A JAACAP PUBLICATION Connectjaacap.com/pb/assets/raw/Health Advance/journals... · The Boy Who...

JAACAP ConnectA J A A C A P P U B L I C A T I O N

SPRING 2017 • VOLUME 4 • ISSUE 2

PROMOTING DEVELOPMENT OF TRANSLATIONAL SKILLS AND PUBLICATION AS EDUCATION

Receiving the TorchOliver M. Stroeh, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Unaccompanied Latino Minors, Immigration, and Mental Health: An Opportunity for AdvocacyBarbara Robles-Ramamurthy, MD, Milangel T. Concepcion Zayas, MD, MPH, Lisa Fortuna, MD, MPH, MDIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Talking to Parents About Behavioral Problems in Children Following Prenatal Illicit Substance ExposureElizabeth Wagner, BA, Mary Margaret Gleason, MD, FAAP. . . . . . . . . . . . . . . . . 8

The Boy Who Lived Well: Harry Potter as a Novel Tool for Teaching Cognitive-Behavioral Therapy Skills to YouthMark Sinyor, MD, MSc, FRCPC, Mark Fefergrad, MD, FRCPC, Amy H. Cheung, MD, MSc, FRCPC, Steven Selchen, MD, FRCPC, Ari Zaretsky, MD, FRCPC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

The Tarasoff Duty to Warn in Child and Adolescent PsychiatryKim J. Masters, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

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2 Spring 2017 www.jaacap.com/content/connect

JAACAP Connect

Welcome to JAACAP Connect!What is JAACAP Connect?

All are invited! JAACAP Connect is an online companion to the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP), the leading journal focused exclusively on psychiatric research and treat-ment of children and adolescents. A core mission of JAACAP Connect is to engage trainees and practi-tioners in the process of lifelong learning via readership, authorship, and publication experiences that emphasize translation of research findings into the clinical practice of child and adolescent psychiatry.

Why do we need JAACAP Connect?

The field of child and adolescent psychiatry is rapidly changing, and translation of scientific liter-ature into clinical practice is a vital skillset that takes years to develop. JAACAP Connect engages clini-cians in this process by offering brief articles based on trending observations by peers, and by facilitating development of lifelong learning skills via mentored authorship experiences.

Who reads JAACAP Connect?

All students, trainees, and clinicians who are interested in child and adolescent mental health will benefit from reading JAACAP Connect, available online at www.jaacap.com/content/connect. AACAP members will receive emails announcing new quarterly issues.

Who writes JAACAP Connect?

You do! We seek highly motivated students, trainees, early career, and seasoned clinicians and researchers from all disciplines with compelling observations about child and adolescent psychiatry. We pair authors with

mentors when necessary, and work as a team to create the final manuscripts.

What are the content requirements for JAACAP Connect articles?

JAACAP Connect is interested in any topic relevant to pediatric mental health that bridges scientific findings with clinical reality. As evidenced by our first edition, the topic and format can vary widely, from neuroscience to teen music choices.

How can JAACAP Connect help with my educational requirements?

Motivated by the ACGME/ABPN Psychiatry Milestone Project©, JAACAP Connect aims to promote the devel-opment of the skillset necessary for translating scientific research into clinical practice. The process of science-based publication creates a vital set of skills that is rarely acquired elsewhere, and models the real-life thought process of translating scientific findings into clinical care. To bring this experience to more trainees and providers, JAACAP Connect aims to enhance mastery of translating scientific findings into clinical reality by encouraging publishing as education.

JAACAP Connect combines education and skill acqui-sition with mentorship and guidance to offer new expe-riences in science-based publication. We will work with students, trainees, early career, and seasoned physicians, regardless of previous publication experi-ence, to develop brief science-based and skill-building articles. Opportunities for increasing knowledge and skills through publishing as education will be available through continued contributions and direct involve-ment with the JAACAP Connect editorial team, using an apprenticeship model.

Start Thinking About Authorship With JAACAP Connect

What trends have you observed that deserve a closer look? Can you envision reframing key research findings into clinical care? Do you want to educate others on a broader scale, thereby improving the health of children around the country, the world? We encourage all levels of practitioners and researchers, from students to attendings, to join in and participate. All are welcome, and you are invited.

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http://breakthecycle.aacap.org/

http://www.aacap.org/

A J A A C A P P U B L I C A T I O NJAACAP Connect



Receiving the Torch

I write this introduction, my first as editor of Connect, with both excitement and a sense of privilege. I have greatly appreciated the opportunity over the previous

one-and-a-half years to work alongside Michelle Horner (Connect’s founding editor), the Connect editorial board, and the broader JAACAP team, to establish Connect as it is today. As a child and adolescent psychiatry residency training director, I value the mission of Connect, which is to engage trainees and practitioners in the process of lifelong learning via readership, authorship, and publica-tion experiences that emphasize translation of research findings into the clinical practice of child and adolescent psychiatry. I applaud all of the authors, readers, and editorial team members who make Connect possible.

It is my pleasure to introduce this issue of Connect, the articles of which outline the ever-expanding scope of our practice as child and adolescent psychiatrists and encourage us to broaden our efforts beyond the four walls of our offices, clinics, and hospitals.

Robles-Ramamurthy and colleagues (p. 5) echo the presidential initiative of AACAP President Gregory K. Fritz, MD,1 and encourage all child and adolescent psychiatrists to recognize the responsibility we share to become involved in larger-scale advocacy efforts—ones that extend beyond the individual patient. In reviewing the particular vulnerabilities and mental health needs of unaccompanied Latino immigrant children, the authors encourage us all to raise the torch higher: “Social justice and policy issues are well within the scope of practice for those who care for and promote the well-being, devel-opment, and mental health of children. These issues are important to public health and clinical practice as well as to global child psychiatry, imperatives to which we are all held accountable.” They also charge us and our institutions of higher learning and training to educate trainees about social justice and policy issues, to model the inclusion of advocacy efforts in the practice of our profession, and to encourage and facilitate our trainees’ early involvement in such efforts.

Wagner and Gleason (p. 8) next bring to light the vulner-abilities of children with histories of prenatal substance exposure (PSE) and their families. They highlight the important role that we, as child and adolescent psychi-atrists, can play through the provision of education to parents and families about the effects of PSE and the ways in which the parents can work to mitigate these effects through the caregiving environment. Wagner and Gleason encourage us to empower families with such knowledge, to combat the stigma of substance use disorders, to advocate for policies and services that may reduce PSE, and to call for further research that investigates both the effects of drugs of abuse on brain development and potential interventions for children affected by PSE.

Sinyor and colleagues (p. 15) challenge us to think creatively about ways to provide primary prevention of mental illness. They propose that the third book in J.K. Rowling’s series (Harry Potter and the Prisoner of Azkaban) may serve as a ubiquitous, engaging, and largely untapped resource through which to increase middle-schoolers’ mental health literacy and to teach basic cognitive-behavioral therapy skills that might prove universally beneficial and protective against the development of future clinical difficulties.

Rounding out this issue, Masters (p. 22) reminds us of potential limitations to the frequently perceived sanctity and inviolability of our professional four walls and asso-ciated clinician–patient confidentiality. He reviews the Tarasoff rulings and highlights circumstances in which our responsibilities may extend beyond our patients to include protecting others. He recommends that any such intervention provide the least possible disruption to the therapeutic relationship while effectively fulfilling our potentially dueling responsibilities.

Our current world is an extremely dynamic place. While the (increasingly) expansive scope of child and adoles-cent psychiatry may seem intimidating at times, the


Receiving the Torgh

4 Spring 2017BACK TO TABLE OF CONTENTS

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clear and broad need for our professional expertise wards off complacency and provides exciting opportu-nities for us to reach out and connect with diverse and, at times, unexpected allies. The tensions that may arise as we consider the well-being of the patient/family in front of us, of the community and populations outside of our workplace, and of our ourselves can be challenging. However, with increasing awareness of these poten-tially competing demands and associated deliberate thought and action, we perhaps may be more able to establish and assert our positions with growing balance and comfort.

Through this issue and those to come, I look forward to working with you all to promote Connect’s ongoing evolution and to ensure its pertinence to the devel-opment of authorship and to the reading clinicians’ practice of child and adolescent psychiatry.

Oliver M. Stroeh, MD Editor, JAACAP Connect

Reference1. Fritz GK. Presidential Address: Child and Adolescent

Psychiatry in the Era of Health Care Reform. J Am AcadChild Adolesc Psychiatry. 2016;55:3-6.

http://www.jaacap.com/

AACAP Award OpportunitiesFOR MEDICAL STUDENTS, RESIDENTS, AND EARLY CAREER PSYCHIATRISTS

RESIDENTS

AACAP Pilot Awards 2017 applications are closed. Stay tuned for 2018 updates.

AACAP Educational Outreach Programs (EOP) Application Deadline: June 30, 2017Provides the opportunity for residents to travel to AACAP’s Annual Meeting

Research Award for General Psychiatry Residents, Supported by Pfizer and Arbor Pharmaceuticals

Research Award for Child Psychiatry Residents and Junior Faculty focusing on Attention Disorders and/or Learning Disabilities, Supported by AACAP’s Elaine Schlosser Lewis Fund

Research Award for Child and Adolescent Psychiatry Residents and Junior Faculty, Supported by AACAP

AACAP Junior Investigator Award, Supported by AACAP’s Research Initiative2017 applications are closed. Stay tuned for 2018 updates.Provides $30,000 a year for two years for one child and adolescent psychiatry junior faculty

Provides $15,000 to members with a career interest in child and adolescent mental health research

MEDICAL STUDENTSAACAP Medical Student Summer Fellowships2017 applications are closed. Stay tuned for 2018 updates. Provides a $3,500 to $4,000 stipend for 12 weeks of research training and covers travel expenses for AACAP’s Annual Meeting

EOP for Child and Adolescent Psychiatry Residents, Supported by the AACAP Endowment, AACAP’s John E. Schowalter, MD, Endowment Fund, and AACAP’s Life Members FundEOP for General Psychiatry Residents, Supported by the AACAP Endowment

AACAP Life Members Mentorship Grants for Medical StudentsApplication Deadline: June 30, 2017Provides a travel grant of $1,000 for medical students to travel to AACAP’s Annual Meeting and network with leaders in the field

AACAP Jeanne Spurlock Minority Medical Student Research Fellowships in Substance Abuse and Addiction, Supported by the National Institute on Drug Abuse (NIDA) and AACAP’s Campaign for America’s Kids (CFAK)AACAP Summer Medical Student Fellowship Program, Supported by CFAK

For more information, visit www.aacap.org/awards.

AACAP Systems of Care Special Program Clinical Projects Scholarship, Co-sponsored by SAMHSA’s Center for Mental Health Services and AACAP’s Community-Based Systems of Care CommitteeApplication Deadline: June 30, 2017Provides support of $750 to attend AACAP’s Annual Meeting and present a poster on a systems-of-care-related topic

JUNIOR FACULTY

RESIDENTS AND JUNIOR FACULTY

*All awards contingent upon available funding.


https://www.aacap.org/AACAP/Awards/Award_Home.aspx

AACAP Distinguished Member Award Opportunities2017 applications are closed. Stay tuned for 2018 updates.

Academic Paper Awards 2017 applications are closed. Stay tuned for 2018 updates.

AACAP Norbert and Charlotte Rieger Psychodynamic Psychotherapy Award recognizes the best published or unpublished paper written by an AACAP member using a psychodynamic psychotherapy framework.

AACAP Robinson-Cunningham Award recognizes the best manuscript written by a resident during child and adolescent psychiatry training.

International Scholar Award Opportunities Application Deadline: July 14, 2017

AACAP Paramjit Toor Joshi, MD, International Scholar Awards recognize mid-career international physicians who primarily work with children and adolescents providing mental health services outside the United States.

AACAP Ülkü Ülgür, MD, International Scholar Award recognizes a child and adolescent psychiatrist or a physician in the international community who has made significant contributions to the enhancement of mental health services for children and adolescents.

For details about all awards, eligibility requirements, and for access to

applications and nomination information, visit www.aacap.org/awards.

AACAP Cancro Academic Leadership Award for master educators, which is offered in odd-numbered years, recognizes a currently serving Associate or Full professor, Chair, Dean, or equivalent rank for outstanding and sustained contributions to child and adolescent psychiatry education through teaching, mentorship, scholarship, and leadership.

AACAP George Tarjan, MD, Award for Contributions in Developmental Disabilities recognizes a child and adolescent psychiatrist and AACAP member who has made significant contributions in a lifetime career or single seminal work to the understanding or care of those with intellectual and developmental disabilities.

AACAP Irving Philips Award for Prevention recognizes a child and adolescent psychiatrist and AACAP member who has made significant contributions in a lifetime career or single seminal work to the prevention of mental illness in children and adolescents.

AACAP Jeanne Spurlock Lecture and Award on Diversity and Culture recognizes individuals who have made outstanding contributions to the advancement of the understanding of diversity and culture in children’s mental health, and who contribute to the recruitment into child and adolescent psychiatry from all cultures.

AACAP Norbert and Charlotte Rieger Service Program Award for Excellence recognizes innovative programs led by AACAP members that address prevention, diagnosis, or treatment of mental illnesses in children and adolescents, and serve as model programs to the community.

AACAP Sidney Berman Award for the School-Based Study and Treatment for Learning Disorders and Mental Illness recognizes an individual or program that has shown outstanding achievement in the school-based study or delivery of intervention for learning disorders and mental illness.

AACAP Simon Wile Leadership in Consultation Award, supported by the Child Psychiatry Service at Massachusetts General Hospital, acknowledges outstanding leadership and continuous contributions in the field of consultation-liaison child and adolescent psychiatry.






Unaccompanied Latino Minors, Immigration, and Mental Health: An Opportunity for Advocacy

Barbara Robles-Ramamurthy, MD, Milangel T. Concepcion Zayas, MD, MPH, Lisa Fortuna, MD, MPH, MDIV

Child and adolescent psychiatrists (CAPs) have a duty to be patient advocates in multiple ways. Indeed, the Child and Adolescent Psychiatry

Milestone Project’s inclusion of advocacy within the

systems-based practice competency recognizes this

role as a core element of practice. However, while training

programs focus on teaching advocacy for individual

patients’ needs, such as securing insurance coverage

for medical treatment or obtaining school accommoda-

tions, preparedness in public policy and social justice

domains is often limited. Accordingly, the current presi-

dent of the American Academy of Child and Adolescent

Psychiatry (AACAP), Dr. Gregory Fritz, has highlighted

advocacy as one of four areas that his presidential initia-

tive on integrated care will tackle.1 The main goals of this

article are to discuss the role of CAPs in advocacy efforts

as they apply to the vulnerable population of unaccom-

panied children from Central America, to discuss ways

in which CAP training programs can promote the special

interests and advocacy efforts of their trainees, and to

encourage all CAPs to consider ways to amplify their

voices and roles as children’s advocates.

Child Migration: History of the Problem

Between 1850 and 1930, more than 100,000 children

were sent from the northeast of the US to rural areas;

while some families were looking to adopt a child, many

families saw these children as aid for manual labor.2

These children, placed on “orphan trains” by their

parents or by welfare agencies due to homelessness,

were victims of poverty, culminating in their being sold

or offered to farmers. Meanwhile, in the early 1960s,

fearful parents wishing for a better future for their

children outside of an antidemocratic government sent

more than 10,000 children from Cuba.3

The current child migrant crisis in the US involves unac-companied minors fleeing violence in Honduras, El Salvador, Guatemala, and Mexico. While unaccompa-nied children from Latin America have been crossing the border in smaller numbers for decades, largely unnoticed by the media, the issue has been publicized due to the increased volume of child migrants appre-hended at the US–Mexico border.4 The humanitarian crisis prompting this exodus is unique in that it is a chronic and gradual forced displacement, in contrast to the high-acuity mass migrations associated with natural disasters or violent conflicts.

Mental Health Implications

Though limited systematic research has focused on the psychological experience of immigrant children, these minors are at high risk of trauma and harm. Many would meet legal criteria for asylum if they had an opportu-nity to tell their stories. The report by the United Nations High Commissioner for Refugees in 2014 notes that almost 50% of displaced children shared experiences of violence associated with organized crime, including drug cartels, gangs, or governmental corruption. In a Mexican sample, 38% of children reported having been recruited into and exploited for human smug-gling.5 These stressors, coupled with those experienced during the immigration process, predispose them to substance use, anxiety, and adjustment disorders. Upon reunification, stressful living conditions can hinder the capacities of parents to nurture their children’s socioemotional development.

How the children experience separation from family members, the social conditions in their home coun-tries, their immigration experiences, and the new envi-ronments and opportunities upon arrival in the US will influence their development and adaptation.6 Even




Unaccompanied Latino Minors, Immigration, and Mental Health

after arrival in the US, where they are seeking refuge, they continue to experience stressors added by the uncompassionate nature of our systemic immigration procedures. Additionally, given their language barrier, frequent lack of insurance, and high rates of placement in the foster care system, most of these children will not have the opportunity to seek and obtain needed mental health care. Depending on the clinical system and location in which they practice, CAPs may rarely inter-face with immigrant Latino children and other vulnerable populations, who are at the highest risk of psychiatric illness; the vulnerability of this population is therefore greatly worsened as their needs are under-recognized and often ignored by the health care system.

Opportunity for Advocacy

Children have rights, and it is our duty as health providers to foster policies and interventions in their best interest. Children coming from Central America or elsewhere should be protected in America. The high barriers they face to receiving mental health care and to maintaining mental health, as we have illustrated, require our advocacy to lower. Reform and progress do not happen by themselves. Whenever we stand up for an individual child or for a family, an extra step is needed to extend our actions into the larger community. CAPs have unique expertise in child development that should be brought to bear in educating policymakers dealing with the vulnerable population of unaccompa-nied Latino minors.

Our colleagues from the American Academy of Pedi-atrics (AAP) have set forth outstanding examples of promoting advocacy activities among members.7 We are grateful that, in these times of political discord, AACAP’s political action committee has encouraged members to engage in social policy activities. Dr. Fritz’s address to AACAP in January 2017 regarding the proposed immi-gration ban demonstrates AACAP’s commitment to the humane treatment of all individuals “without regard to their race, religion, ethnicity, or immigration status.”8 We are grateful that his message expanded past the effect of the immigration ban on the medical workforce into the greater needs of immigrant communities as a whole.

High-level advocacy is also illustrated by AACAP members Dr. Andres Pumariega and Dr. William Arroyo through their participation in an advisory committee created by the US Immigration and Customs Enforce-ment agency (ICE), which provided recommendations to improve detention practices of undocumented immi-grant children and families. Their report notes that the detention of migrant children and families by the US government has been “controversial since its inception,” and lists evidence-based recommendations for a more humane approach to detention practices for children and families. Most noteworthy was their primary recom-mendation that family detention be discontinued, stating that it should be presumed that “detention or the sepa-ration of families for purposes of immigration enforce-ment or management is never in the best interest of children.”9

A Path Forward

Following the examples of these AACAP leaders, CAP trainees and training programs must also focus on advocacy. The process begins by engaging in self-re-flection about one’s biases, lack of experience in navigating complex systems, interest or disinterest in advocacy, and knowledge about how one’s own skills and abilities are best utilized. Training programs can promote advocacy by creating opportunities for trainees. For example, training programs may develop clinical rotations tailored to the trainee’s interest. Part-nerships with other professionals such as lawyers, poli-ticians, and organizational leaders can promote the development of leadership skills in public health efforts. Additionally, exposure to CAPs involved in advocacy or those working in the public sector is important, thus creating mentorship opportunities. We have found such mentors by engaging with AACAP and APA committees and attending committee meetings, conference calls, or other events, such as the AACAP Legislative Confer-ence, creating opportunities to develop requisite leader-ship and advocacy skills.

Colleagues previously published in JAACAP verbatim accounts from refugee children to beautifully describe why it is imperative that CAPs continue their advocacy





and compassionate care to immigrant populations. They state that “one of the most pernicious effects of the politicization of immigration has been to obscure the humanity of those children traveling to this country.”10 These children’s integral well-being and their human rights are at stake. Silence and neutrality are not options for those working with developing human beings. Social justice and policy issues are well within the scope of practice for those who care for and promote the well-being, development, and mental health of children. These issues are important to public health and clinical practice as well as to global child psychiatry, impera-tives to which we are all held accountable.

Take Home Summary

Child and adolescent psychiatrists have an ethical responsibility to promote access to quality mental health care for vulnerable populations, such as unaccompanied Latino immigrants. Dr. Fritz has focused on advocacy during his presidency. We urge CAP training programs to promote advocacy efforts and for trainees to join AACAP commit-tees so that CAPs can have a larger impact at the population level.

References1. Ambler H. Five questions with: Dr. Gregory Fritz. Provi-

dence Business News. www.pbn.com. November 30,2015. Accessed March 31, 2017.

2. Schene P. Past, present, and future roles of Child Protec-tive Services. Future Child. 1998;8:23-38.

3. History: The Cuban children’s exodus. http://www.pedropan.org/category/history. Accessed January 5, 2017.

4. Childhood and Migration in Central and North America:Causes, Policies, Practices and Challenges. San Fran-cisco: Center for Gender and Refugee Studies, Universityof California Hastings College of Law, Universidad Centralde Lanus; 2015.

5. Children on the Run: Unaccompanied Children LeavingCentral America and Mexico and the Need for Inter-national Protection. A Study Conducted by the UnitedNations High Commissioner for Refugees Regional Officefor the United States and the Caribbean. Washington, DC:UNHCR, the UN Refugee Agency; 2014.

6. Fortuna L, Porche M. Clinical issues and challenges intreating undocumented immigrants. Psychiatric Times.www.psychiatrictimes.com. August 15, 2013. AccessedMarch 31, 2017.

7. Protecting Immigrant Children. American Academyof Pediatr ics. https://www.aap.org/en-us/advoca-cy-and-policy/federal-advocacy/Pages/ImmigrationReform.aspx. Accessed December 5, 2016.

8. AACAP Releases Statement on Immigration Execu-tive Orders. American Academy of Child and Adoles-cent Psychiatry. <https://www.aacap.org/AACAP/Press/Press_Releases/2017/Immigration_Executive_Orders.aspx> Accessed February 28, 2017.

9. Report of the DHS Advisory Committee on Family Resi-dential Centers. US Immigration and Customs Enforce-ment. https://www.ice.gov/sites/default/files/documents/Report/2016/ACFRC-sc-16093.pdf September 30, 2016.Accessed April 3, 2017.

10. Henderson S, Baily C. In their Own Words: Immigrationand Pediatric Mental Health in 2016. J Am Acad ChildAdolesc Psychiatry. 2016;55:833-834.

About the Authors

Barbara Robles-Ramamurthy, MD, is a Child and Adolescent Psychiatry fellow at the Children’s Hospital of Philadelphia.

Milangel T. Concepcion Zayas, MD, MPH, is an early career psychiatrist at Brattleboro Retreat in Vermont.

Lisa Fortuna, MD, MPH, MDIV, is director of Child and Adolescent Psychiatry, Boston Medical Center, Boston University School of Medicine.

Disclosure: Drs. Robles-Ramamurthy, Concepcion Zayas, and Fortuna report no biomedical financial inter-ests or potential conflicts of interest.


https://pbn.com/

http://www.pedropan.org/category/history

http://www.pedropan.org/category/history

http://www.psychiatrictimes.com/

https://www.aap.org/en-us/advocacy-and-policy/federal-advocacy/Pages/ImmigrationReform.aspx



http://www.aacap.org/AACAP/Press/Press_Releases/2017/Immigration_Executive_Orders.aspx



https://www.ice.gov/sites/default/files/documents/Report/2016/ACFRC-sc-16093.pdf

https://www.ice.gov/sites/default/files/documents/Report/2016/ACFRC-sc-16093.pdf

J. Michael Houston, MD Local Arrangements Chair

Micah J. Sickel, MD, PhD Local Arrangements Chair

Boris Birmaher, MD Program Chair

64TH ANNUAL MEETINGOCTOBER 23–28, 2017

WASHINGTON, DCWashington Marriott Wardman Park & Omni Shoreham Hotel

Visit www.aacap.org/AnnualMeeting/2017 for the latest information!

Save the Dates! AACAP Member Registration Opens Online: August 1, 2017

General Registration Opens Online: August 8, 2017Early Bird Registration Deadline: September 15, 2017

http://www.aacap.org/annualmeeting/2017





Talking to Parents About Behavioral Problems in Children Following Prenatal Illicit Substance Exposure

Elizabeth Wagner, BA, and Mary Margaret Gleason, MD, FAAP

Case: A 36-month-old girl with a reported history of prenatal substance exposure is brought to an outpatient pediatric clinic to establish care and receive immunizations to enroll in daycare. The father reports that he became custodial parent of the child in the past week, following the mother’s arrest for possession of an illegal substance. Previously, the child lived in another state with her mother and had limited contact with him. He is unaware of her medical history. When he brings her to the clinic, she is wearing her nightgown, and her hair is not brushed. She makes little eye contact and sometimes appears to actively avert her eyes. At the mention of her mother, she becomes more agitated, crying and tearing at the exam table paper, but uses few words. Her general physical exam is otherwise benign. Her father notes that he can’t get her to talk and that he is overwhelmed by her screams and tantrums. He wonders if her behavior is due to prenatal drug exposure, since her mother was “taking something” while she was pregnant.

Medical professionals are likely to encounter a situation similar to the one above during their careers given that prenatal substance exposure

(PSE) continues to affect many infants born in the US. Negative outcomes from PSE are varied, with the poten-tial to cause significant harm. PSE can lead to short-term sequelae such as low birth weight, intrauterine growth restriction, and neonatal abstinence syndrome (NAS), a form of opiate withdrawal. Long-term outcomes can include behavioral and cognitive problems and early initiation of substance use.1 Rates of PSE are difficult to estimate accurately because of stigma associated with reporting and inconsistent screening practices. Despite these difficulties, estimates exist for the proportion of children in the US who have been exposed prena-tally to an illicit substance such as marijuana, opioids, cocaine, and methamphetamine (see Table 1). For example, among a nationwide sample of approximately 70,000 randomly selected individuals in the US, 4.7% of pregnant women interviewed reported use of an illicit substance within the last month.2,3 For perspective, consider the rising incidence of neonatal abstinence syndrome, an outcome associated with prenatal opiate exposure. According to a study conducted using two nationwide inpatient databases, the incidence of infants born in the US showing signs of NAS has been rising

since 2000, from 1.2 per 1,000 live births in 2000, to 3.4 per 1,000 in 2009, and 5.8 per 1,000 in 2012.4,5

While perinatal outcomes following prenatal drug exposure have been fairly well documented, research of long-term outcomes is more limited and includes neuro-behavioral outcomes posing significant implications for clinicians, including child and adolescent psychiatrists, caring for children with a history of PSE. This article will discuss examples of large cohort studies and the methodological challenges, then describe psychoedu-cation statements clinicians can use based on current knowledge of long-term neurodevelopmental outcomes for children exposed prenatally to illicit substances. We will then share clinical and policy implications, as there are substantial opportunities in our field to advo-

Table 1. 2015 Drug Use Among Women Aged 15-44 by Pregnancy Status in Percentage

PREGNANT WOMEN %

NONPREGNANT WOMEN %

Illicit drugs 4.7 12.5

Illicit drugs other than marijuana

1.8 4.3

Tobacco products 13.9 23.6

Alcohol 9.3 54.8

Note: Table data were adapted from 3.


Prenatal Illicit Substance Exposure



catfor further research and services for these vulnerable children and families.

Methodologic Issues in PSE Research

There are multiple challenges in studying long-term outcomes related to PSE. Self-report of substance use by mothers may be an inaccurate report of fetal exposure due to a number of factors, including issues with underreporting due to lack of knowledge of exact substances used, difficulties recalling dose, recall bias, reliability of estimates of conception dates, and disclo-sure of a highly stigmatized, reportable, and potentially illegal activity. The timing of exposure affects outcomes variably depending on stages of fetal development during the PSE. Polysubstance use reporting compli-cates interpretation of outcomes since it is difficult to link specific exposures to specific outcomes. Studies of polysubstance use generally control for concurrent use statistically rather than in vivo. Prospective longitudinal cohort study designs necessary for long-term follow-up are limited by attrition (i.e., loss of some of the sample over time), and outcome may be affected by prenatal and postnatal environmental risk factors, which may moderate or mediate effects on the study outcomes.

Despite these challenges, a number of rigorous cohort studies reveal valuable findings about this population. For example, reviews indicate 14 different cohorts are included in studies of the effects of prenatal cocaine exposure on the developing child, including the Maternal Lifestyle Study, which has followed 1,000 children from birth into adolescence and young adulthood.6 The Infant Development, Environment and Lifestyle Study (IDEAL) is the only study currently in the US describing the effects of prenatal methamphetamine exposure and includes 320 children followed up to 7 years of age to date.7 Studies of opioid exposure show little consensus on long-term outcomes in children. Of the data that exists, methadone exposure is the most robust; however, there is a dearth of research specifically examining the effects of prenatal exposure to opiate prescription medication on long-term outcomes on development.1,6 The existing cohorts provide valuable information to describe the

behavioral effects of prenatal drug exposure on the developing child, albeit with limitations.

PSE Outcomes for Children and Talking Points for Families

The following section reviews the literature on PSE and outcomes in offspring, focusing on 1) perinatal outcomes, 2) longer-term psychiatric outcomes, and 3) caregiving environment. Each section is followed by a summary of clinical talking points that can be used to help families like the one presented above.

1. Perinatal Outcomes

Neonatal outcomes of PSE vary to some degree by substance but can include low birth weight, intrauterine growth restriction, NAS after opioid exposure, and other neurobehavioral effects (see Table 2).1 The signs of NAS are summarized in Table 3. Taken together, infants with PSE may be more difficult to soothe, and parents may find it harder to interpret the infant’s cues. Importantly, perinatal outcomes may be affected by other prenatal risk factors associated with PSE, including concomitant use of licit substances such as tobacco and alcohol, poor nutrition, physical or mental health problems, and environmental stressors including violence exposure.8,9

Clinical talking point: As a group, babies exposed to substances during pregnancy are at higher risk of some problems immediately after birth. However, not all babies show these problems. The specific risks for each child depend on a combination of factors that include the substance exposure, but also other prenatal experi-ences and factors.

Table 2: Signs of Neonatal Abstinence Syndrome

77 Increased muscle tone and activity

77 Seizures

77 Sweating

77 Nasal flaring

77 Irritability

77 Feeding problems

77 Diarrhea

Note: See Behnke et al.1 for further information.





2. Longer-Term Psychiatric Outcomes

The long-term psychiatric outcomes for these children are complex, with both biological and environmental processes likely contributing to risk and resilience.

In their review of follow-up studies of children with prenatal drug exposure, Lester and Lagasse identified 42 studies published between 1996 and 2008 specifically looking at prenatal exposure to cocaine (PCE), metham-phetamine, and opiates.6 In studies that controlled for confounding factors, PCE was associated with adverse outcomes in language, attention, externalizing behavior, and cognition. The Maternal Lifestyle Study (MLS)10

demonstrated the dose-dependent effects of PCE on emotional and behavioral problems. Heavy prenatal cocaine exposure was associated with an increase in the prevalence of internalizing, externalizing, and total problems in children between 3 and 7 years of age (21% vs. 16%). Importantly, despite the high media attention to cocaine exposure,11 the combined effects of prenatal and postnatal alcohol and tobacco were stronger than that of heavy cocaine abuse for all ages. It should be noted that the increased rates of adverse behavioral effects with PCE compared with non-exposed children were not evident until age 5, and that life events are strongly associated with behavioral presentation.12

Since that review in 2010, prenatal cocaine exposure in the MLS has also been shown to be related to a need for

special education services at 7 and 11 years old, espe-cially in children with psychopathology, a finding repli-cated in other but not all studies.13 There is a suggestion that behavioral dysregulation patterns are moderated by gender; however, findings are mixed.14 New research focuses on the role of the parasympathetic system and the hypothalamic-pituitary-adrenal axis as a mediator of dysregulation patterns.15

In the major study of prenatal methamphetamine exposure (PME), the IDEAL study, PME had no associa-tion with behavior problems at age 3, but was indirectly associated with emotional and behavioral problems at age 5, which was associated with executive functioning problems at age 6½.7 The association between PME and emotional and behavior problems at ages 5 and 7.5 was fully mediated by early adversity, measured at 5 time points before age 3, meaning that early adver-sity explains the variance in behavior problems, not the biological central nervous system effects of the meth-amphetamine exposure (see Figure 1). Methamphet-amine exposure is, however, associated with the risk of experiencing early adversity. This study highlights the potential for interventions that target the risk of early adversity in children with PME to reduce emotional and behavioral sequelae associated with PME.

Studies focused on opiate exposure alone are more limited by sample size and less rigorous control for

Table 3. Perinatal Findings in Substance-Exposed Infants

OPIATES COCAINE METHAMPHETAMINE CANNABIS

Birthweight

Congenital anomalies

– – (with the exception of risk of prenatal CVA)

– –

Withdrawal +++ – n/a –

Perinatal neurobehavioral changes

Diaphoresis, irritability, increased muscle tone, feeding problems, diarrhea

Irritability, state dysregulation, autonomic and behavioral dysregulation, limited alertness and orientation

Poor movement quality, decreased arousal, and increased stressa

Hyperstartle and tremor

Note: Table contents were adapted from Behnke et al.1 CVA = cardiovascular abnormalities.a For further information, see Smith LM, Lagasse LL, Derauf C, et al. Prenatal methamphetamine use and neonatal neurobehavioral outcome. Neurotoxicol Teratol. 2008;30:20–28.





confounding factors, but suggest the possibility of cogni-tive and emotional associations with the exposure.16

In the MLS, examining all PSE together, PSE predicted increases in behavioral dysregulation across adoles-cence directly, and indirectly was associated with increases in executive function difficulties.17 This indirect relationship was mediated by early adversity and behavioral dysregulation. Controlling extensively for potentially confounding variables, adolescents with PCE show persistent behavioral dysregulation and associated early substance use by age 16 compared to non-PCE youth (27.9% vs 19.9% in the MLS) and especially with higher rates of marijuana use (39.6% vs 16.3% in a smaller study).18,19 A similar pattern of early substance use has been reported in youth prenatally exposed to marijuana.20

Taken together, these studies suggest that children with PSE have higher rates of behavioral problems, execu-tive function difficulties, and early substance use and that early adversity is an important mediator in some of these associations.

Clinical talking point: As a group, older preschoolers, school-age children, and adolescents who were exposed to illicit substances during pregnancy may

have higher than usual rates of difficulty with paying attention and disruptive behaviors compared to other children their age.

3. Caregiving Environment

The current studies demonstrate that the caregiving environment plays a significant role in the behavioral outcomes of children exposed prenatally to drugs of abuse. As above, despite higher rates of some adverse behavioral outcomes, behavioral problems, executive function difficulties, and early substance use occur in a minority of children with PSE. Studies of behavioral and cognitive outcomes suggest early adversity, whose converse is a positive caregiving environment, appears to be a primary mediator of the association between PSE and behavioral dysregulation,17 suggesting quality caregiving can help ameliorate the risk for behav-ioral problems. One component of early adversity is a measure of the caregiving environment itself (the home) along with other components that shape a child’s safety and a parent’s ability to offer sensitive caregiving.

Clinical talking point: Despite the risk of difficulties children exposed to substances in utero may have, a supportive caregiving environment can be powerful and help a child develop the strengths and skills to overcome

Figure 1. Early adversity mediates association between prenatal methamphetamine exposure and behavioral/emotional problems. Note: see Abar et al.7 for further information.

Early adversity 0-3 years old(postnatal exposure, poverty, violence, maternal depression, poor caregiving quality, community violence, low social standing)

Prenatal methamphetamine exposure

Emotional and behavioral problems at 5 years old

Executive functioning problems at 6½ years old





these potential challenges. Prenatal exposure to drugs does not have to define the child’s life.

Clinical and Policy Implications

The extant literature suggests that children exposed prenatally to drugs of abuse exhibit more problem behaviors and attention problems than their non-ex-posed peers, although a minority of children develop these clinical-level problems. The studies also demon-strate the importance of the caregiving environment in shaping behavioral regulation. The caregiving envi-ronment, especially protection from early adversity including ongoing substance use, violence, maltreat-ment, and symptoms of parental psychopathology, has a significant effect on the behavioral outcomes of children exposed to drugs of abuse prenatally. The finding that the caregiving environment offers protec-tion is important since factors that contribute to the caregiving environment are responsive to change, and offer points of engagement for intervention in the lives of children.21

Existing literature demonstrates the substantial influ-ence of other factors, including influences at the indi-vidual, family, community, and society level, in the clinical outcomes of children exposed to illicit substances prenatally, as represented in Figure 2.22 Individual-level

factors are controlled for in the studies reviewed above; however, these factors can have a substantial influence on a child’s life. Public policy interventions can be devel-oped to engage factors at all levels (individual, family, community, and society) and to promote resilience in children exposed to drugs of abuse prenatally.

For example, intervening at the family level, physicians and other health care providers are in a position to support parental treatment for substance abuse disorders and treatment for concurrent psychopathology. According to the National Survey on Drug Use and Health, even though women who discover they are pregnant tend to reduce their previous use of drugs, alcohol, and tobacco, most resume use following delivery.23 Therefore, preg-nancy and following delivery is an ideal time to support parents in maintaining or working towards sobriety with clinical treatment and engagement of natural supports. Screening for substance use is an important topic of conversation at all postpartum healthcare-related visits.

Child psychiatrists can play an important role in educating parents about the effects of prenatal substance exposure when seeing children who may have been exposed to PSE. This education includes acknowledging the known physical, developmental, and mental health effects of PSE as well as debunking myths that suggest that PSE fully determines a child’s

Figure 2. Social–ecological model of factors influencing psychiatric outcomes following prenatal substance exposure. Note: see McLeroy et al.22 for further information.





life course. Children benefit when their caregivers see them as a unique individual with a balance of strengths and challenges and when caregivers are flexible in responding to a child’s unique developmental path.24 Clinicians can empower families with the knowledge that the caregiving environment, a modifiable factor, strongly influences a child’s development. At the community and society level, physicians can advocate for policies and services that may reduce PSE by supporting women of childbearing age to engage in treatment of substance misuse, increasing access to family planning resources, and improving access to treatment of psychiatric disor-ders and social support services to reduce isolation. Fighting against the stigma of substance abuse disor-ders is necessary for women to receive treatment and for babies to benefit. Clinicians, researchers, and families can move the field forward by calling for research that investigates the mechanisms and timing by which drugs of abuse alter brain development and study interven-tions for children affected by PSE.

To apply this discussion to the vignette at the outpa-tient pediatric clinic: the clinician can explain that the child may be at higher than typical risk of behav-ioral dysregulation; however, studies suggest that the independent emotional and behavioral effects of PSE may no longer be evident at 36 months. Her postnatal factors—including exposure to a caregiver with an active substance abuse disorder, possible developmental delays, recent caregiving disruption (from the likely primary attachment figure, the mother, and introduction to a relative stranger, father)—may be powerful contrib-utors to her behavior, such as her dysregulated mood with her father, as observed in the outpatient pediatrics office. Long-term psychiatric effects of prenatal drug exposure can include problems in attention, behavior, language, and executive functioning. However, early intervention that includes medical and social services can be of great benefit and target parents’ drug use, improve parental functioning, and better the caregiving environment.25,26

Take Home Summary

Use of illicit drugs during pregnancy carries signif-icant stigma; however, many infants exposed to drugs of abuse prenatally have the potential to develop typically, and effects of the exposure may be ameliorated by environmental enrichment and quality caregiving.

References1. Behnke M, Smith VC; Committee on Substance Abuse;

Committee on Fetus and Newborn. Prenatal substanceabuse: short- and long-term effects on the exposed fetus.Pediatrics. 2013;131:e1009-1024.

2. Center for Behavioral Health Statistics and Quality. 2017National Survey on Drug Use and Health (NSDUH): CAISpecifications for Programming (English Version). Rock-ville, MD: Substance Abuse and Mental Health ServicesAdministration; 2016.

3. Substance Abuse and Mental Health Services Adminis-tration (SAMHSA). Results from the 2015 National Surveyon Drug Use and Health: Detailed Tables. Rockville,MD: Center for Behavioral Health Statistics and Quality,SAMHSA; 2016.

4. Patrick SW, Davis MM, Lehmann CU, Cooper WO.Increasing incidence and geographic distribution ofneonatal abstinence syndrome: United States 2009 to2012. J Perinatol. 2015;35:650-655.

5. Patrick SW, Schumacher RE, Benneyworth BD, Krans EE,McAllister JM, Davis MM. Neonatal abstinence syndromeand associated health care expenditures: United States,2000-2009. JAMA. 2012;307:1934-1940.

6. Lester BM, Lagasse LL. Children of addicted women.J Addict Dis. 2010;29:259-276.

7. Abar B, LaGasse LL, Derauf C, et al. Examining the rela-tionships between prenatal methamphetamine exposure,early adversity, and child neurobehavioral disinhibition.Psychol Addict Behav. 2013;27:662-663.

8. Havens JR, Simmons LA, Shannon LM, Hansen WF.Factors associated with substance use during pregnancy:results from a national sample. Drug Alcohol Depend.2009;99:89-95.

9. Hutchins E, DiPietro J. Psychosocial Risk Factors Associ-ated With Cocaine Use During Pregnancy: A Case-ControlStudy. Obstet Gynecol. 1997;90:142-147.





10. Bada HS, Das A, Bauer CR, et al. Impact of PrenatalCocaine Exposure on Child Behavior Problems ThroughSchool Age. Pediatrics. 2007;119:e348-e359.

11. Okie S. “The Epidemic That Wasn’t.” The New York Times26 Jan. 2009. D1. Print.

12. Lester B, Das A, LaGasse L, et al. Prenatal cocaineexposure and 7–year outcome: IQ and special education.Pediatr Res. 2004;53:534a.

13. Levine TP, Liu J, Das A, et al. Effects of Prenatal CocaineExposure on Special Education in School-Aged Children.Pediatrics. 2008;122:e83-e91.

14. Sood BG, Nordstrom Bailey B, Covington C, et al. Genderand alcohol moderate caregiver reported child behaviorafter prenatal cocaine. Neurotoxicol Teratol. 2005;27:191-201.

15. Ross EJ, Graham DL, Money KM, Stanwood GD. Devel-opmental consequences of fetal exposure to drugs: whatwe know and what we still must learn. Neuropsychophar-macology. 2015;40:61-87.

16. Rosen TS, Johnson HL. Long-term effects of prenatal meth-adone maintenance. NIDA Res Monogr. 1985;59:73-83.

17. Fisher PA, Lester BM, DeGarmo DS, et al. The CombinedEffects of Prenatal Drug Exposure and Early Adversity onNeurobehavioral Disinhibition in Childhood and Adoles-cence. Dev Psychopathol. 2011;23:777-788.

18. Lester BM, Lin H, DeGarmo DS, et al. Neurobehav-ioral Disinhibition Predicts Initiation of Substance Use inChildren with Prenatal Cocaine Exposure. Drug AlcoholDepend. 2012;126:80-86.

19. Richardson GA, Goldschmidt L, Larkby C, et al. Effectsof prenatal cocaine exposure on adolescent development.Neurotoxicol Teratol. 2015;49:41-48.

20. Porath AJ, Fried PA. Effects of prenatal cigarette andmarijuana exposure on drug use among offspring. Neuro-toxicol Teratol. 2005;27:267-277.

21. Suchman NE, McMahon TJ, Slade A, Luthar SS. How earlybonding, depression, illicit drug use, and perceived supportwork together to influence drug-dependent mothers’ care-giving. Am J Orthopsychiatry. 2005;75:431-445.

22. McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecologicalperspective on health promotion programs. Health EducQ. 1988;15:351-377.

23. Center for Substance Abuse Treatment. Substance AbuseTreatment: Addressing the Specific Needs of Women.Rockville (MD): Substance Abuse and Mental HealthServices Administration (US); 2009.

24. Zeanah CH, Benoit D. Clinical applications of a parentperception interview in infant mental health. Child AdolescPsychiatr Clin N Am. 1995;4:539-554.

25. Emmalee S, Bandstra MD, Morrow CE, Mansoor E,Accornero VH. Prenatal Drug Exposure: Infant and Toddler Outcomes. J Addict Dis. 2010;29:245-258.

26. Minnes S, Lang A, Singer L. Prenatal tobacco, marijuana,stimulant, and opiate exposure: outcomes and practiceimplications. Addict Sci Clin Pract. 2011;6:57-70.

About the Authors

Elizabeth Wagner, BA, is a fourth-year medical and public health student at Tulane University School of Medicine and School of Public Health and Tropical Medicine. She will begin residency training in pediatrics and child and adolescent psychiatry in July 2017.

Mary Margaret Gleason, MD, FAAP, is an associate professor of Psychiatry and Behavioral Sciences and assistant professor of Pediatrics at Tulane University School of Medicine. She is interested in the clinical care of high-risk young children and their families.

Disclosure: Dr. Gleason has held stock in Merck but is now divested. Ms. Wagner reports no biomedical financial interests or potential conflicts of interest.


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The Boy Who Lived Well: Harry Potter as a Novel Tool for Teaching Cognitive-Behavioral

Therapy Skills to YouthMark Sinyor, MD, MSc, FRCPC, Mark Fefergrad, MD, FRCPC, Amy H. Cheung, MD, MSc, FRCPC,

Steven Selchen, MD, FRCPC, Ari Zaretsky, MD, FRCPC

After accidental injury, mental disorders including depression are the leading cause of disability globally in those aged 10-241 and the leading

cause of death (by suicide) in high-income countries.2 In the United States, the yearly cost of treating depression has been estimated to be $23 billion, and that number doubles when costs associated with lost productivity are included.1,2

Mental health literacy is considered a critical aspect for primary prevention of mental illness as it functions to increase awareness and recognition, decrease stigma, and encourage help-seeking.3 Cognitive-behavioral therapy (CBT) is an effective treatment for youth anxiety disorders, although it has not been shown to be more effective than other bona fide psychotherapies.4 These two approaches represent promising candidates for potential population-wide mental health interventions. Further, because psychoeducation is a core compo-nent of CBT, a CBT-based approach may be ideal for teaching mental health literacy.

School-based interventions for depression, often involving CBT or its elements, have been tested in several studies and often yield positive outcomes,5-8 although evidence is mixed as to whether teacher-led CBT inter-ventions are beneficial.5,9-10 One limitation of existing school-based programs is that most have focused on interventions for secondary school students,9 with only a small number specifically targeting younger children prior to the typical onset of mood and anxiety disor-ders.5-6,11 Given the dearth of available evidence-based primary prevention strategies in mental health, even a small impact of universally acquired CBT skills could likely be highly meaningful and could likely substantially reduce disease burden as well as healthcare costs.

Harry Potter as a Teaching Tool for Mental Health Literacy

The 7-volume Harry Potter series has sold over 450 million copies, placing the series among the best-selling books of all time.12 In addition to being adored by readers worldwide, a number of mental health experts have written scholarly articles about these books, high-lighting their value as a tool in psychotherapy as well as for mental health education. The novels have been identified as addressing central themes of adolescent development from a psychoanalytic framework,13,14 as well as addressing the major questions of Yalom’s exis-tential psychotherapy.15 The themes of bereavement in the series, most prominently Harry’s loss of his own parents, have been highlighted for use with youth who are processing and grieving their own losses.16

One of the major advantages of Harry Potter as a teaching tool is that readers are able to identify with the characters in the books and to ponder links with their own experiences including their relationships and emotional reactions.17 It has been shown that exposure to Harry Potter may decrease prejudice and stigma in readers.18 Perhaps most importantly, a key element of the books is Harry’s remarkable resilience in the face of severe adversity,19 an outcome that has important impli-cations for readers identifying with him since instilling hope may both protect youth from negative mental health outcomes and encourage help-seeking.

J.K. Rowling, the author of the Harry Potter series, has revealed to the popular press that she previously suffered from depression and was treated with CBT.20,21 Rowling has stated that the “dementor” characters that Harry first encounters in the third book in the series are patterned after her own experience of depression.20,22


Nitrous Oxide Use Disorder In Adolescents: The Serious Side Effects Of “Whippits”



Despite the fact that the Harry Potter series was appar-ently informed by Rowling’s experience of CBT, no one has explicitly analyzed the books using a CBT frame-work. This is a missed opportunity in the literature as the books may present a ubiquitous, untapped resource for dissemination of basic CBT skills.

Our group has argued that CBT and other basic mental health skills ought to be incorporated into youth educa-tion as a primary prevention intervention.23 In this article, we present a framework for teaching basic CBT skills and mental health literacy to middle-school youth using the third book in the Harry Potter series.

Harry Potter and the Prisoner of Azkaban as a Tool for Teaching CBT Skills

Common elements of CBT include identifying thoughts, emotions, and behaviours, learning specific strategies to

modify them (e.g. cognitive restructuring, exposure exer-cises, behavioral activation, problem solving), facilitating change through practice and homework, and relapse prevention.24,25 All of these elements are presented in a structured format following a typical sequence of CBT skill acquisition in Harry Potter and the Prisoner of Azkaban, the third book in the series.22 This will be summarized here according to topic and chapter(s).

Psychoeducation: Risk Factors for Depression (Chapters 1-4)

Chapters 1-4 provide a recap of the events of the first two books that functions as a synopsis of Harry Potter’s risk factors for experiencing depression (Table 1). The breadth and severity of these risk factors are notable since most youth will be able to find something with which they identify. These risk factors are also noteworthy because of the implicit message of hope

The Boy Who Lived Well

Table 1. Harry Potter’s Risk Factors for Depression22

RISK FACTOR DETAILS

Early parental loss 77 Parents murdered when he was an infant

Abuse and neglect 77 Aunt and uncle fail to acknowledge him

77 Relegated to his room

77 Confined to a cupboard under the stairs in Harry Potter and the Sorcerer’s Stone

High “expressed emotion” environment 77 Yelled at, insulted, scapegoated by aunt, uncle, and cousin

Socioeconomic deprivation 77 Belongings locked up

77 Given a sock for his birthday

Limited peer support system 77 Not allowed to have friends growing up

77 Prevented from communicating by phone with his best friend Ron

Victimization/bullying 77 Multiple antagonists including his cousin (Dudley), school rival (Malfoy), and teacher (Snape)

77 Discrimination for minority status (targeted for being a wizard in the muggle world and for being the son of a muggle-born mother by some of his wizard peers)

Medical illness 77 Facial scarring

77 Repeated hospitalizations for injuries (see Harry Potter and the Sorcerer’s Stone and Harry Potter and the Chamber of Secrets)

Stressful life events 77 School problems (believes he is facing expulsion)

77 Criminal justice problems (believes he has violated laws for underage wizards)

77 Homelessness

77 Under physical threat (Voldemort, serial killer/Sirius Black)





presented throughout the book: that with the right tools,

a person can overcome tremendous obstacles.

Psychoeducation About Depression (Chapter 5)

In chapter 5, Harry first encounters a dementor that,

as mentioned above, is a proxy for the experience of

depression. Table 2 presents both his experience of

the dementor and his reaction afterwards. Harry’s initial

response is to minimize the impact of the dementor and

decline help. This functions as psychoeducation about

help-seeking, a running theme in the novel; Harry invari-

ably feels worse when he keeps his worries to himself

and feels better when he shares them with trusted

confidantes. In this chapter, he is also introduced to

Professor Lupin, who can be thought of as Harry’s CBT

therapist throughout the book.

Introduction to Cognitive Distortions (Chapter 6)

Here the reader is first introduced to Professor

Trelawney, the divination teacher who is the embodi-

ment of distorted and magical thinking. She predicts a

negative future for Harry citing the “Grim,” a dog-shaped

death omen. Her lesson on reading tea leaves illustrates

common cognitive distortions such as catastrophizing,

jumping to conclusions, and the fortune-telling error.

This is in contrast to Harry’s subsequent interaction

with his teacher Professor McGonagall and his friend

Hermione, who are both paragons of rational thinking.

Professor McGonagall encourages cognitive restruc-

turing by highlighting the evidence that Professor

Trelawney’s predictions never come true. Following this

lesson, the book notes that “Harry felt better. It was

harder to be scared of a lump of tea leaves away from…

Professor Trelawney.”22(p110)

Introduction to Fear Hierarchies, Behavioral Activation, and Core Beliefs (Chapters 7-8)

In chapter 7, Professor Lupin begins formal CBT training

by introducing his class to the “boggart,” a creature that

takes on the shape of the thing that the person encoun-

tering it most fears. He invites the class to practice

neutralizing the boggart and, through the exercise,

presents several key concepts of CBT, including that

distress often takes a highly personal form but can have

a similar impact on everyone, and that developing skills

takes practice. The exercise ends with Lupin inadver-

tently triggering Harry’s negative core belief that he is

incompetent by stopping him before he can take part.

Harry assumes that this is because Lupin thinks he is

weak and cannot succeed, when in fact Lupin is worried

that the boggart will turn into Harry’s arch-nemesis, Lord

Voldemort, and terrify the class. Chapter 8 provides

powerful evidence to disconfirm Harry’s core belief of

his own incompetence through the introduction of a

fear hierarchy, behavioral activation, and explicit core

belief work. Lupin continues his lessons by encouraging

the students to gradually expose themselves to and

master increasingly difficult magical creatures. Harry is

encouraged to resume activities that give him a sense

of pleasure and accomplishment, chiefly Quidditch,

a sport at which he excels. Finally, Lupin meets with

Harry, expresses his confidence in him, and provides

evidence that Harry’s worries about the boggart were a

cognitive distortion.

Table 2. Harry Potter’s Experience of the Dementor as a Metaphor for Depression22

REACTION DURING EXPOSURE

77 Perceives that time slows down

77 Feels like he will never be cheerful again

77 Experiences heightened awareness of his environment

77 Experiences confusion/a mysterious feeling that is experienced as intensely unpleasant

77 Feels physical sensations of intense cold, shortness of breath, drowning

77 Feels unable to move

77 Experiences painful recollections of past trauma

REACTION AFTER EXPOSURE

77 Disorientation

77 Embarrassment, worries about what others think

77 Weakness, vulnerability

77 Worries about it happening again

77 Reluctance to seek help/go to the hospital wing





Setbacks (Chapters 9-11)

Problems and setbacks are aspects of CBT treatment that function as opportunities to re-evaluate and refine the treatment plan.25 In chapter 9, Harry again encoun-ters a dementor and then loses at Quidditch for the first time in his life. He experiences grief, embarrassment, disrupted sleep, and a renewed reluctance to share his problems with others. He worries that the Grim will haunt him for the rest of his life. This depiction of his fear of relapse illustrates a common feature of early recovery from depression.26 Lupin continues cognitive restruc-turing work, targeting Harry’s feelings of shame.

Putting Skills Into Practice (Chapters 12-16)

In chapter 12, Lupin begins formal anti-dementor lessons with Harry. He warns Harry that this is a challenging task even for experienced adults and reassures him that he can overcome a dementor. This provides a parallel to the notion that just as many adults struggle with over-coming depression, youth can learn strategies to do so, as well. Harry begins tentatively, but sees early gains. With renewed confidence, he resumes his pleasurable activity, Quidditch, fends off bullies who have dressed as dementors to frighten him, and wins the match for his team. Shortly after that, during end-of-term exams, he receives full marks for dispatching a boggart and then actively challenges distorted thinking from Professor Trelawney, who presents him with a fortune-telling error during his oral exam.

Core Belief Work, Part II (Chapters 17-20)

By this stage, Harry has gathered enough evidence and done sufficient core belief work to have overcome his belief that he is incompetent. However, his second major negative core belief is addressed in chapters 17-20. Harry is an orphan who has been left with no meaningful connection to his parents. He believes that he is alone. Adding to this is his belief that his own godfather and parents’ former best friend, Sirius Black, is a serial killer who betrayed his parents and caused their deaths. In chapter 18, Harry has the chance to capture Sirius and turn him over to the dementors to be executed, but instead pauses to gather evidence

and ultimately learns that Sirius is a good man who was framed and has actually been trying to help him. This demonstrates cognitive flexibility and openness to other ways of thinking, of which Harry was not capable at the beginning of the book. By being both flexible and open, he discovers that he has the love and support of his parents’ oldest friends, Sirius and Lupin, a powerful refutation of the notion that he is alone.

Consolidation and Relapse Prevention (Chapters 21-22)

CBT commonly terminates with a review of learning, rein-forcement that patients now have many skills that they can draw upon if symptoms re-emerge, and planning for how they will respond to challenges after the therapy.25 In chapter 21, Harry and Hermione use a “time-turner” to go back in time with the knowledge that they have gained to create a different outcome in which Sirius’s life is saved. Harry neutralizes a large group of dementors and tells Hermione, “I knew I could do it this time…because I’d already done it. Does that make sense?”22(p412) This underscores Harry’s new understanding that his CBT skills allow him to anticipate and master challenges. The book concludes with Lupin reaffirming Harry’s learning and noting that he is no longer needed, mirroring the CBT approach whereby patients are encouraged to view themselves as their own therapists.25

Discussion and Next Steps

Based on the above, Harry Potter and the Prisoner of Azkaban is a promising and largely untapped resource for teaching CBT skills to youth. Potential advantages include that (a) as one of the best-selling novels of all time, copies of the book are ubiquitously available world-wide, meaning that it has the potential to be applicable and relevant across countries and school systems; (b) it communicates the core concepts of CBT elegantly in the context of a highly engaging narrative and; (c) it does so with characters to whom youth can relate. The Harry Potter novels are already in wide use in classrooms for the purpose of encouraging general literacy,27 and there is a rich tradition of using novel study as a means of teaching youth about the world and about their own





life experiences.28 We propose that studies of the use of Harry Potter and the Prisoner of Azkaban should be undertaken in middle school classrooms to deter-mine whether, as we anticipate, it is useful in advancing mental health literacy. School-based curricula could teach basic CBT principles as they relate to the book and encourage students to reflect on how the skills that Harry is learning could apply to themselves or their friends and family.

This approach would also require basic CBT education for teachers as well as support from local mental health resources should challenging questions arise or should students be identified as requiring mental health inter-ventions. While we acknowledge, as described above, that evidence for universal, teacher-led mental health literacy programs is mixed at best, the potential use of Harry Potter for this purpose is sufficiently unique to merit consideration.

While the novel is well-suited to impart basic CBT skills in the classroom, it could also easily be adapted for use as a therapeutic aid in mental healthcare settings or in the home environment. Clinically, the novel could continue to function as a reference for patients and be paired with standard CBT exercises such as thought records and formal behavioral activation plans. Indeed, under ideal circumstances, youth patients presenting with mood and/or anxiety disorders would have already read the book in this context in school and would enter therapy already familiar with the concepts. This could facilitate both the efficiency and depth of CBT. At home, a parental guide could accompany the novel so that parents also learn some basic CBT skills and are supported in trying to have these conversations with their children in a supportive environment.

We acknowledge several limitations to this approach. First, since this is the third book in the series, reading the first two novels would be a prerequisite for an optimal understanding of the details and plot of the story. Second, for certain children, the written words in a chapter book may seem inaccessible and steps would need to be taken to facilitate other modes of learning such as having the book read aloud. Third, cultural

sensitivity is an important consideration, and we don’t necessarily advocate for a global Harry Potter solution—in some areas, local traditions and stories may be much more pertinent. In this light, our Harry Potter approach is only one suggested template. Finally, while the cost of these books is modest and they are readily available at many public libraries, students and families struggling with poverty may have challenges procuring the text.

Conclusion

There is a demonstrated need for improved mental health literacy among youth, and Harry Potter and the Prisoner of Azkaban is a ubiquitous resource that can create a rich and accessible representation of CBT prin-ciples for young people. It has the potential to reach youth worldwide for this purpose. Whether its use will affect mental health literacy and outcomes has yet to be established empirically.

Take Home Summary

Harry Potter and the Prisoner of Azkaban is one of the best depictions of a youth learning cogni-tive-behavioral therapy skills in literature. The novel represents a potentially untapped resource for imparting CBT skills to youth in the classroom and beyond, which merits further attention.

References1. Gore FM, Bloem PJ, Patton GC, et al. Global burden of

disease in young people aged 10-24 years: a systematicanalysis. Lancet. 2011;377:2093-2102.

2. Patton GC, Coffey C, Sawyer SM, et al. Global patterns ofmortality in young people: a systematic analysis of popu-lation health data. Lancet. 2009;374:881-892.

3. Kutcher S, Wei Y, Morgan C. Successful Application of aCanadian Mental Health Curriculum Resource by UsualClassroom Teachers in Significantly and SustainablyImproving Student Mental Health Literacy. Can J Psychi-atry. 2015;60:580-586.

4. James AC, James G, Cowdrey FA, Soler A, Choke A.Cognitive behavioural therapy for anxiety disorders inchildren and adolescents. Cochrane Database Syst Rev.2015;(2):CD004690.

5. Stallard P, Skryabina E, Taylor G, et al. Classroom-basedcognitive behaviour therapy (FRIENDS): a cluster





randomised controlled trial to Prevent Anxiety in Children through Education in Schools (PACES). Lancet Psychiatry. 2014;1:185-192.

6. Manassis K, Wilansky-Traynor P, Farzan N, Kleiman V,Parker K, Sanford M. The feelings club: randomizedcontrolled evaluation of school-based CBT for anxious ordepressive symptoms. Depress Anxiety. 2010;27:945-952.

7. Carnevale TD. Universal adolescent depression preven-tion programs: a review. J Sch Nurs. 2013; 9:181-195.

8. Lai ES, Kwok CL, Wong PW, Fu KW, Law YW, Yip PS. TheEffectiveness and Sustainability of a Universal School-Based Programme for Preventing Depression in ChineseAdolescents: A Follow-Up Study Using Quasi-Experi-mental Design. PLoS One. 2016;11:e0149854.

9. Calear AL, Christensen H. Systematic review of school-based prevention and early intervention programs fordepression. J Adolescence. 2010;33:429–438.

10. Wahl MS, Adelson JL, Patak MA, Pössel P, Hautzinger M.Teachers or psychologists: who should facilitate depres-sion prevention programs in schools? Int J Environ ResPublic Health. 2014;11:5294-5316.

11. de Girolamo G, Dagani J, Purcell R, Cocchi A, McGorryPD. Age of onset of mental disorders and use of mentalhealth services: needs, opportunities and obstacles.Epidemiol Psychiatr Sci. 2012;21:47-57.

12. BBC News. Harry Potter series to be sold as e-books.http://www.bbc.com/news/entertainment-arts-13889578.June 23, 2011. Accessed April 22, 2016.

13. Rosegrant J. The deathly hallows: Harry Potter andadolescent development. J Am Psychoanal Assoc.2009;57:1401-1423.

14. Noctor C. Putting Harry Potter on the couch. Clin ChildPsychol Psychiatry. 2006;11:579-589.

15. Thunnissen M. Harry Potter, script, and the meaning oflife. Transactional Analysis J. 2010;40:32-42.

16. Brewer A. Review of the children who lived: Using HarryPotter and other fictional characters to help grieving childrenand adolescents. Contemp Fam Ther. 2009;31:68-69.

17. Das R. ‘To be number one in someone’s eyes ...’: Chil-dren’s introspections about close relationships in readingHarry Potter. Eur J Commun. 2013;28:454-469.

18. Vezzali L, Stathi S, Giovannini D, Capozza D, Trifiletti E.The greatest magic of Harry Potter: Reducing prejudice.J Appl Soc Psychol. 2015;45:105-121.

19. Provenzano DM, Heyman RE. Harry Potter and the resil-ience to adversity. In Mulholland N, ed. The psychologyof Harry Potter. Dallas, TX: BenBella Books; 2007:105-119.

20. Dunbar P. I hit rock bottom over Harry Potter: J K Rowlingreveals how instant fame and a ‘tsunami’ of beggingletters drove her to therapy. The Daily Mail. http://www.dailymail.co.uk/news/article-2207319/J-K-Rowling-re-veals-hit-rock-Harry-Potter-fame.html#ixzz46qcB5HU6.September 23, 2012. Accessed April 25, 2016.

21. Johnson S. JK Rowling contemplated suicide. The Tele-graph. http://www.telegraph.co.uk/news/ uknews/1582552/JK-Rowling-contemplated-suicide.html. March 28, 2008.Accessed April 25, 2016.

22. Rowling JK. Harry Potter and the Prisoner of Azkaban.New York: Scholastic; 1999.

23. Sinyor M, Fefergrad M, Zaretsky A. Cognitive behaviouraltherapy or antidepressants for acute depression? BMJ.2015;351:h6315.

24. O’Donohue WT, Fisher JE. The Core Principles of Cogni-tive Behavior Therapy. In O’Donohue WT, Fisher JE, eds.Cognitive behavior therapy: core principles for practice.Hoboken, NJ: Wiley; 2012.

25. Beck J. Cognitive behavior therapy: basics and beyond.2nd ed. New York: Guilford Press; 2011.

26. Henderson AR. A substantive theory of recovery fromthe effects of severe persistent mental illness. Int J SocPsychiatry. 2011;57:564-573.

27. Driscoll B. Using Harry Potter to teach literacy:Different approaches. [References]. Cambridge J Educ.2013;43:259-271.

28. Courtland MC, Gambell TJ. Young adolescents meet liter-ature: Intersections for learning. Vancouver, BC: PacificEducational Press; 2000.

http://www.bbc.com/news/entertainment-arts-13889578

http://www.dailymail.co.uk/news/article-2207319/J-K-Rowling-reveals-hit-rock-Harry-Potter-fame.html#ixzz46qcB5HU6

http://www.dailymail.co.uk/news/article-2207319/J-K-Rowling-reveals-hit-rock-Harry-Potter-fame.html#ixzz46qcB5HU6

http://www.telegraph.co.uk/news/uknews/1582552/JK-Rowling-contemplated-suicide.html

http://www.telegraph.co.uk/news/uknews/1582552/JK-Rowling-contemplated-suicide.html






About the Authors

Mark Sinyor, MD, MSc, FRCPC, is an assistant professor in the Department of Psychiatry, University of Toronto, and a psychiatrist with Sunnybrook Health Sciences Centre, Toronto.

Mark Fefergrad, MD, FRCPC, is an assistant professor and postgraduate training director in the Department of Psychiatry, University of Toronto, and a psychiatrist with Sunnybrook Health Sciences Centre, Toronto.

Amy H. Cheung, MD, MSc, FRCPC, is an associate professor in the Department of Psychiatry, University of Toronto, and a psychiatrist with Sunnybrook Health Sciences Centre, Toronto.

Steven Selchen, MD, FRCPC, is an assistant professor in the Department of Psychiatry, University of Toronto, and a psychiatrist with Sunnybrook Health Sciences Centre, Toronto.

Ari Zaretsky, MD, FRCPC, is an associate professor in the Department of Psychiatry, University of Toronto, and the psychiatrist-in-chief, Sunnybrook Health Sciences Centre, Toronto.

Disclosure: Dr. Sinyor has received grant support from the American Foundation for Suicide Prevention, the Physicians’ Services Incorporated Foundation, the Dr. Brenda Smith Bipolar Fund, the University of Toronto Department of Psychiatry Excellence Fund, and the Innovation Fund of the Alternative Funding Plan from the Academic Health Sciences Centres of Ontario. Dr. Fefergrad receives residuals from two cognitive-behav-ioral therapy (CBT) books published by W.W. Norton and Company. Dr. Cheung has received grant support from Ontario Mental Health Foundation, Canadian Institutes of Health, Ministry of Health and Long Term Care Ontario, and Physicians’ Services. Dr. Zaretsky receives residuals from one CBT book published by W.W. Norton and Company. Dr. Selchen reports no biomedical financial interests or potential conflicts of interest.

AACAP offers resources and programs to nurture a new generation of child and adolescent psychiatrist leaders. Visit the AACAP website and find out about the opportunities available to you!

Value: I loved meeting and receiving wisdom from the

Owls as well as the many other mentors at AACAP who

are at different stages in their careers, including

residents and fellows. I was provided with valuable

guidance for applying to residencies and pursuing

extracurricular activities in the field of Child and

Adolescent Psychiatry. I was also grateful to connect

with other trainees who share similar interests – they

have since become good friends, co-residents and col-

leagues, and even co-collaborators on research and

other projects.

Value: I had never considered myself an “advocate”

before this experience. The conference gave me the

practical tools and confidence to meet with legislators

to voice my support for causes I believe in, most

notably regarding children’s mental health. The most

powerful and memorable aspect of this experience was

listening to clinicians share compelling patient

stories and to family advocates discuss their own lived

experiences. The energy of the AACAP advocacy

community is inspiring.

Joined AACAP: September 2013

Position: Resident Physician, PGY-1, Psychiatry Residency Program, Child and Adolescent Psychiatry Track

Employer: Massachusetts General Hospital/McLean Hospital

CAP Interests: Transgender and gender-nonconforming youth, child abuse/neglect, and autism spectrum disorders

2014 AACAP Legislative Conference Travel Grant

Cordelia Ross, MD, MS

2014, 2015 Life Members Mentorship Grant for Medical Students

AACAP Award Spotlight

For more information, visit: www.aacap.org/awards





The Tarasoff Duty to Warn in Child and Adolescent Psychiatry

Kim J. Masters, MD

Case: “John” is a 15-year-old male being evaluated for the first time by a child and adolescent psychiatrist for depression. During the clinical interview, John says that he has been thinking about killing himself with a rope or a rifle that he uses for target practice. His symptoms have become much more acute in the last week, when his 14-year-old girlfriend told him that she wanted to end their relationship. He says he cannot imagine living without her and is contemplating killing her as well as himself.

How should the clinician proceed? Two options are detailed below.

Background: The Tarasoff Decisions

The Tarasoff I and II v. Regents of the University of California decisions created a responsibility for clini-cians to warn or protect potential victims of threats of violence by the clinicians’ patients.1 The case involved Prosenjit Poddar, who murdered Tatiana Tarasoff, a fellow student at University of California, Berkeley. He had met Ms. Tarasoff at folk dancing classes in the fall of 1968. She socialized with him there and kissed him. Mr. Poddar assumed these actions indicated that Ms. Tarasoff was interested in a relationship with him. When she rejected his advances and told him that she was involved with other men, he became depressed and angry. He went to the counseling center at the university for therapy. In a session with his counselor, Mr. Poddar expressed his intent to kill Ms. Tarasoff, who he felt had jilted him. However, Ms. Tarasoff was not informed of this threat because the director of the counseling center viewed disclosure to her as a violation of clinician–patient confidentiality.

Mr. Poddar again approached Ms. Tarasoff in October of 1969, and when she once again rejected his advances, he stabbed her to death. Subsequently, her parents sued the university. The case was reviewed twice by the California Supreme Court and was ultimately remanded for settlement.

Tarasoff I, the 1974 decision, established a clinician’s duty to warn potential victims, if patients communicated

threats of harm to their clinician during treatment. With

Justice Matthew Tobriner writing in summary for the

majority, the Court stated:

We conclude that the public policy favoring protec-

tion of the confidential character of patient–psycho-

therapist communications must yield to the extent

to which disclosure is essential to avert danger to

others. The protective privilege ends where the

public peril begins.2

This case was reviewed again in 1976. That decision,

known as Tarasoff II, created a clinician’s “duty” to

protect potential victims when threats of harm against

them were expressed by patients during treatment.2

Since 1976 over 30 states have considered the limits

of clinician–patient privilege, and over 20 have affirmed

the Tarasoff decision either as a duty to warn or protect.

Other states have either made the disclosure volun-

tary or found no clinician obligation to warn poten-

tial victims.3,4 In most states, the warning process is

restricted to identified potential victims, but some

states have established a duty to protect the public

from a potentially violent patient even if unnamed.3 A

website for individual states’ duty to warn or protect

laws is available online.5 Mobley and Naughton5 and

Applebaum and Gutheil6 have suggested that obligation

to protect potential victims is an ethical obligation that

overrides states’ legal determinations.


The Tarasoff Duty



A Tarasoff I warning by a clinician to a potential victim and the police is an unusual activity for a mental health clini-cian, and in addition, it may disrupt the therapeutic rela-tionship with the patient and the family. A complicating issue is determining what the warning would entail: for example, whether the clinician should disclose only that a threat had been made, or the specifics of the threat.7

One way to try to prevent the rupture of the clinician–patient relationship is with pre-treatment consents, reviewed with patients and families, that define the limits of patient–therapist confidentiality in the event of threats of harm to others. Another is to apply protec-tion strategies as an alternative to warnings. Overall, as Applebaum and Gutheil have noted, “Clinicians should choose the intervention that occasions the least disrup-tion of the therapeutic relationship while still being effec-tive. On some occasions hospitalization is appropriate; on others, police notification serves the purpose.”6

To Protect or to Warn?

Intent and Substantial Risk

Before embarking on a Tarasoff notification, it is important to consider when a duty to warn or protect obligation exists. In many states, Tarasoff statutes require that the patient has identified a victim by name, while in others, simply the threat of violence to others is sufficient grounds for a warn or protect action.3,8

Determining the dangerousness of a homicidal threat can be informed by the concept of “substantial risk.” As Resnick has noted, the determination of substantial risk is based on the magnitude and probability of harm.9 A threat to kill with a butcher knife could be fatal and thus represents substantial risk to the victim’s life, even if it has

a low likelihood of happening. On the other hand, a threat to slap a victim in the face would not have the potential to create a life-threatening situation, even if it had a high probability of occurring, and so would not be the type of situation for which the Tarasoff obligation was established.

Any youth who communicates threats to a clinician to harm another person needs to be assessed to deter-mine the danger level of the threat. In substantial risk situations, the clinician needs to meet the Tarasoff warn or protect obligation requirements according to rules in that jurisdiction. It is important to understand facilities’ policies and local laws to help clarify how these situa-tions should be handled.

Treatment Planning

Individuals who threaten harm to others typically need intensive treatment such as hospitalization because it provides both supervision and therapy. If the adoles-cent or the parent does not agree with the treatment plan, then it would be necessary for the clinician to forge a compromise that meets his or her responsibility to protect potential victims. If that cannot be achieved, then immediate warnings to the victims and the police may be necessary (see Table 1).

23 Spring 2017

Tarasoff I (1974) determined that clinicians had a duty to warn potential victims of threats made by patients during therapy

Tarasoff II (1976) determined that clinicians had the responsibility to protect potential victims if threats against them were made by patients during therapy

Table 1. Steps for Dealing With a Tarasoff Duty to Warn/Protect Situation

77 Clarify the specifics of the threat

77 Formulate an intervention

77 Immediately remove weapons, especially firearms

77 Review if possible with a consultant

77 Present the intervention to the adolescent patient

77 With the adolescent, present the situation and interven-tion to the parent

77 Carry out the intervention; hospitalization preferred but warn if refused

77 Address the underlying psychiatric issues

77 Review the specifics of the threat during hospitalization

77 Attempt resolution with the patient and the family and, if appropriate, intended victim and his/her family

77 Review threat at discharge and in follow-up visits, employing an intervention when indicated

77 Document all steps taken, including correspondence, in the medical record




24 Spring 2017 www.jaacap.com/content/connectBACK TO TABLE OF CONTENTS


Elements to include in the treatment plan are: inquiry about weapons, especially firearms and documented evidence of their immediate removal; psychiatric diag-noses; cultural attitudes; statement of the threat; results of rating scales; interventions to address patient and victim safety; family and patient input in treatment goals; planned therapeutic individual and family interventions; and documentation of response to interventions. A copy of the treatment plan should be provided to the patient and the parents.

Rating scales such as the Brief Rating of Aggression by Children and Adolescents (BRACHA),10 Structured Assessment for Violence in Youth (SAVRY),11 and the Modified Overt Aggression Scale12 provide state and trait information that may clarify patients’ states of mind, for example, whether threats of harm are part of a stable coping response to stress or are specific to the indi-vidual abandonment situation. However, these scales do not provide information about the implementation of threats. The Columbia Suicide Severity Scale,13,14 although not without clinical concerns,15 could be used to ask questions about both suicide and homicide intent. Asking youths about the likelihood of acting on the plan (intent) is important, because patients’ predic-tion of their own potential for violence has been shown to be a reliable indicator of future action.16

Cultural Considerations

During adolescence, disruptions in romantic relation-ships (as in the original Tarasoff case) are a well-recog-nized stressor that may precipitate homicidal and suicidal planning. Cultures may view this situation and its reso-lution differently, depending on societal expectations.17 When an adolescent female makes threats entailing the use of violence, it can be occasioned by ongoing sexual abuse or a history of antisocial behavior.18 There has also been growing concern in the US,19 Japan,20 and the UK21 about the use of the internet, particularly among adolescents, to make murder–suicide pacts.

Firearms remain the most common method for both suicide and homicide events.22,23 Table 2 lists biologic, social, and history events that increase the potential for violence.

Seeking consultation from a colleague about the clinical situation and the planned intervention can be helpful because it provides an independent opinion on how to proceed.

Possible Interventions

A. Hospitalize the adolescent; have the weapons removed; do not provide victim warnings at this time. If at discharge the threat of harm is no longer present, there is no duty to warn. Document these actions in the medical record. If the intervention is successful and leads to the elimination of harm risk, this option has the advantage of allowing a thera-peutic intervention with patients, their families, and, if appropriate, the potential victims and their families. It may be the choice that causes the least disruption in the treatment alliance. If the threat remains active at discharge, then the warnings can be delivered to the potential victim and the police.

B. Discuss the warning plan, including its content, with the facility’s legal counsel; as soon as possible, share this information with the patient and, if appro-priate, the family. Warn the victim by phone and with regular and certified mail to increase the likelihood of delivery, and the police. Notification of both is neces-sary, because notification of the victim alone does not provide protection, and notification of the police alone does not ensure immediate action to protect

Table 2. Historical Elements in the Psychiatric History that Help in Assessing the Likelihood of a Patient Carrying Out Threats to Harm Someone

77 Self-harm, suicidal, assault, and homicidal ideation

77 Self-harm, suicidal, assault, and homicidal plans

77 Internet/social media communications about these issues including pacts for suicide

77 History of both with emphasis on the most dangerous thoughts and actions

77 Current and previous history of relationship initiation and ending

77 Availability of weapons and specific plans to use them

77 Current and previous history of substance use

77 Adolescent patient’s assessment of likelihood of acting on these thoughts and plans




the intended victim.6 Document these actions in the medical record. This option is likely to disrupt the treatment alliance, and it also might make the patient less likely to share these issues with other clini-cians (as may have happened in the Tarasoff case).1 However, warning may be the only workable choice.

Take Home Summary

The limits of clinician–patient confidentiality need to be discussed with patients and families at the initial visit. When youth threaten harm to others in treatment, weapons need to be immediately removed, and clinicians have a duty to protect potential victims, either by warnings or through intensive treatment, including hospitalization if necessary (Tarasoff obligation). All of these actions need to be documented in the medical record. The intervention should provide the least disruption to the therapeutic relationship that is effective.

References1. Gostin LO. Surveillance and Public Health Research:

Privacy and the “Right to Know.” Tarasoff v. Regents of the University of California. In Public Health Law and Ethics: A Reader. 2002. http://www.publichealthlaw.net/Reader/docs/Tarasoff.pdf. Accessed June 14, 2016.

2. Wise TP. Where the public peril begins: a survey of psycho-therapists to determine the effects of Tarasoff. Stanford Law Review. 1978;31:165-190.

3. Herbert PB, Young KA. Tarasoff at 25. J Am Acad Psychi-atry Law. 2002;30:275-281.

4. National Conference of State Legislatures (NCSL) staff, Simms G. Database of State Tarasoff Laws. http://www.ncsl.org/research/health/mental-health-professionals-du-ty-to-warn.aspx. February 2010. Accessed June 16, 2016.

5. Mobley KA, Naughton E. Tarasoff and the duty to protect in North Carolina. NC Perspectives. 2011;4:5-14.

6. Applebaum PS, Gutheil TG. Clinical Handbook of Psychi-atry and the Law. Philadelphia, PA: Wolters Kluwer; 2007.

7. Felthaus AR. Warning a potential victim of a person’s dangerousness: clinician’s duty or victim’s right? J Am Acad Psychiatry Law. 2006;34:338-348.

8. Buckner F, Firestone M. “Where the public peril begins”. 25 years after Tarasoff. J Leg Med. 2000;21:187-222.

9. Resnick PJ. Risk assessment for violence. Audio Digest Psychiatry. 2015;44:01.

10. Barzman DH, Brackenbury L, Sonnier L, et al. Brief rating of aggression by children and adolescents (BRACHA) development of a tool for assessing risks of inpatients’ behavior. J Am Acad Psychiatry Law. 2011;39:170-179.

11. Borum R, Bartel P, Forth A. Manual for Structured Assess-ment for Violence in Youth (SAVRY). Tampa: University of South Florida; 2002.

12. Yudofsky SC, Silver JM, Jackson W, Williams D. The Overt Aggression Scale for the Objective Rating of Verbal and Physical Aggression. Am J Psychiatry. 1986;143:35-39.

13. Posner K, Brown GK, Stanley B, et al. The Columbia-Sui-cide Severity Scale. Initial Validity and Internal Consistency Findings from Three Multisite Studies with Adolescents and Adults. Am J Psychiatry. 2011;168:1266-1277.

14. Research Foundation for Mental Hygiene. Suicide Risk Identification and Triage Using the Columbia-Suicide Severity Rating Scale. http://zerosuicide.sprc.org/sites/zerosuicide.actionallianceforsuicideprevention.org/files/cssrs_web/course.htm. 2013. Accessed June 16, 2016.

15. Giddens JM, Sheehan KH, Sheehan DV. The Colum-bia-Suicide Severity Scale (CSSR-S): Has the Gold Standard become a Liability? Innov Clin Neurosci. 2014;11:66-80.

16. Skeen JL, Manchak SM, Lidz CW, Mulvey EP. The utility of patients’ self perceptions of violence risk: consider asking the person who may know best. Psychiatr Serv. 2013;64:410-415.

17. Cultural and societal influences on adolescent develop-ment. Boundless Psychology. https://www.boundless.com/psychology/textbooks/boundless-psychology-textbook/human-development-14/adolescence-73/cultural-and-so-cietal-influences-on-adolescent-development-285-12820/. 26 May 2016. Retrieved 4 November 2016.

18. Roe-Sepowitz D. Adolescent female murderers: charac-teristics and treatment implications. Am J Orthopsychi-atry. 2007;77:489-496.

19. Covington C. How a Florida teenage romance ended in a violent suicide pact. The Week. http://www.theweek.co.uk/crime/57878/how-florida-teenage-romance-end-ed-violent-suicide-pact. March 27, 2014. Accessed June 16, 2016.

20. Ozawa-de Silva C. Too lonely to die alone: internet suicide pacts and existential suffering in Japan. Cult Med Psychi-atry. 2008;32:516-551.

21. Rajagopal S. Suicide pacts and the internet. BMJ. 2004;329:1298-1299.

22. Fingerhut LA, Christoffel KK. Firearm-related death and injury among children and adolescents. Future Child. 2002;12:24-37.

23. Harvard Injury Control Research Center. Homicide. https://www.hsph.harvard.edu/hicrc/firearms-research/guns-and-death/ Accessed June 16, 2016.

The Tarasoff Duty

25 Spring 2017


http://www.publichealthlaw.net/Reader/docs/Tarasoff.pdf

http://www.publichealthlaw.net/Reader/docs/Tarasoff.pdf

http://www.ncsl.org/research/health/mental-health-professionals-duty-to-warn.aspx



http://zerosuicide.sprc.org/sites/zerosuicide.actionallianceforsuicideprevention.org/files/cssrs_web/course.htm



https://www.boundless.com/psychology/textbooks/boundless-psychology-textbook/human-development-14/adolescence-73/cultural-and-societal-influences-on-adolescent-development-285-12820/

http://www.theweek.co.uk/crime/57878/how-florida-teenage-romance-ended-violent-suicide-pact



https://www.hsph.harvard.edu/hicrc/firearms-research/guns-and-death/

https://www.hsph.harvard.edu/hicrc/firearms-research/guns-and-death/




About the Author

Kim J. Masters, MD, is a fellow in the American College of Physicians and a Distinguished Fellow of AACAP and the American Psychiatric Association. He currently teaches physician assistant students principles of psychiatric care. He is an assistant adjunct professor of Psychiatry in the Department of Psychiatry and in Physician Assistant Studies at Wake Forest University, and an assistant adjunct professor in Physician Assis-tant Studies at the Medical University of South Carolina. He is a faculty member of AT Still Health University, Mesa, Arizona.

Disclosure: Dr. Masters reports no biomedical financial interests or potential conflicts of interest.




A J A A C A P P U B L I C A T I O N

Author GuidelinesJAACAP Connect is interested in any topic relevant to pediatric mental health that bridges scientific findings with clinical reality. As evidenced by our previous editions, the topic and format can vary widely, from neuroscience to teen music choices. What trends have you observed that deserve a closer look? Can you envision reframing key research findings into clinical care? Do you want to educate others on a broader scale, thereby improving the health of children around the country, the world? We encourage all levels of practitioners and researchers, from students to attendings, to join in and participate.

Authors are strongly encouraged to submit an initial outline to the editors, so that early feedback and guidance can be provided prior to the development of a full manuscript. An invitation to submit does not ultimately assure acceptance of the manuscript.

Manuscript Format

The manuscript word count, including references, should be approximately 1,200-1,500 words. Authors should use no more than 5-10 references and have the option of including 1-2 figures or tables. Manuscripts should follow the general JAACAP Guide for Authors regarding the formatting of the title page, figures and tables, and references. Include preferred corresponding author contact information.

All submitted articles should include a title, author list (in order), About the Authors, and Take Home Summary. About the Author: Include the name, position, and affil-iation of each author. Take Home Summary: Include a short sound bite (less than 40 words) to draw readers to your article and remind readers of the most important take home message from the article. Translational articles should include a brief concluding summary of the article, highlighting the main points of the article, with an emphasis on the clinical relevance.

Manuscript Submission Form

The Journal requires that a Manuscript Submission Form (MSF) be completed for each submission. The MSF is available at www.jaacap.org. For assistance in completing this form, please contact [email protected].

Peer Review and MentorshipOutlines and manuscripts will be reviewed by the editors, editorial board members, and select experts. Translational articles are challenging and authors are strongly encouraged to find and work with a mentor/expert to develop the content of their article and navigate the submission process. We recognize that mentorship for manuscript authorship may not be available to everyone. We will work with students, trainees, early career, and seasoned physicians, regardless of previous publication experience, to develop brief science-based and skill-building articles.

As a general rule, JAACAP Connect does not publish case reports. Brief cases (<100 words) may be used to provide clinical context or as a sidebar, but stand-alone case reports are not encouraged and may be rejected. Prospective authors interested in writing an article inspired by a case may wish to partner with a mentor in transforming a case report into a more broadly applicable article.

Submission / ContactMore information is available at http://www.jaacap.com/content/connect under the “Submit” tab. Please send inquiries, potential topics, outlines, and draft articles to [email protected].

Editorial Board

EditorOliver M. Stroeh, MD

Founding EditorMichelle S. Horner, DO

Deputy EditorsSchuyler W. Henderson, MD, MPHJessica Jeffrey, MD, MPH, MBAMisty Richards, MD, MSGerrit van Schalkwyk, MDJustin Schreiber, DO, MPH

AdvisorAndrés Martin, MD, MPH

JAACAP Editorial OfficeMary K. Billingsley, ELSKristine PumphreyAlyssa Murphy, MA

27 Spring 2017

3615 Wisconsin Ave. NW Washington, DC 20016



JAACAP Connect is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

ISSN 2472-3401 © 2017 American Academy of Child and Adolescent Psychiatry







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