathology. Psychopathology was associated only with the total amount of self-reported adverse experiences, with depressive symptoms being predicted by both documented and self-reported sexual abuse. Females reported and had more documented adversities, presenting an increased risk for psychopathology. The under-report group had a higher mean of documented experiences and a lower mean in psychopathology.

Conclusions:  Despite the limitations of a self-report methodology, our findings attest to its contribution in predicting health outcomes. Professionals from CPS need to be thorough when assessing and documenting the multiple experiences that may co-occur in a household, paying particular attention when young girls are involved, as the experience of sexual abuse has been shown to be independently associated with later risk of developing depressive symptoms. This process may increase the appropriateness of the chosen interventions.

A Comparison Study between Official Records and Self-Reports of Childhood Adversity

Authors:  Ricardo J. Pinto, Ângela C. Maia

Published Date:   13 November 2012


Authors:  Pamela A. Clarkson Freeman

Published Date: 4 September 2014

The risk for persistent adult alcohol and nicotine dependence: the role of childhood maltreatment

Authors:  Jennifer C. Elliott, Malka Stohl, Melanie M. Wall, Katherine M. Keyes, Renee D. Goodwin, Andrew E. Skodol, Robert F. Krueger, Bridget F. Grant, Deborah S. Hasin

Published Date:  16 February 2014.

Child Maltreatment and Household Dysfunction in a British Birth Cohort

Authors:  Rachel Denholm, Chris Power, Claudia Thomas, Leah Li

Published Date:  27 February 2013

Associations between childhood maltreatment and non-medical use of prescription drugs among Chinese adolescents

Authors:  Lan Guo, Yan Xu, Jianxiong Deng, Xue Gao, Guoliang Huang, Jinghui Huang, Xueqing Deng, Wei-Hong Zhang, Ciyong Lu

Published Date:  22 May 2017.

Exploration and Comparison of Adolescents With Autism Spectrum Disorder and Their Caregiver’s Perspectives on Transitioning to Adult Health Care and Adulthood

Nancy C Cheak-Zamora, PhD Michelle Teti, Dr PH Anna Maurer-Batjer, MSW, MPHErica Koegler, PhD, MSW

Journal of Pediatric Psychology, Volume 42, Issue 9, 1 October 2017, Pages 1028–1039,

Published:  04 May 2017

Background: Adolescents with autism spectrum disorder (ASD) experience challenges achieving independence. Few studies assess both adolescents and caregivers’ needs as adolescents transition to adult health care. Objective/Methods: This study explored and compared the health-related independence experiences of 27 adolescents with ASD and their caregivers. Caregivers participated in focus groups and adolescents participated in semi-structured interviews.

Results: Thematic analysis of dyads’ responses highlighted three common themes: (a) efforts toward independence, (b) low self-efficacy for adolescents’ independence, and (c) desire for independence. Nuances in responses indicated that although members of dyads shared many experiences, they were not communicating these experiences with each other. Conclusions: Results suggest both groups understand the importance of health-related independence and are motivated to achieve independence but lack skills and supports. Improved communication about experiences and goals between caregivers, adolescents, and the care team are needed. These findings can inform future interventions to better support adolescents’ transition to adult health care.

Integrated Primary Medical-Behavioral Health Care for Adolescent and Young Adult Depression: Predictors of Service Use in the Youth Partners in Care Trial

Amy M. Rapp, MA Denise A. Chavira, PhD Catherine A. Sugar, PhDJoan R. Asarnow, PhD     Journal of Pediatric Psychology, Volume 42, Issue 9, 1 October 2017, Pages 1051–1064,

Published:  25 March 2017

Objectives Depression, a chronic and disabling condition, frequently has its first onset during adolescence, underscoring the value of early effective treatment and prevention. Integrated medical-behavioral health care provides one strategy for improving treatment access for adolescents and young adults (AYA).

Methods: This study examined predictors of accessing treatment in a multisite randomized controlled trial evaluating an integrated collaborative care intervention aimed at improving access to evidence-based depression treatment through primary health care, compared with usual care. Results: The integrated care intervention was able to overcome barriers to care associated with an initial reluctance to pursue active treatment and older age. Service use was low in both conditions among less acculturated/non-English-speaking families. Conclusions: Results support the value of integrated medical-behavioral health care for improving rates of care. Findings highlight mechanisms by which integrated care may lead to improved rates of care and outcomes for AYA, an underserved and understudied group.

Familial Risk and a Genome-Wide Supported DRD2 Variant for Schizophrenia Predict Lateral Prefrontal-Amygdala Effective Connectivity During Emotion Processing

Tiziana Quarto Isabella Paparella Davide De Tullio Giovanna Viscanti Leonardo FazioPaolo Taurisano Raffaella Romano Antonio Rampino Rita Masellis Teresa Popolizio …

Schizophrenia Bulletin, sbx128,

Published:  16 September 2017   The brain functional mechanisms translating genetic risk into emotional symptoms in schizophrenia (SCZ) may include abnormal functional integration between areas key for emotion processing, such as the amygdala and the lateral prefrontal cortex (LPFC). Indeed, investigation of these mechanisms is also complicated by emotion processing comprising different subcomponents and by disease-associated state variables. Here, our aim was to investigate the relationship between risk for SCZ and effective connectivity between the amygdala and the LPFC during different subcomponents of emotion processing.

Thus, we first characterized with dynamic causal modeling (DCM) physiological patterns of LPFC–amygdala effective connectivity in healthy controls (HC) during implicit and explicit emotion processing. Then, we compared DCM patterns in a subsample of HC, in patients with SCZ and in healthy siblings of patients (SIB), matched for demographics. Finally, we investigated in HC association of LPFC–amygdala effective connectivity with a genome-wide supported variant increasing genetic risk for SCZ and possibly relevant to emotion processing (DRD2rs2514218). In HC, we found that a “bottom-up” amygdala-to-LPFC pattern during implicit processing and a “top-down” LPFC-to-amygdala pattern during explicit processing were the most likely directional models of effective connectivity. Differently, implicit emotion processing in SIB, SCZ, and HC homozygous for the SCZ risk rs2514218 C allele was associated with decreased probability for the “bottom-up” as well as with increased probability for the “top-down” model. These findings suggest that task-specific anomaly in the directional flow of information or disconnection between the amygdala and the LPFC is a good candidate endophenotype of SCZ.

Psychiatry Research  Volume 257, November 2017, Pages 34-39

Cognitive, affective, and social factors maintaining paranoia in adolescents with mental health problems: A longitudinal study

Author links open overlay panel  Jessica C.Birda   FelicityWaitea EleanorRowsellb        Emma C.Fergussona   DanielFreemana

A Department of Psychiatry, University of Oxford, Oxford, United Kingdom

B Buckinghamshire CAMHS, Oxford Health NHS Foundation Trust, The Sue Nicholls Centre, Bierton Road, Aylesbury, Buckinghamshire HP20 1EG, United Kingdom.


  • We examined the predictors of paranoia persistence in adolescents over three months.

  • Thirty four adolescents with mental health problems were assessed.

  • Cognitive processes, affective reactivity, and social stress maintained paranoia.

  • Cognitive treatment studies targeting paranoia mechanisms in adolescents are needed.

Paranoia may be a significant concern during adolescence, but there has been little research on excessive mistrust in young people. In this longitudinal study we set out to test the predictive ability of a number of cognitive, affective, and social factors in the early development of paranoia in a clinical adolescent population. Thirty four help-seeking adolescents, aged 11–16 years, reporting paranoid thoughts and attending mental health services were recruited. Self-report and interview assessments of paranoia were conducted at baseline. Measures relating to a cognitive model of persecutory delusions were completed. Paranoia was reassessed after three months with thirty three participants.

Significant predictors of paranoia persistence were anxiety, depression, worry, negative self-beliefs, perceptual anomalies, insomnia, affective reactivity, bullying, and cyber victimization. No effect was found for reasoning bias or negative perceptions of academic ability, social competence, and physical appearance. In conclusion, many of the maintenance factors implicated in adult paranoia are likely to prove important in the early development of paranoia in young people. Further experimental and treatment studies are now needed to examine the causal role of these factors in the occurrence of paranoia in adolescents.

The unique associations between rape acknowledgment and the DSM-5 PTSD symptom clusters.   Authors:  Laura C. Wilson  Angela Scarpa

Department of Psychological Science, University of Mary Washington, 1301 College Ave, Fredericksburg, VA, USA  Psychology Department, Virginia Tech, Blacksburg, VA, USA.    It is well documented in the sexual assault literature that more than half of rape survivors do not label their experience as rape. This is called unacknowledged rape. Although this phenomenon is common and undoubtedly has huge implications for psychotherapy, the impact of acknowledgment status on psychological adjustment is unclear. The present study aimed to delineate the unique impact of rape acknowledgment on psychopathology by examining PTSD symptoms at the cluster level.

To examine this, 178 female college students who reported rape completed an online survey, including an assessment of PTSD symptoms in the past month. The results suggested that, after accounting for several covariates, acknowledged rape survivors reported significantly greater levels of intrusion and avoidance symptoms compared to unacknowledged rape survivors. The findings suggest that examining PTSD symptoms at the cluster level may provide more insight into the process of recovery following rape and therefore may better inform treatment decisions.

Keywords:   Unacknowledged rape,  Posttraumatic stress disorder,  Label, Psychopathology.

Child Abuse & Neglect  Volume 70, August 2017, Pages 210-221,  Child Abuse & Neglect

Research article  “Talking about child sexual abuse would have helped me”: Young people who sexually abused reflect on preventing harmful sexual behaviour.

Authors:  Gemma McKibbin,  Cathy Humphreys,  Bridget Hamilton,

Melbourne School of Health Sciences, University of Melbourne, Melbourne, Australia.   Harmful sexual behavior carried out by children and young people accounts for about half of all child sexual abuse perpetration. The aim of this study was to draw on the insights of young people who had been sexually abusive to enhance the current prevention agenda. The study involved semi-structured interviews with 14 young people and six treatment-providing workers. Sampling was purposive and the young people had previously completed a treatment program for harmful sexual behaviour in Victoria, Australia.

The young people were approached as experts based on their previous experience of engaging in harmful sexual behavior. At the same time, their past abusive behavior was not condoned or minimised. Constructivist Grounded Theory was used to analyse the qualitative data. Opportunities for preventing harmful sexual behavior were the focus of the interviews with young people and workers. The research identified three opportunities for prevention, which involved acting on behalf of children and young people to: reform their sexuality educationredress their victimization experiences; and help their management of pornography. These opportunities could inform the design of initiatives to enhance the prevention agenda.

Keywords:  Public health, Prevention, Child sexual abuse, Children and young people with harmful sexual behaviour,  Problematic sexual behaviour, Sexually abusive behaviour.

Psychiatry Research

Volume 257, November 2017, Pages 361-366

Parental reflective functioning as a moderator of child internalizing difficulties in the context of child sexual abuse.

Authors   Karin Ensinka    Michaël Bégina    Lina Normandina   Peter Fonagyb


      Parental mentalizing involves imagining the child’s experience and understand what their behavior communicates about this.

      The findings show that better parental mentalizing is linked to fewer child internalizing and externalizing problems.

      Parental mentalizing is a protective factor for sexually abused children.

The objective was to examine pathways from child sexual abuse(CSA) and maternal mentalizing to child internalizing and externalizing difficulties and to test a model of MRF as a moderator of the relationships between CSA and child difficulties. The sample was comprised of 154 mothers and children aged 2–12 where 64 children had experienced CSA. To assess parental mentalizing the Parental Development Interview was rated with the Parental Reflective Functioning Scale. Child internalizing and externalizing difficulties were assessed with the Child Behavior Checklist (CBCL). Results indicate that there were significant inverse relationships between maternal mentalizing and child internalizing and externalizing difficulties. When maternal mentalizing was considered together with CSA, only maternal mentalizing was a significant predictor of child difficulties. Furthermore, maternal mentalizing moderated the relationship between CSA and child internalizing difficulties. These findings provide evidence of the importance of the parents’ mentalizing stance for psychiatric symptoms of children aged 2–12, as well as children’s recovery from CSA. The clinical implications of the findings are discussed.

  1. Introduction

Sexual abuse affects a sizable minority of children and a recent meta-analysis   indicates that on average, 20% of girls and 8% of boys experience sexual abuse (Pereda et al., 2009b) although rates vary depending on country and context (0–60% of girls and 0–50% of boys; Pereda, et al., 2009a). Child sexual abuse (CSA) is associated with a range of short term and long term physical and mental health problems (Briere and Elliot, 2003Collin-Vézina et al., 2013Mathews et al., 2013Pollio et al., 2011Sadowski et al., 2003).

Up to 60% of sexually abused children develop moderate to severe symptoms of psychopathology (Maniglio, 2009; Putnam, 2003) and over one third of sexually abused children manifest clinically significant internalizing difficulties and 46–47% develop externalizing difficulties (Beaudoin et al., 2013; Mathews et al., 2013; McCrae et al., 2006; Paolucci et al., 2001). Furthermore, findings from a recent study indicate that sexually abused children showed significantly more internalizing and externalizing difficulties than children exposed to other forms of abuse (Lewis et al., 2016).

The increased risk of health and mental health problems can be understood in part by the fact that sexual abuse undermines the development of positive sense of self and trust in others (Hébert et al., 2016) and disrupts the development of emotional regulation through dysregulation of the HPA axis (Kuhlman et al., 2015). It is thus a priority to identify potential resilience processes and consider how they can be supported and enhanced. Parenting may be particularly important to modulate the impact of child sexual abuse (CSA).

Seeking Certainty? Judicial Approaches to the (Non-)Treatment of Minimally Conscious Patients | Medical Law Review | Oxford Academic

A modest, but growing, body of case law is developing around the (non-)treatment of patients in the minimally conscious state. We sought to explore the approaches that the courts take to these decisions. Using the results of a qualitative analysis, we identify five key features of the rulings to date. First, the judges appear keen to frame the cases in such a way that these are rightly matters for judicial determination. Secondly, the judges appraise the types and forms of expertise that enter the courtroom, seeming to prefer the ‘objective’ and ‘scientific’, and particularly the views of the doctors.

Liminality and the Limits of Law in Health Research Regulation: What are we Missing in the Spaces in-Between? | Medical Law Review | Oxford Academic

This article fundamentally challenges the way in which law currently regulates human health research. It invokes the anthropological concept of liminality—the quality of in-between-ness—to suggest deeper ways of understanding ongoing challenges in delivering acceptable and effective regulation of research involving human participants. In stark contrast to the structural regulatory spaces constructed by law.

Using and Disclosing Confidential Patient Information and the English Common Law: What are the Information Requirements of a Valid Consent? | Medical Law Review | Oxford Academic

The National Health Service in England and Wales is dependent upon the flow of confidential patient data. In the context of consent to the use of patient health data, insistence on the requirements of an ‘informed’ consent that are difficult to achieve will drive reliance on alternatives to consent. Here we argue that one can obtain a valid consent to the disclosure of confidential patient data, such that this disclosure would not amount to a breach of the common law duty of confidentiality, having provided less information than would typically be associated with an ‘informed consent’.

Adherence to Antipsychotic Medication and Criminal Recidivism in a Canadian Provincial Offender Population 

Schizophrenia Bulletin, Volume 43, Issue 5, 1 September 2017, Pages 1002–1010,
Published:  20 June 2017
Preliminary evidence suggests that adherence to antipsychotic medication reduces criminal recidivism among patients diagnosed with schizophrenia. However, existing studies operationalize antipsychotic adherence as a binary variable (usually using a threshold of ≥80%), which does not reflect the prevalence of suboptimal adherence in real-world settings. The purpose of the current analysis was to investigate the association between successive ordinal levels of antipsychotic adherence and criminal recidivism in a well-defined sample of offenders diagnosed with schizophrenia (n = 11462). Adherence was measured using the medication possession ratio (MPR) and analyzed as a time-dependent covariate in multivariable regression models. Data were drawn from linked, comprehensive diagnostic, pharmacy and justice system records, and individuals were followed for an average of 10 years. Adjusted rate ratios (ARR) and confidence intervals (CI) are reported. Overall mean MPR was 0.41. Increasing levels of antipsychotic adherence were not associated with progressively lower rates of offending. However, when compared to the reference group (MPR ≥ 80%) all lower adherence levels were significantly associated (P < .001) with increased risk of violent (ARR = 1.58; 95% CI = 1.46–1.71) and nonviolent (ARR = 1.41; 95% CI = 1.33–1.50) offenses. Significance was replicated in separate sensitivity analyses. Previously published studies reporting reductions in crime may have been influenced by antipsychotic adherence ≥80%. Binary operationalization of adherence is an inaccurate predictor of recidivism. Future research addressing functional outcomes of antipsychotic adherence should conceptualize adherence as an incremental independent variable.


Antipsychotic medication is the cornerstone of treatment for schizophrenia and considered instrumental in the management of violent behavior. A groundbreaking study in a general population (published in 2014) reported a 45% reduction in violent crime among patients when they received antipsychotic medication compared to when they did not.1 A more recent analysis concluded that pharmacological treatment of schizophrenia significantly delayed time to violence by 18% among offenders released from prison.2 Nonetheless, the relationship linking violence and psychosis is unclear.3

A limitation of existing research involves the definition of adherence. Although routinely operationalized in binary terms (ie, adherent vs nonadherent), adherence to antipsychotics varies considerably,4 and the term “partially adherent”5 may best describe the status of most patients when observed over time. Previous research addressing violent offending1 applied an innovative within-participant analytic approach, but nevertheless investigated adherence in binary terms, concluding that any adherence (at least one prescription within 120 days) was superior to none.

Clinical practice guidelines often recommend adherence levels at or above 80%6: the cut-off point attributed to a 1975 definition of adherence involving antihypertensive medication.7 Empirical evidence in support of this threshold is limited,8 although it is widely used in drug adherence research,9 including studies focused on antipsychotics. Very few studies report multiple levels of adherence from 0% to 100%,10 and the definition of “poor adherence” (vs nonadherence) is obscure.11

Preliminary evidence suggests that ≥80% antipsychotic adherence is associated with lower criminal justice involvement and related costs.12,13 This research represents important groundwork addressing the relationship between adherence and criminality, but is subject to methodological constraints, including the use of self-reported criminal history, relatively short periods of follow-up, and heterogeneous samples (ie, hospitalized psychiatric patients and individuals eligible for Medicaid). These limitations are problematic, and the validity of self-reported justice-system involvement is particularly low.14 Additional research addressing the relationship between adherence and crime (ie, violent and nonviolent offending) has been explicitly recommended.15

The current study addresses this recommendation, using comprehensive administrative records from a well-defined offender population diagnosed with schizophrenia and adjudicated in British Columbia (BC, Canada). We compared guideline level adherence (≥80%) with lower levels of adherence (ie, ≤19%; 20%–39%; 40%–59%; 60–79%). Participants were followed over a mean observation period of nearly 10 years.

Our primary hypothesis was that antipsychotic adherence at or above the 80% threshold would be associated with a significantly reduced rate of violent and nonviolent convicted offenses, when compared to lower levels of adherence. To examine whether higher levels of adherence were associated with incrementally less offending, we tested the secondary hypothesis that the lowest level of adherence (0%–19%) would be associated with the highest rate of criminal recidivism.


Data Sources

The study was approved by the Research Ethics Board at Simon Fraser University. Analyses were conducted using data from the BC Inter-Ministry Research Initiative (IMRI), which integrates linked, nonidentifying administrative data spanning multiple decades from 3 independent BC government ministries: 1990–2015 from the Ministry of Health (MoH), and 1997–2015 from the Ministries of Justice (MoJ) and Social Development. The database includes individual-level records related to diagnoses, hospital and outpatient services, prescription medications, income assistance, justice encounters, and sociodemographic variables. Details of the IMRI database not essential to the current study have been described elsewhere.16–18

The current analysis used 3 specific data sets: Medical Services Plan (MSP) billing data and BC PharmaNet from the MoH, and convicted offense data from the MoJ. The MoJ administers sentences for all provincial offenders. MSP data represent medical services delivered to all residents of BC, including dates, costs and diagnostic codes (based on International Classification of Diseases: ICD-9). Participation in MSP is mandatory and comprises the single source of payment for publicly administered medical services in BC.

All prescriptions dispensed in BC are recorded in BC PharmaNet, which has been shown to accurately reflect medication adherence for most patients.19These data are sufficiently detailed to calculate long-term adherence to prescription medications and have previously been used to assess antipsychotic adherence.20,21 IMRI data, including PharmaNet records, cover periods of time when offenders were incarcerated, as well as all available time before and after involvement with the criminal justice system. Financial disincentive against the use of prescribed medications is minimized in BC as the out-of-pocket cost is incrementally linked to income. Individuals with low incomes are eligible for publicly funded prescription coverage. Antipsychotic medications were identified using the American Hospital Formulary Service List.

Study Design and Participants

The population available for analysis consisted of all individuals convicted under BC jurisdiction between January 1, 1998 and March 31, 2015. We only included those offenders diagnosed with schizophrenia (ICD-9; code 295), and following the convention used in previous research,1 for whom we had at least 120 days of follow-up. A diagnosis of schizophrenia at any time during the study period was used to identify individuals eligible for the study. All diagnoses were made by licensed practitioners in British Columbia. Clinicians were identified as psychiatrists, general practitioners, and nurses/allied health professionals to allow for diagnostic comparison based on practitioner specialty.

Because comprehensive Justice records are only available for individuals 18 years of age and older, we excluded those prescribed antipsychotics prior to the age of 18. Offenders were followed from the date of first dispensed antipsychotic prescription until censoring (date of death or March 31, 2015).

Variables of Interest

Adherence to antipsychotic prescription was our primary independent variable, operationalized using the medication possession ratio (MPR). MPR represents the percentage of time that an individual was dispensed prescribed medication (ie, the number of days of medication supplied within a refill interval divided by the total number of days in the interval), and is the preferred measure of adherence using administrative data.22 Antipsychotic MPR has previously been correlated with likelihood of arrest among adults with serious mental illness.12,13

Following Fazel et al,1 we calculated adherence (in our case, MPR) for each 120-day interval, beginning with the date of antipsychotic medication initiation. Antipsychotic polypharmacy on any given day did not result in double counting or inflation of the MPR (ie, upper bound = 1.0 per day). Although participants may have received more than one antipsychotic agent or varying doses over time, the current analysis did not focus on changes in medication regimen during the follow-up period. MPR was categorized into 5 groups (≤0.19; 0.20–0.39; 0.40–0.69; 0.60–0.79; ≥0.80) and analyzed as a time-dependent covariate in the regression model. Consistent with existing literature, MPR ≥0.80 was used as the reference group.

Our primary outcome of interest was the number of convicted offenses recorded in each 120-day interval for all participants in the cohort. These were classified as violent or nonviolent based on the type of offense (specified). The date of the offense was the date of the outcome. In cases where the date of offense was not reported, this was approximated using the date of conviction and the average latency of 5 months between the date of offense and date of conviction.

Statistical Analyses

We used generalized estimating equations (GEE) to estimate the effect of MPR on the rate of violent and nonviolent crime,23 while adjusting for confounding variables. We selected GEE negative binomial models (negative binomial distribution with log link) due to the over-dispersion and count nature of the outcome data, and for the better goodness of fit statistics relative to Poisson regression. Autoregressive (first-order) correlation structure was chosen to control for the correlation in repeated measures of the number of offenses. As an additional safeguard against heteroskedasticity and potential misspecification, we used the robust variance estimator to estimate standard errors for the parameters.24–27 In the GEE negative binomial regression analysis, we initially estimated the dispersion parameter ignoring the correlation between individuals, and then imputed the value of the dispersion parameter in the model, as suggested by Hilbe.26

Each multivariable model controlled for several variables selected a priori as potential confounders associated with criminal behavior. These include: patient age (centered; age 18), gender (men and women), ethnicity (White, Indigenous and other), education level (<Gd. 10, Gd. 10/11, Gd. 12, and Vocational/University), frequency of substance use-related services in each 120-day interval (continuous variable), frequency of prior convicted offenses in each 120-day interval (continuous variable), and duration of follow-up in days (offset variable). We report unadjusted and adjusted rate ratios along with 95% confidence intervals as measures of association (effect sizes). Significance of estimated parameters is reported using alpha level (P ≤ .05), and all P values are 2-sided.

Cases with missing values were included in the primary analysis. Demographic information was missing for 1280 (11%) of participants: age, n = 3(<1%); ethnicity, n = 573 (5%); and education level, n = 1193 (10%). These participants were included using mean age as well as “unknown ethnicity” and “unknown education level” as separate categories in the multivariable model.

Sensitivity Analyses

Sensitivity analysis was performed to compare results of the primary analysis to those based on complete cases (n = 10182). Further sensitivity analyses were conducted: (a) using standard follow-up times of: <5 years, 5–<10 years, and ≥10 years; (b) restricted to surviving participants only (n = 10514); and (c) based on the origin of diagnosis (psychiatrist vs nonpsychiatrist). IBM SPSS Statistics 2328 and STATA 1329 were used to conduct all analyses.


Sample Characteristics

Figure 1 illustrates the flow of patients included in the current study. Between January 1998 and March 2015, 39591 offenders convicted under BC provincial jurisdiction received at least one antipsychotic prescription. Of these individuals, 31% (n = 12102) were diagnosed with schizophrenia (the majority—71%—were diagnosed by psychiatrists and the remainder by other specialists). We excluded 640 offenders due to insufficient follow-up time (<120 days) and/or initiation of an antipsychotic prescription prior to age 18. In total, 11462 individuals met our inclusion criteria.

Fig. 1.

Flow chart of offenders included in the study.


Offenders in the study sample were predominantly men, with a mean age of 35 years at enrollment (table 1). The majority identified ethnically as White, and 11% were of self-reported Indigenous ethnicity. Roughly half of the sample (48%) had completed grade 12 and/or vocational or postsecondary training.

Table 1.

Sociodemographic Characteristics of the Study Population (n = 11462)

Variable Mean (SD)/ n (%)
Age at enrollmenta
 Mean (SD) 35.2 (11.0)
 Median (IQR) 34.1 (26.2, 42.6)
Men, n (%) 9022 (78)
Ethnicity, n (%)
 White 8210 (72)
 Indigenous 1289 (11)
 Other 1390 (12)
 Unknown 573 (5)
Education level, n (%)
 <Grade 10 1613 (14)
 Grade 10/11 3205 (28)
 Grade 12 3694 (32)
 Vocational/University 1757 (16)
 Unknown 1193 (10)

Note: IQR, inter-quartile range; SD, standard deviation.

aAge at enrollment was based on the date of initiation of antipsychotic treatment (between January 01, 1998 and March 31, 2015).

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Antipsychotic MPRs

Antipsychotic adherence and crime-related characteristics of the study sample are provided in table 2. The mean follow-up period approached 10 years, and overall MPR was 0.41. The percentage of participants who met or exceeded the recommended 0.80 adherence threshold dropped from 35% in the first 120 days of follow-up to 27% in the subsequent 120-day interval. Concurrently, the percentage with MPR below ≤0.19 increased from 21% to 46%, indicating that initial adherence levels were not sustained.

Table 2.

MPR and Crime-Related Characteristics of the Study Population (n = 11462)

Individual-Level Variable Mean (SD) / n (%)
Number of days with antipsychotic medication in follow-up period
 Mean (SD) 1475 (1544)
 Median (IQR) 883 (210, 2334)
Follow-up period, in years
 Mean (SD) 9.8 (5.1)
 Median (IQR) 9.7 (5.4, 14.3)
 Minimum, maximum 0.3, 17.2
 Total follow-up time (person years) 112, 275
MPR (during entire follow-up period)
 Mean (SD) 0.41 (0.32)
 Median (IQR) 0.36 (0.09, 0.70)
MPR (during 1st 120-day interval of follow-up period), n (%)
 ≤0.19 2392 (21)
 0.20–0.39 2052 (18)
 0.40–0.59 1435 (12)
 0.60–0.79 1628 (14)
 ≥0.80 3955 (35)
MPR (during 2nd 120-day interval of follow-up period), n (%)
 ≤0.19 5222 (46)
 0.20–0.39 1001 (9)
 0.40–0.59 955 (8)
 0.60–0.79 1197 (10)
 ≥0.80 3087 (27)
No. of offenses in the year prior to enrollment, mean (SD) 0.8 (1.9)
Any offense in the year prior to enrollment, n (%) 3341 (29)
Violent offenses in follow-up period
Mean no. of offenses (SD) 0.8 (1.8)
Median no. of offenses (IQR) 0 (0, 1)
Total no. of violent events in the entire cohort 8619
Rate (per 100 person years) 7.7
Nonviolent offenses in follow-up period
Mean no. of offenses (SD) 3.0 (7.3)
Median no. of offenses (IQR) 1 (0, 2)
Total no. of nonviolent events in the entire cohort 34733
Rate (per 100 person years) 30.9

Note: IQR, inter-quartile range; SD, standard deviation; MPR, medication possession ratio.

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The vast majority (87%) of prescribed antipsychotics were atypical (supplementary table 1). Of these, quetiapine (39%), olanzapine (19%), and risperidone (17%) were the most common. Only 7% of prescriptions were for clozapine. Loxapine and methotrimeprazine were the most commonly prescribed typical antipsychotics.

Justice Outcomes

Convicted violent offenses totaled 8619 throughout follow-up; averaging nearly one (0.8) violent offense per person during the study period, or a rate of 7.7 violent offenses per 100 person years. The rate of nonviolent offending was 4 times higher (30.9 per 100 person years), averaging 3 nonviolent offenses per person, and totaling 34733 during follow-up. Although the overall mean number of convicted offenses in the year prior to enrollment approached one (0.80) per person, these were committed by less than one-third (29%) of the cohort. Categories and frequencies of violent and nonviolent crime are provided in supplementary table 2.

GEE Negative Binomial Regression Analysis

Crude and adjusted rate ratios (ARR) and 95% confidence intervals (CI) are reported for each level of adherence compared to the reference (ie, ≥0.80; table 3). Each of the lower adherence quintiles was associated with significantly (P < 0.001) higher rates of both violent and nonviolent offending. The lowest level of MPR (≤0.19) was associated with the lowest mean rate of violent (ARR: 1.39; CI: 1.27–1.52) and nonviolent (ARR: 1.31; CI: 1.21–1.41) offending among the 4 comparison levels. The effect of antipsychotic adherence was consistently greater for violent offenses. Restricting the sample to complete cases (ie, those with complete information across all databases; n = 10182) and repeating the above analysis revealed a similar pattern of findings (supplementary table 3).

Table 3.

GEE Negative Binomial Regression Analysis Estimating the Association Between Medication Possession Ratio (MPR) and Violent/Nonviolent Crime (n = 11462a)

Variable Unadjusted Rate Ratio Adjusted Rate Ratio
(95% CI)b (95% CI)c
Violent offenses MPR
≤0.19 1.54 (1.41, 1.68)d 1.39 (1.27, 1.52)
0.20–0.39 2.68 (2.39, 3.01) 2.28 (2.03, 2.56)
0.40–0.59 2.58 (2.29, 2.91) 2.21 (1.96, 2.50)
0.60–0.79 1.95 (1.74, 2.19) 1.73 (1.55, 1.94)
≥0.80 Reference Reference
MPR (<0.80) 1.78 (1.64, 1.93) 1.58 (1.46, 1.71)
Nonviolent offenses MPR
≤0.19 1.50 (1.39, 1.62) 1.31 (1.21, 1.41)
0.20–0.39 2.01 (1.83, 2.21) 1.64 (1.50, 1.80)
0.40–0.59 1.86 (1.70, 2.03) 1.64 (1.50, 1.80)
0.60–0.79 1.65 (1.53, 1.78) 1.48 (1.37, 1.60)
≥0.80 Reference Reference
MPR (<0.80) 1.62 (1.52, 1.73) 1.41 (1.33, 1.50)

Note: GEE: generalized estimating equation; MPR: medication possession ratio; CI: confidence interval.

aDemographic information was unknown for 1280 participants (11%): age n = 3 (<1%); ethnicity n = 573 (5%); and education level n = 1193 (10%). Unknown age was replaced by mean age. Unknown ethnicity and education level were included as separate categories in the multivariable model.

b95% CIs and both unadjusted and adjusted rate ratios were estimated using robust standard errors.

cEach multivariable GEE model controlled for age at enrollment (centered, age 18), gender (men and women), ethnicity (White, Indigenous, other, and unknown), education level (<Gd. 10, Gd. 10/11, Gd. 12, Vocational/University, and unknown), use of substance disorder-related services (continuous variable), number of offenses in the previous year (continuous variable), number of 120-day intervals (continuous variable), and duration of follow-up in days (offset variable).

dBold indicates significant at P value <.001.

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The relationship between MPR and violent/nonviolent offending was also subject to sensitivity analysis by duration of available follow-up. Table 4demonstrates that MPR levels ≤0.79 were each associated with significantly higher rates of both violent (P < .001) and nonviolent (P < .05) offending compared with the reference group, regardless of the length of follow-up. Similar overall results were generated when individuals who died during follow-up were excluded from analyses. Sensitivity analysis estimating the association between MPR and violent/nonviolent offenses by diagnostic source (psychiatrist vs nonpsychiatrist) also yielded the same pattern of findings (supplementary table 4).

Table 4.

Sensitivity Analysis Estimating the Association Between Medication Possession Ratio (MPR) and Violent/Nonviolent Crime (by Death and Duration of Follow-Up)

Subgroup MPR Violent Crime Nonviolent Crime
ARRa (95% CIb) ARR (95% CI)
Surviving participants (n = 10514,c92%)
≤0.19 1.35 (1.23, 1.48)d 1.22 (1.22, 1.42)
0.20–0.39 2.29 (2.03, 2.58) 1.63 (1.49, 1.79)
0.40–0.59 2.26 (1.99, 2.56) 1.65 (1.50, 1.81)
0.60–0.79 1.70 (1.51, 1.91) 1.47 (1.36, 1.60)
≥0.80 Reference Reference
MPR (<0.80) 1.55 (1.43, 1.68) 1.41 (1.33, 1.51)
<5 years of follow-up (n = 2530, 22%)
≤0.19 1.57 (1.18, 2.09) 1.44 (1.17, 1.78)
0.20–0.39 2.31 (1.55, 3.44) 1.69 (1.29, 2.22)
0.40–0.59 2.18 (1.46, 3.27) 1.40 (1.08, 1.80)
0.60–0.79 1.89 (1.20, 2.96) 1.29 (1.00, 1.65)e
≥0.80 Reference Reference
MPR (<0.80) 1.77 (1.35, 2.32) 1.43 (1.19, 1.72)
5–<10 years of follow-up (n = 3395, 30%)
≤0.19 1.48 (1.24, 1.76) 1.28 (1.13, 1.45)
0.20–0.39 2.27 (1.84, 2.81) 1.51 (1.29, 1.78)
0.40–0.59 2.16 (1.71, 2.72) 1.59 (1.36, 1.86)
0.60–0.79 1.67 (1.34, 2.08) 1.41 (1.23, 1.61)
≥0.80 Reference Reference
MPR (<0.80) 1.64 (1.40, 1.92) 1.37 (1.23, 1.53)
≥10 years of follow-up (n = 5537, 48%)
≤0.19 1.36 (1.22, 1.51) 1.31 (1.18, 1.44)
0.20–0.39 2.28 (1.97, 2.65) 1.70 (1.50, 1.91)
0.40–0.59 2.24 (1.93, 2.61) 1.69 (1.50, 1.91)
0.60–0.79 1.74 (1.52, 2.00) 1.53 (1.38, 1.69)
≥0.80 Reference Reference
MPR (<0.80) 1.55 (1.41, 1.71) 1.43 (1.32, 1.55)

Note: ARR, adjusted rate ratio; CI: confidence interval; MPR, medication possession ratio.

aEach multivariable GEE model controlled for age at enrollment (centered, age 18), gender (men and women), ethnicity (White, Indigenous, and other); education level (<Gd. 10, Gd. 10/11, Gd. 12, and Vocational/University), use of substance disorder-related services (continuous variable), number of offenses in the previous year (continuous variable), number of 120-day intervals (continuous variable), and duration of follow-up in days (offset variable).

b95% CIs for the adjusted rate ratios were estimated using robust standard errors.

c948 participants (8%) who died during the study period were excluded from the analysis.

dBold indicates significant at P value <.001.

eItalics bold indicates significant at P value ≤.05.


Antipsychotic adherence at or above an MPR of 0.80 was associated with a significantly lower risk of nonviolent offending (up to 65%), and violent offending (up to 128%) when compared to all lower levels of adherence. To our knowledge, this is the first longitudinal population-level study to investigate the association between multiple levels of antipsychotic adherence and convicted offenses.

Contrary to our secondary hypothesis, the lowest adherence level (MPR ≤ 0.19) was not associated with a relatively high offense rate. Although symptom improvement and/or remission (leading to treatment discontinuation) could explain the association between low MPR and comparatively low rates of offending, existing studies suggest that antipsychotic persistence is enhanced by effective symptom control.30,31

Increasing levels of adherence (ie, from 0.00 to 0.79) were not associated with progressive decreases in rates of offending. Clinical practices that achieve relatively high levels of adherence may have a more marked effect on crime reduction than practices intended to achieve incremental improvements in adherence below the 0.80 level. Of note, we observed relatively less criminal activity among patients in the lowest tier of adherence (ie, ≤0.19), which may have been the result of severe symptomatology (and associated impaired function) and/or hospitalization. Alternatively, titration from medication due to symptom improvement and recovery may account for the observed relationship between low adherence and offending in these patients. Further research is needed to establish the relationship between levels of adherence, patient functioning, and crime. In addition, research is needed to investigate the relationship between levels of adherence and a broad range of additional outcomes (eg, psychiatric symptoms, side effects, etc.).

Our results are consistent with those of the PRIDE study,32 in which the use of long-acting injectable (LAI) antipsychotics was associated with longer time to treatment failure (including arrest and incarceration) when compared to oral formulations. Authors of the study attributed these results to more consistent treatment exposure (ie, higher rates of adherence) in participants treated with injectables; a conclusion reiterated by authors of a second randomized controlled trial published in the same year,33 and further reinforced by research demonstrating superior psychopathological outcomes associated with “full” adherence (100%) when compared to “non-full” adherence (80%–99.9%) to both oral and depot antipsychotics.34 Over an average follow-up period of 10 years, mean MPR in our offender cohort was about half (0.41) the recommended level. Efforts targeted at reaching ≥80% adherence thus present an achievable opportunity for substantial crime reduction and meaningful violence prevention. Moreover, criminal justice involvement is strongly associated with negative health outcomes for offenders,35 and has distinct consequences for public health.36 Given the relatively high prevalence of schizophrenia among justice-involved individuals, the promotion of high antipsychotic adherence may also reduce a range of harms experienced by an already vulnerable population.

A further observation of note is that adherence achieved in the first 120 days of our study was not sustained in the subsequent 120-day period. Viewed chronologically, the first observed time interval had the highest proportion of offenders (35%) at or above 80% adherence. In the second interval, this proportion had declined to 27%. This is consistent with existing—but limited—research demonstrating that adherence to antipsychotic medication is unstable over time.37 Although current practice guidelines recommend “indefinite and continuous” antipsychotic treatment,38 discontinuation is common and is associated with extremely high risk of relapse.39

The significant reduction in offending associated with ≥0.80 adherence to medication demonstrated in the current study reinforces the importance of identifying and building on effective practices used during the first months of prescription to achieve sustained adherence over the longer term—particularly among patients involved with the criminal justice system.

Strengths and Limitations

The current study extends existing research on the validity of 80% as a meaningful adherence threshold for antipsychotic medications and addresses a number of methodological constraints in previous studies (including the use of self-reported criminal history,12 binary adherence measurement,1 and relatively short periods of follow-up.40 We examined comprehensive administrative records from a large and well-defined population of offenders diagnosed with schizophrenia, spanning a mean observation period of nearly 10 years. Our study contributes novel outcome analysis by comparing guideline level adherence (≥80%) with lower levels (ie, ≤19%; 20%–39%; 40%–59%; 60–79%).

Nonetheless, our research has some limitations. Although MPR based on pharmacy records is a useful measure of adherence, it may overestimate actual ingestion of prescribed medication. Moreover, our dataset does not include the specific dosage prescribed to participants, and further research is needed investigating whether dose plays a role in promoting adherence and in reducing the risk of criminal recidivism. For reference, the strengths of all (oral) antipsychotic medications dispensed in British Columbia are presented in supplementary tables 5 and 6.

Medications administered in the hospital are not recorded in PharmaNet, and our analysis did not consider time at risk of offending (ie, time incarcerated). However, recent assessment of the BC offender population (n = 188625) demonstrated mean hospitalization of just 4.2 days, and mean custody convictions of merely 0.5 over a 5-year period (April 2007–March 2012).16

Although we maximized the use of available data by operationalizing MPR as a ratio, collapsing all prescribed antipsychotics into a single group potentially masked important variability between different medications and/or methods of administration (eg, LAIs), each of which warrants further research. Categorization of MPR in quintiles revealed important information about varying levels of adherence and our results lend support to the use of the 80% adherence threshold in scientific and clinical literature. Future research is needed to investigate the long-term associations between different levels of adherence and particular outcomes, specific formulations, and individual patient characteristics.

Existing literature suggests that untreated schizophrenia is associated with greater risk of police contact41 and violence.42 Large, longitudinal cohort studies have demonstrated significant reductions in violent recidivism among individuals when they were dispensed antipsychotic medication compared to when they were not.1,43 Nevertheless, a causal relationship between antipsychotic adherence and criminality cannot be inferred from the available evidence, and considerable debate remains over the relative importance of criminogenic factors vs psychotic symptoms in the treatment of mentally disordered offenders. Specifically, important correlates of criminal behavior, including personality traits (eg, impulsivity/aggression, poor self-control) and undiagnosed concurrent mental illness (eg, fetal alcohol spectrum disorders, personality disorders) were unaccounted for in the current multivariable model and may have resulted in residual confounding. Our findings may also have been subject to compliance bias, as treatment adherence captures unmeasured behaviors that may also lead to better patient outcomes (eg, willingness to comply with prescribed treatment, consistent engagement with health services and better patient insight).


The current study is the first to examine the full range of antipsychotic medication adherence in an offender population spanning multiple years and found that adherence above 80% was associated with a significantly reduced risk of offending compared to all lower levels of adherence. Investigation of the links between adherence, violence, and offending among patients diagnosed with schizophrenia is indicated using experimental designs and investigating measures to achieve high levels of adherence.

Our findings provide empirical evidence of the effectiveness of antipsychotic medication for reducing both violent and nonviolent offending when adherence levels meet or exceed the 0.80 threshold. Further investigation addressing the association between different levels of antipsychotic adherence and diverse relevant clinical and social outcomes is required to inform optimal prescribing practices and objectives for patients with schizophrenia, and to set the stage for more personalized approaches to pharmacotherapy.

Supplementary Material

Supplementary data are available at Schizophrenia Bulletin online.


S.N.R. receives funding from the Canadian Institutes of Health Research (MFE148262). S.F. receives research funding from Wellcome Trust (095806). J.M.S. receives research funding from the Canadian Institutes of Health Research (SCT – 151611), the British Columbia Ministry of Justice (2014s0040), and Health Canada (2009s0231).


The authors gratefully acknowledge the support of the British Columbia Inter-Ministry Initiative (IMRI) and members of the IMRI Steering Committee. S.N.R. would also like to express thanks for input and support provided by Dr Robert Hogg, Dr Simon Verdun-Jones, and Dr Stuart Kinner. The authors have

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Childhood Videotaped Social and Neuromotor Precursors of Schizophrenia: A Prospective Investigation

, Ph.D., , Ph.D., , M.D., , M.D., , M.D., and , Ph.D., Dr.Med.

OBJECTIVE: The authors examined videotaped behaviors of children who developed schizophrenia as adults and of comparison subjects to disclose possible social and neuromotor deficits foreshadowing later development of schizophrenia. METHOD: In 1972, a sample of 265 11–13-year-old Danish children were filmed under standardized conditions while they were eating lunch. The examination was part of a larger study investigating early signs of schizophrenia spectrum disorders. Many of the subjects had a parent with schizophrenia, leaving them at high risk for developing a schizophrenia spectrum disorder. In 1991, adult psychiatric outcome data were obtained for 91.3% (N=242). This study systematically analyzed the videotapes to determine whether the children who developed schizophrenia as adults evidenced greater social and/or neuromotor deficits than children who did not develop a psychiatric disorder and children who developed other psychiatric disorders. RESULTS: The findings from this study suggest that the brief videotaped footage of children eating lunch was able to discriminate between the individuals who later developed schizophrenia and those who did not. Specifically, the preschizophrenia children evidenced differences on measures of sociability and general neuromotor functioning (among boys) from the children who developed other psychiatric disorders and the children who did not develop a psychiatric disorder. CONCLUSIONS: Social and neuromotor deficits specific to children who develop schizophrenia in adulthood provide further support for a neurodevelopmental hypothesis of schizophrenia.

The majority of individuals with schizophrenia manifest the illness in the second or third decade of life (1), yet subclinical signs of neuropathology are already evident during adolescence (2) and possibly as early as birth and infancy (35). Although some research suggests that the early signs of schizophrenia are nonspecific and that no one sign predicts schizophrenia uniquely and effectively (6), other studies indicate that both social and neuromotor abnormalities in childhood are reliable developmental precursors of the disorder.

Social deficits exhibited before the onset of schizophrenia suggest that interpersonal difficulties precede recognizable psychotic symptoms. A unique study by Walker and colleagues (7) evaluated childhood home movies of schizophrenia patients and comparison subjects. The authors reported that girls who later developed schizophrenia showed fewer expressions of joy than did same-sex comparison subjects from infancy through adolescence; preschizophrenia boys showed nonsignificantly more negative expressions in preadolescence and early adolescence.

Longitudinal study of “high-risk” individuals (those having at least one parent with schizophrenia) provides an alternative opportunity to view the developmental course of schizophrenia. Several investigations have followed high-risk subjects through the age of risk, providing information regarding premorbid functioning and adult diagnostic outcome. In an investigation in the Copenhagen High-Risk Study (8), teachers noted more negative-type behavior (e.g., having difficulty making friends or being passive, socially unresponsive to peers, or unresponsive to praise or punishment from the teacher) among high-risk subjects who later succumbed to predominately negative-symptom schizophrenia than among those who developed predominately positive-symptom schizophrenia. In a study from the New York High-Risk Project incorporating adult diagnostic information, Amminger and colleagues (9) found more behavior problems in childhood among adults who developed a schizophrenia-related psychosis than among adults who developed anxiety or affective disorders, adults who developed substance abuse, or adults with no disorders. Although limited in number, these studies following high-risk subjects through adulthood provide compelling evidence for the developmental nature of social deficits in schizophrenia.

In addition to social deficits, researchers have also investigated neuromotor deficits in childhood preceding the development of schizophrenia. Walker et al. (10) evaluated the neuromotor functioning of preschizophrenia patients through the naturalistic observation of home movies filmed by parents during the patients’ childhoods. The results suggested more neurological soft signs (abnormalities without a known area of localization in the brain) and poorer motor skills than in the comparison groups. In a separate study of adolescents diagnosed with schizotypal personality disorder, Walker and colleagues (11) found a higher rate of involuntary movements than in adolescents with other diagnoses and normal comparison subjects.

Several studies investigating neuromotor functioning have followed subjects from childhood through the age of risk. Investigating a large birth cohort, Rosso and colleagues (12) found neuromotor deficits in children ages 4 and 7 who later developed schizophrenia. More recent follow-up studies from the New York High-Risk Project indicated that neuromotor deficits predicted schizophrenia spectrum disorders in adulthood (13).

Collectively, the studies reviewed suggest that schizophrenia is a longitudinal syndrome, with premorbid signs of social and neuromotor deficits already present during childhood. The current study was intended to replicate and extend earlier findings by examining observable behavior from childhood, using a sample of children ages 11–13 who were observed in 1972. Videotape records, the primary source of data in this study, were uniformly and systematically obtained in 1972 during preadolescence, before any of the subjects developed a psychiatric disorder. We now have DSM-III-R adult outcome data for these subjects based on structured psychiatric interviews and psychiatric hospital records obtained in 1992.

Given the literature supporting differences in neuromotor and social functioning between children who do and do not develop schizophrenia in adulthood, it was hypothesized that children who later developed schizophrenia would manifest more social and neuromotor deficits than 1) children who did not develop a mental illness and 2) children who developed a nonpsychotic disorder.

The current study was part of a larger longitudinal high-risk project investigating the precursors of schizophrenia. We have described the design of the study, the subject characteristics, and the premorbid and follow-up diagnoses in greater detail elsewhere (14).

Diagnostic Methods: The Parents

The present study investigated high-risk children in a major perinatal cohort of 9,182 deliveries in Copenhagen during 1959–1961. In order to identify high-risk children and comparison subjects, in 1969 the lifetime record of psychiatric admissions was checked through the Danish psychiatric record for the 18,012 parents of the birth cohort.

Subjects were drawn from a Danish birth cohort consisting of all children born between Sept. 1, 1959, and Dec. 31, 1961, at Rigshospitalet in Copenhagen (15). In 1972, a sample of 265 11–13-year-old children from this cohort was intensively examined (16). Of this sample, 242, falling into three groups, were available for follow-up examinations at ages 31–33. All children with a mother or father who had a psychiatric hospital diagnosis of schizophrenia comprised the first group (N=81). One group of comparison subjects consisted of 87 children who had a parent with a psychiatric record of hospitalization for a disorder other than schizophrenia. The remaining 74 subjects were comparison subjects drawn from the original cohort with no parental records of psychiatric hospitalization. An effort was made to match these subjects on the basis of gender, social class, parent’s age, and mother’s marital status.

Diagnostic Methods: The Offspring

In 1992, when the subjects were between 31 and 33 years of age, their psychiatric status was ascertained. A psychiatrist administered two structured clinical psychiatric interviews, the Structured Clinical Interview for DSM-III-R (SCID) (17) and the psychosis section of the Present State Examination (18). In addition, Danish psychiatric hospital records of the subjects were examined. A detailed coding scheme yielded DSM-III-R diagnoses. On the basis of the interviews and/or hospital records, we obtained adult diagnostic outcomes for 242 of the 265 subjects (91.3% successful follow-up after 20 years; 23 subjects had neither an interview nor hospital records) (Table 1). After complete description of the study to the subjects, written informed consent was obtained.

1972 Videotaping Procedures

In 1972, when the subjects were 11–13 years of age, they came to a laboratory at Kommunehospitalet in Copenhagen for a 1-day assessment. At noon on the day of the assessment, the researchers provided the subjects with a lunchtime meal in a specially designated room. The videotaping took place during lunch under highly standard conditions, by camera operators blind to psychiatric risk status and, obviously, blind to diagnostic outcome 20 years later.

Generally, two randomly paired children were examined each day. In the case of 41 subjects, lunch partners were not available. When two children were present, they sat on the two sides of the corner of a table facing the tripod-mounted video camera. The children, who were of the same age level, did not know each other before entering this situation. Some pairs of children began a conversation during their meal. The meal consisted of Danish open-face sandwiches. These sandwiches were constructed in layers and required some motor skills.

The camera was an Akai VT-100R black-and-white, 0.25-inch, reel-to-reel video and audio recorder new to the market that year, 1972 (Akai, Tokyo). The lighting, distance of the camera from the subjects, and sound recording level were not altered during the course of the study. During each recording, the camera angle was changed from 1) an initial focus on both children (2 minutes) to 2) a close-up of the subject sitting to the left (1 minute), 3) a close-up of the subject sitting to the right (1 minute), and a final focus on both children (1 minute). These changes were done with the same timing for all of the subject dyads. The camera operator made an effort to ensure that variations in the subjects’ videotaped behavior were not partly ascribable to variations in situational factors. These videotapes were transcribed onto videocassettes.

Training in Coding Procedures

We established a coding scheme for the videotapes sensitive enough to detect interindividual variability among the subjects. The coding scheme yielded 10 continuously distributed variables similar to variables established in previous video studies investigating early signs of schizophrenia (710). The number of instances of each behavior was noted. Figure 1 contains the coding form and coding instructions.

A research assistant was trained in the coding system. Together, this research assistant and one of us (J.S.) trained another research assistant. Training involved specific instructions followed by evaluation and discussion of independent work. Questions from the raters regarding the independent coding were addressed in regular training meetings to avoid drift; however, all coding decisions were made independently. All raters, including the principal investigator, were completely blind to adult diagnostic outcome.

Statistical Analysis

Coding of the videotapes resulted in 10 continuous measures of behavior. We analyzed the dimensionality of the 10 coding scores by using a principal components factor analysis. The factor analysis yielded three factors with an eigenvalue greater than 1. Consequently, we rotated the three factors using a varimax rotation procedure. The rotated solution yielded three interpretable factors: sociability, involuntary hand movements, and general neuromotor signs. The sociability factor accounted for 26.8% of the item variance, the involuntary hand movements factor accounted for 18.1%, and the general neuromotor factor accounted for 15.7%. One item, involuntary facial movements, loaded on both the involuntary hand movements factor and the general neuromotor factor at a value above 0.400 but did not differ by more than 0.100 in magnitude between factors. It did, however, load more strongly on the general neuromotor factor. Another item, other abnormal movements, loaded on both the involuntary hand movements factor and the general neuromotor factor at a value above 0.400 but loaded significantly higher on the general neuromotor factor. As a result, we assigned involuntary facial movements and other abnormal movements to the general neuromotor factor, leaving the second factor purely involuntary hand movements (Table 2).

To create scales representing the three factors, we first standardized the scores for the behavioral variables, setting them to equal means and standard deviations. We then summed the scores for all of the variables that loaded on each factor. To account for missing data, we divided the summed scores by the number of variables available per subject (missing data were rare).

To determine the level of interrater agreement between coders, a subset of subjects (N=50, 32.7% of the 153 subjects included in the analyses) was evaluated separately by the two raters. Two-way random, absolute agreement intraclass correlation coefficients (ICCs) for the three scales were 0.91 for sociability, 0.65 for involuntary hand movements, and 0.65 for general neuromotor signs. The value of Cronbach’s alpha for each scale was 0.83 for sociability, 0.73 for involuntary hand movements, and 0.52 for general neuromotor signs.

Given the limited number of schizophrenia subjects and the uniqueness of these data, we were concerned about type II error (not detecting a significant difference when a significant difference exists). Consequently, rather than employing omnibus tests to assess for overall group differences and correcting significance levels to reflect multiple tests, we used uncorrected-planned-comparison t tests as the primary statistical analyses assessing group differences on the scales for sociability, involuntary hand movements, and general neuromotor signs. While these practices minimized the chances of type II error, they increased the risk for type I error (detecting a significant difference when one does not exist). All statistical tests were two-tailed, and alpha levels were set at p=0.05.

Missing Data

Of the 265 original subjects videotaped in 1972, 23 either died or refused to participate. Additionally, 48 subjects did not have videotapes. As mentioned previously, the camcorder used was among the first personal video recording devices, using reel-to-reel technology. When the reel-to-reel tapes were converted to modern standards, a reel from some may have been missing, accounting for the 48 subjects without footage. The subjects without videotapes, however, did not systematically differ from the subjects with videotapes in terms of diagnostic outcome, sex, or psychiatric risk status (Table 3). Because of equipment failure, one subject who was given ratings for raised elbows, nystagmus-like eye movements, involuntary facial movements, involuntary hand movements, and other abnormal movements was not rated for smiles, laughs, vocalization responses, and initiated vocalizations.

As discussed in the Method section, every effort was made to standardize the conditions of the videotaping. Not every subject, however, had a lunch partner (41 subjects were without a partner). Although two subjects were invited for testing every day, occasionally only one came. The subjects without partners did not systematically differ from the subjects with partners in terms of diagnostic outcome, psychiatric risk status, or sex (Table 3). However, t tests revealed significant differences between those with and without partners on all three scales (Table 4). Because of these differences between partnered and nonpartnered subjects and the limited number of nonpartnered subjects, we excluded the nonpartnered subjects from further analyses. In total, we had 153 subjects with complete scores on the scales for general neuromotor signs and involuntary hand movements and 152 subjects with complete sociability scale scores (Table 3). In unreported analyses, the results for the partnered and nonpartnered subjects combined resembled the results for the partnered-only subjects.

We tested for potential confounding effects of socioeconomic status and sex on all three scales. Socioeconomic status at rearing did not significantly correlate with the scores on any of the three scales. Similarly, males and females did not significantly differ on the scales for sociability and involuntary hand movements. The males did, however, show higher scores on the general neuromotor scale than the females (males, N=81: mean=–0.02, SD=0.46; females, N=72: mean=–0.22, SD=0.40) (t=2.81, df=151, p<0.01).

Relation of Adult Psychiatric Outcome to Videotaped Childhood Behaviors

The mean scale scores by diagnostic group are presented in Table 5. Comparisons of mean scores on the sociability scale revealed that the children who later developed schizophrenia had lower scores than did the children who did not develop mental illness (t=4.48, df=87.8, p<0.001). These two groups did not significantly differ from each other on the scale for involuntary hand movements (t=–0.74, df=99, p=0.47) or the general neuromotor scale (t=1.94, df=99, p=0.06). When males and females were analyzed separately, the scores for general neuromotor signs did not significantly differentiate between an outcome of schizophrenia and an outcome of no mental illness (males: t=1.93, df=49, p=0.06; females: t=0.85, df=48, p=0.41). Although the findings were not significant at the p=0.05 level, the difference for male subjects approached significance.

In addition to the main hypotheses regarding the behavior of the preschizophrenia subjects in relation to that of the normal comparison subjects, we were also interested in the specificity of these effects to children who would later develop schizophrenia as compared to children who would later develop other psychopathology. We repeated the preceding analyses but compared subjects with an outcome of schizophrenia to those with an outcome of some other psychopathology on all three scales. Compared to the subjects who developed nonschizophrenia psychopathology, the schizophrenia group had significantly lower sociability scale scores (t=2.51, df=51.9, p=0.02). A higher general neuromotor scale score did not significantly differentiate an outcome of schizophrenia from other psychopathology (t=2.05, df=10.3, p=0.07). Among males, the score on the general neuromotor scale significantly differed between the schizophrenia group and the group with other psychopathology (t=3.36, df=30, p=0.002). Among females, however, the general neuromotor scale failed to significantly differentiate an outcome of schizophrenia from other psychopathology (t=1.19, df=20, p=0.25). The involuntary hand movements scale did not significantly differentiate the schizophrenia group from the other psychopathology group (t=–0.93, df=52, p=0.36).


Overall, the observations from these standardized videotapes suggest differences between children who do and who do not develop schizophrenia in adulthood. Specifically, the schizophrenia patients showed premorbid social deficits, and male schizophrenia patients showed a tendency toward premorbid neuromotor deficits (as measured by the general neuromotor scale but not the scale for involuntary hand movements) in relation to comparison subjects with no psychiatric diagnosis in adulthood. Furthermore, the findings from this study suggest impairments unique to schizophrenia. Differences were observed between the subjects with a schizophrenia outcome and those with no mental illness and between those with a schizophrenia outcome and those with an outcome of other psychopathology. We did not detect significant differences between outcome groups on the involuntary hand movements scale.

Overall, boys showed higher scores on the scale for general neuromotor signs than did girls. Similarly, Rieder and Nichols (19) and Marcus and colleagues (20) found more neuromotor impairment among high-risk boys than high-risk girls. Differences between boys and girls on the neuromotor scale may suggest differences in vulnerability to disruption of the early neural development responsible for neuromotor functioning.

The current investigation has several notable strengths. All measures for this study were prospective. The data were gathered 20 to 33 years before diagnosis, thus reducing the likelihood that the adult clinical picture influenced measurement of early childhood behaviors. We assessed the subjects at ages 11–13, before any overt signs of mental illness. In 1972, when the tapes were created, the researchers were blind to psychiatric risk status and, obviously, blind to diagnostic outcome. Additionally, all of the current research team members (raters, data entry assistants, statisticians) were blind to the adult diagnostic outcomes until after the coding of the videotapes.

The high-risk subjects from this study were selected from a Danish birth cohort consisting of all children born between Sept. 1, 1959, and Dec. 31, 1961, at Rigshospitalet in Copenhagen. Every child having a parent diagnosed with schizophrenia was included in our sample. Thus, rather than being selected through various means, the 81 identified high-risk subjects were representative of high-risk children in Denmark. Therefore, the 16 patients with schizophrenia in this sample are representative of genetically at-risk Danish children born around 1960 who later developed schizophrenia.

Previous work discerning social and neuromotor deficits in premorbid schizophrenia suffers from lack of standardized conditions (710). The protocol for this project, however, dictated strict standardization. The attention to a uniform and systematic protocol reduced measurement error.

This study also suffered from notable limitations. The 10 variables measuring the observed behaviors from the videotapes yielded three scales. Agreement between raters ranged from high for the sociability scale (ICC=0.91) to moderate for the involuntary hand movements scale (ICC=0.65) and the general neuromotor scale (ICC=0.65). The two neuromotor scales contained items that were more ambiguous. Subtle distinctions between behaviors likely resulted in less agreement between raters.

Measurement of internal consistency varied across the scales as well. The scale for involuntary hand movements showed moderate internal consistency (alpha=0.73). The general neuromotor scale showed only modest internal consistency (alpha=0.52). Low internal consistency may result from the low number of items in the scales and low behavioral frequencies of each item. Poorer reliability suggests that a scale might not measure a single factor and might contribute to a failure to reject the null hypothesis, particularly when the sample size is small. Despite these limitations, however, we still found the hypothesized significant effects on scores on the general neuromotor scale among boys.

This study suffers from sizable numbers of missing data. Of the 242 subjects with adult follow-up information, 48 subjects did not have videotapes. The subjects with and without tapes did not seem to systematically differ in terms of adult diagnostic outcome, sex, or psychiatric risk status. We therefore assume that the subjects we did have were representative of the original study sample. Furthermore, we also excluded 41 subjects who did not have partners. While the partnered and nonpartnered subjects differed on the scales, they did not significantly differ in terms of demographic characteristics. Most important, the findings from analyses of only the subjects with partners were similar to the results of tests on the combined group of subjects with and without partners.

We based our results on a relatively small number of patients with schizophrenia (N=10). Additionally, because the scores on the general neuromotor scale differed by sex, we analyzed boys and girls separately, further reducing our sample of patients. Our analyses may have lacked the power to detect significant differences and reduce our confidence in interpreting null findings as evidence that significant differences do not exist. Furthermore, significant differences observed between groups with small sample sizes should be viewed with caution.

The results from this study suggest that brief videotaped footage of children eating lunch can discriminate between individuals who later develop schizophrenia and individuals who do not. In particular, the children who developed schizophrenia in adulthood showed deficits on measures of sociability relative to children with an outcome of no mental illness. Boys who later developed schizophrenia showed nonsignificantly greater impairment on a measure of general neuromotor functioning than did boys who had an outcome of no mental illness. Additionally, the findings appear specific to schizophrenia, as children who later developed schizophrenia showed deficits in sociability and differences on a measure of neuromotor functioning (among boys) compared to children who developed other, nonpsychotic, psychopathology.

UK  Crown Prosecution Service   Use of Psychotherapy:

Thank you,  Ladies and Gentlemen,  for listening to this presentation and I hope that these materials can be helpful for your work also.

Connect on twitter:  @markfernando   

The talk’s literature review materials and web hyperlinks for further reading,  are to be at: 

Selected Bibliography for further reading:

Mark’s early education was in West London and North West London, then attending SOAS and LSE, graduated from the London School of Economics, University of London, with a BSc Honours Degree from LSE. Mark holds at postgraduate level, The Diploma in Psychology (Dip.Psych.) and The Advanced Diploma in Psychotherapy (Adv.Dip.Psych.), Doctoral Degree (PhD) that includes Psychotherapy and Psychology.  Mark’s postdoctoral qualifications are from University of Oxford, Harvard Medical School at Harvard University, Christ Church College (CCCU) Canterbury and University of Kent.  Mark is an Associate Faculty and Alumni member of the University of Oxford,  serving on the University of Oxford Committee for East Kent. An Invited Guest Faculty of Harvard Medical School, an Invited Fellow of the University of Kent and was the lead for the Advanced Research Centre for Comparative Bioethics.  Currently a member of the International Association for Forensic Psychotherapy, UK, a member of the Chartered College of Teaching, UK and serving as a member of  NHS Healthcare Trusts in Kent, London, Oxford and Cambridge. 

Connect on twitter:  @markfernando

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