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Summary Background The effects of the COVID-19 pandemic on mental health have been understudied among vulnerable populations, particularly in fragile and conflict-affected settings. We aimed to analyse how the pandemic is related to early changes in mental health and parenting stress among caregivers, many of whom are internally displaced persons (IDP), in a conflict-affected setting in Colombia. Methods For this cohort study, we used longitudinal data from a psychosocial support programme in which 1376 caregivers were randomly assigned across four sequential cohorts. Recruitment of participants took place in March, 2018, for cohort 1; July, 2018, for cohort 2; March, 2019, for cohort 3; and July, 2019, for cohort 4. Participants completed assessments at baseline, 1-month, and 8-month follow-ups. The 8-month assessment occurred before the COVID-19 pandemic for participants in cohorts 1 and 2 (n=573), whereas those in cohorts 3 and 4 (n=803) were assessed during the early stages of the pandemic, 2–5 weeks after the national lockdown began on March 25, 2020. Primary caregiver anxiety and depression were measured with a scale adapted from the Symptoms Checklist-90-Revised and parenting stress was measured with the short form of the Parenting Stress Index. We estimated how mental health changed by comparing prepandemic and postpandemic 8-month outcomes using lagged-dependent variable models. Findings Results showed that the likelihood of reporting symptoms above the risk threshold increased by 14 percentage points for anxiety (95% CI 10–17), 5 percentage points for depression (0·5–9), and 10 percentage points for parental stress (5–15). The deterioration in mental health was stronger for IDP, participants with lower education or pre-existing mental health conditions, and for those reporting a higher number of stressors, including food insecurity and job loss. Interpretation Maternal mental health significantly worsened during the early stages of the pandemic. Considering the vulnerability and pre-existing mental health conditions of this population, the estimated effects are substantial. Policies in fragile and conflict-affected settings targeting IDP and other vulnerable people will be important to mitigate further mental health and socioeconomic problems. Funding Saving Brains–Grand Challenges Canada, Fundacion Exito, Fundacion FEMSA, United Way Colombia, Universidad de los Andes. Translation For the Spanish translation of the abstract see Supplementary Materials section.

This study examined maternal pregnancy wantedness and perceptions of paternal wantedness, and their associations with maternal perinatal mental health symptoms and relationship dynamics. Low-income, ethnically-diverse pregnant women (N = 101, Mage = 29.10 years, SDage = 6.56, rangeage = 18–44; 37% Latina, 22% African-American, 20% White, 21% biracial/multiracial/other) completed semi-structured interviews of pregnancy wantedness coded by trained raters, and standardized instruments of depression and PTSD symptoms during pregnancy and at 3–4-months postpartum. While maternal pregnancy wantedness (rated from 0-Predominately Ambivalent, 1-Mixed, and 2-Predominately Positive) showed no significant associations, a couple-level scale that combined maternal wantedness and her perceptions of paternal wantedness (Equally Positive Wantedness, Mom Wants More, Dad Wants More and Equally Ambivalent) showed several significant associations. Compared to women in the Equally Positive group, women in the Mom Wants More group had significantly higher prenatal and postnatal depression symptoms, prenatal PTSD symptoms, and prenatal and postnatal relationship conflict; and lower prenatal and postnatal relationship support. Women in the Mom Wants More group also had significantly higher prenatal and postnatal depression symptoms and prenatal conflict; and lower prenatal support than women in the Dad Wants More group. Women who perceive themselves as wanting the pregnancy more than their baby’s father are at higher risk for mental health and relationship problems than women who perceive themselves and their partners as equally ambivalent. Providers should ask women about their perceptions of partners’ pregnancy wantedness to inform delivery of targeted mental health and relationship-based intervention during pregnancy.

PReCIS:: Micropulse cyclophotocoagulation (MPCP) lowered intraocular pressure (IOP) in the short-term but nearly half required additional intervention. Mydriasis was the most common complication (11%); 15% lost ≥3 Snellen lines of acuity; 11% had persistent complications at last follow-up. PURPOSE The purpose of this study was to evaluate the efficacy and complications of MPCP in a large series of patients with all stages of glaucoma. DESIGN Multicenter, retrospective chart review of patients from 3 clinical sites. PARTICIPANTS One hundred sixty-seven eyes of 143 patients. METHODS MPCP was performed with 2000 mW energy, 31.3% duty cycle and 2 to 4 180-degree applications of 80 seconds duration each per treatment. The procedure was considered a failure if any of the following occurred: additional IOP lowering intervention

The psychological consequences of traumatic events for caregivers and their children have been extensively studied, with the majority of literature considering maternal influences. We aimed to compare these associations across caregiver sex in order to provide deeper insight into paternal influences. The indirect association between caregiver exposure to traumatic events (# of types) and child symptomatology (posttraumatic stress symptoms [PTSS] and socioemotional problems) was considered via three pathways: (a) child exposure to traumatic events (# of types), (b) caregiver symptomatology (depressive symptoms and PTSS) and (c) caregiving stress. Participants were caregiver-child dyads referred to an outpatient hospital clinic for treatment of PTSS amongst children aged zero to five (N = 222, 28% male caregivers). Male caregivers reported lower scores on all variables (d= 0.32–0.67) despite there being no caregiver sex differences in number of events experienced by children. Multi-group path analysis revealed that relationships amongst study variables were similar for male and female caregivers, with the exception of caregiver stress and symptoms. There was no relationship between number of events experienced by caregivers and caregiver stress for males, β = −0.07 (SE = 0.08), p = 0.356, though there was for females, β = 0.15 (SE = 0.07), p= 0.021. Additionally, the relationship between number of events and symptomatology was weaker (though still significant) for male caregivers, β = 0.27 (SE = 0.09), p = 0.005, compared to females, β = 0.38 (SE = 0.06), p

The present study examined developmental antecedents of angels and ghosts in the nursery during the pregnancy and postnatal periods. Higher levels of benevolent childhood experiences (BCEs) were hypothesized to predict higher levels of angels in the nursery at both periods, whereas higher levels of adverse childhood experiences (ACEs) were expected to predict higher levels of ghost in the nursery at both periods. Participants were 101 low-income, ethnically diverse pregnant women (M = 29.10 years, SD = 6.56, range = 18–44; 37% Latina, 22% African American, 20% White, 13% biracial/multiracial, 8% other) planning to deliver at an urban general hospital. During their second or third trimester, they reported on ACEs, BCEs, and demographic information. During pregnancy and 3–4 months of postnatal, they completed the Angels in the Nursery Interview (Van Horn, Lieberman, & Harris, 2008), coded by trained raters for quality of loving memories with childhood caregivers (angel memories) and traumatic intrusions of childhood adversity (ghost memories). Results revealed moderate stability of angel and ghost memories across the perinatal period. Higher levels of BCEs directly predicted higher levels of angel memories during pregnancy, and indirectly predicted higher levels of angel memories during the postnatal period through angel memories during pregnancy. Higher levels of ACEs directly predicted higher levels of ghost memories during both periods. BCEs did not predict ghost memories and ACEs did not predict angel memories. Findings support independent pathways of risk and resilience through the pregnancy period with distinct origins in women’s childhood adversity versus positive childhood experiences. Implications for promoting intergenerational resilience by linking and leveraging BCEs and angel memories and recovering from ACEs and ghost memories are discussed.

Romantic partner support from the father-to-be is associated with women’s mental health during pregnancy. However, most studies of partner support rely upon women’s responses to self-report questionnaires, which may be biased and should be corroborated by efficient, coder-rated measures of partner support. This study tested whether the Five-Minute Speech Sample (FMSS), adapted to assess expressed emotion about romantic partners, can provide information about partner support during pregnancy that is less prone to bias than self-report. Participants were 101 low-income, ethnically diverse pregnant women who completed self-report questions on partner support quality and the FMSS. Self-reported and coder-rated (FMSS) partner support were highly correlated and were each significantly associated with self-reported depressive and post-traumatic stress disorder (PTSD) symptoms, perceived stress, and partner victimization during pregnancy. Self-reported and coder-rated support corresponded in approximately 75% of cases; however, nearly 25% of women self-reported high support but received low FMSS support ratings. These women reported elevated PTSD symptoms, perceived stress, and victimization during pregnancy. While self-reported partner support may be valid for many respondents, the FMSS is less susceptible to reporting biases and may better identify women facing heightened psychopathology and stress during pregnancy, who would benefit from supportive intervention.

Early childhood is a developmental period characterized by significant plasticity, heterogeneity in behaviors and biological functioning. Yet, cumulative cortisol secretion, as measured by hair cortisol, has not been examined longitudinally in relation to change in behavioral problems in young children. The current study examined cross-sectional and longitudinal associations between hair cortisol and changes in behavior problems in a combined sample (N = 88) of two groups of young children from low-income families: 1) A trauma-exposed sample that participated in Child-Parent Psychotherapy (CPP) (n = 43; Mean Age = 4.31, SD = 1.16; 53% Female; 77% Hispanic), and 2) A community sample of children from families experiencing high stress (n = 45; Mean Age = 3.20, SD = 0.29; 67% Female; 58% Hispanic). Cortisol was assayed from hair collected from children at baseline and, on average, one year later. Mothers completed the Child Behavior Checklist at the same time hair samples were collected. Baseline hair cortisol in children was not associated with maternally-reported child behavioral problems at baseline and did not predict change in behavior problems over time. In contrast, increases in cortisol were associated with greater improvement in child behavior problems (b = -2.98, p 0.05), controlling for group status and relevant covariates. Subgroup analyses showed that cortisol change across one year significantly differed between the two groups (p = 0.043): on average, community children exhibited a decrease, whereas CPP children demonstrated no change. Hair cortisol concentration was similarly related to improvements in mother-reported behavior problems across both CPP and community groups over time. In summary, there were no cross-sectional associations with hair cortisol, whereas increases were associated with improved child well-being. Findings demonstrate an important link between this increasingly common biomarker and child health, but suggest that changes over time may be more informative than cross-sectional associations.

Inflammatory pathways predict antidepressant treatment non-response among individuals with major depression; yet, this phenomenon may have broader transdiagnostic and transtherapeutic relevance. Among trauma-exposed mothers (Mage = 32 years) and their young children (Mage = 4 years), we tested whether genomic and proteomic biomarkers of pro-inflammatory imbalance prospectively predicted treatment response (PTSD and depression) to an empirically-supported behavioral treatment. Forty-three mother-child dyads without chronic disease completed Child Parent Psychotherapy (CPP) for roughly 9 months. Maternal blood was drawn pre-treatment, CD14 + monocytes isolated, gene expression derived from RNA sequencing (n = 34; Illumina HiSeq 4000;TruSeqcDNA library), and serum assayed (n = 43) for C-Reactive Protein (CRP) and interleukin-1s (IL-1s). Symptoms of PTSD and depression decreased significantly from pre- to post-treatment for both mothers and children (all p's

Early childhood and pregnancy are two sensitive periods of heightened immune plasticity, when exposure to adversity may disproportionately increase health risks. However, we need deeper phenotyping to disentangle the impact of adversity during sensitive periods from that across the total lifespan. This study examined whether retrospective reports of adversity during childhood or pregnancy were associated with inflammatory imbalance, in an ethnically diverse cohort of 53 low-income women seeking family-based trauma treatment following exposure to interpersonal violence. Structured interviews assessed early life adversity (trauma exposure ≤ age 5), pregnancy adversity, and total lifetime adversity. Blood serum was assayed for pro-inflammatory (TNF-a, IL-1ß, IL-6, and CRP) and anti-inflammatory (IL-1RA, IL-4, and IL-10) cytokines. CD14+ monocytes were isolated in a subsample (n = 42) and gene expression assayed by RNA sequencing (Illumina HiSeq 4000; TruSeq cDNA library). The primary outcome was a macrophage-associated M1/M2 gene expression phenotype. To evaluate sensitivity and specificity, we contrasted M1/M2 gene expression with a second, clinically-validated macrophage-associated immunosuppressive phenotype (endotoxin tolerance) and with pro-inflammatory and anti-inflammatory cytokine levels. Adjusting for demographics, socioeconomic status, and psychopathology, higher adversity in early life (ß = .337, p = 0.029) and pregnancy (ß = .332, p = 0.032) were each associated with higher M1/M2 gene expression, whereas higher lifetime adversity (ß = −.341, p = 0.031) was associated with lower immunosuppressive gene expression. Adversity during sensitive periods was uniquely associated with M1/M2 imbalance, among low-income women with interpersonal violence exposure. Given that M1/M2 imbalance is found in sepsis, severe COVID-19 and myriad chronic diseases, these findings implicate novel immune mechanisms underlying the impact of adversity on health.

In recent years, research and practice on adverse childhood experiences (ACEs) have shifted from delineating effects of ACEs on adulthood health problems to preventing ACEs in children. Nonetheless, little attention has focused on how parents' own childhood experiences, adverse or positive, may influence the transmission of ACEs across generations. Children's risk for ACEs and potential for resilience may be linked to the early child-rearing experiences of their parents carried forward into parenting practices. Additionally, parents with multiple ACEs may have PTSD symptoms, an under-recognized mediator of risk in the intergenerational transmission of ACEs. Guided by developmental psychopathology and attachment theory with an emphasis on risk and resilience, we argue that a more comprehensive understanding of parents' childhood experiences is needed to inform prevention of ACEs in their children. Part I of this review applies risk and resilience concepts to pathways of intergenerational ACEs, highlighting parental PTSD symptoms as a key mediator, and promotive or protective processes that buffer children against intergenerational risk. Part II examines empirical findings indicating that parents' positive childhood experiences counteract intergenerational ACEs. Part III recommends clinically-sensitive screening of ACEs and positive childhood experiences in parents and children. Part IV addresses tertiary prevention strategies that mitigate intergenerational ACEs and promote positive parent-child relationships.

Prevention and amelioration of the myriad effects of toxic stress on child development is a significant public health concern. Scalable programmes to address this concern are lacking. Attachment Vi...

Background A Dissociative Subtype of Posttraumatic Stress Disorder (PTSD) was added to the DSM-5, but little is known about this symptom pattern in young children exposed to trauma. Tailoring treatment to traumatized young children requires understanding the different patterns of trauma-related symptomatology and important correlates. The current study tested the hypothesis that type and number of child traumatic events, caregiver trauma exposure, and caregiver symptomatology would predict whether traumatized young children presented with PTSD, PTSD with clinical dissociation, or non-clinical trauma symptoms. Methods A multinomial regression was conducted using data collected from an ethnically and economically diverse sample of 297 trauma-exposed children between the ages of 3 and 6 and their caregivers. Based on parent-report on a well-validated measure of trauma symptoms, children were categorized into three groups: non-clinical (n = 128), PTSD only (n = 104), or PTSD with dissociation (PTSD-DISS; n = 65). Predictors included trauma exposure, parent trauma symptoms, and child sex. Results Girls were twice more likely than boys to be in the PTSD-DISS group; sexually abused children were almost three times as likely to be in the PTSD-DISS group; and, for every unit increase in parent avoidance symptoms or number of traumatic events, the odds of being in the PTSD-DISS group increased significantly. Limitations Given the cross-sectional study design, conclusions cannot be drawn regarding causality. Measures were completed by a single reporter. Conclusions Findings suggest that subgroups of children may be especially vulnerable to comorbid PTSD and dissociation. Implications for treatment are discussed.

Five randomized controlled trials have shown that child-parent psychotherapy (CPP) improves trauma symptoms in children. Less is known about parent symptoms or moderators of symptom change. In a sample of 199 parent (81% biological mother; 54% Latina/o) and child (aged 2 to 6 years; 52% male; 49% Latina/o) dyads who participated in an open treatment study of CPP, this study investigated whether parent and child symptoms similarly decreased during treatment and whether improvement was moderated by parent, child, and treatment characteristics. Parents completed baseline and posttreatment interviews regarding exposure to traumatic events, posttraumatic stress symptomatology (PTSS), and other mental health indices. Latent difference score analysis showed that PTSS significantly decreased by more than 0.5 SD for parents and children. The PTSS improvement in parents was associated with reductions in child avoidance, r = .19, p = .040, and hyperarousal, r = .33, p < .001. Girls showed a greater reduction than boys in reexperiencing, β = -.13, p = .018, and hyperarousal, β = -.20, p = .001. Contrary to expectations, parent and child improvement in PTSS was greater for those with fewer parental lifetime stressors, βrange = .15 to .33, and for those who participated in fewer treatment sessions, βrange = .15 to .21. The extent of improvement in parent PTSS varied based on clinician expertise, β = -.20, p = .009. Significant reductions in parent and child PTSS were observed during community-based treatment, with CPP and symptom improvement varying according to child, parent, and treatment characteristics.

Exposure to domestic violence in the preschool years is consistently associated with children’s heightened risk for developing behavior problems. Maternal meta-emotion philosophy (awareness, acceptance, and coaching of children’s emotions) has been identified as an important protective factor in children’s development of internalizing and externalizing behaviors following exposure to domestic violence. However, mothers who are victims of domestic violence often experience symptoms of depression, anxiety, and post-traumatic stress, which may undermine their capacity to respond to their children’s negative emotions. The present study examines the protective role of maternal meta-emotion philosophy among mothers and preschool-aged children exposed to domestic violence. Participants were 95 mothers (mean age = 31.78) and their preschool-aged children (mean age = 4.11) who had witnessed domestic violence involving their mothers. Multiple regression analyses, controlling for family socioeconomic status and child exposure to interpersonal violence in the family, indicated that maternal symptomatology was positively associated with children’s internalizing problems. In addition, maternal awareness and coaching of children’s negative emotions was found to moderate relations between maternal symptomatology and children’s internalizing behaviors, and maternal awareness of children’s negative emotions was found to moderate relations between maternal symptomatology and children’s externalizing behaviors. These findings expand our understanding of maternal meta-emotion philosophy as a protective factor for preschoolers who have witnessed domestic violence.

The present study used a bioecological framework to examine associations between trauma exposure, trauma-related symptomatology, and executive function (EF) in an urban sample of 88 predominantly ethnic-minority, low-income preschoolers (age 2-5) exposed to interpersonal trauma. Contrary to hypotheses based on past literature documenting associations between trauma exposure and EF deficits in childhood, in regressions adjusting for child gender, family income, and caregiver education, neither trauma exposure or trauma-related symptoms (post-traumatic stress symptoms, internalizing behaviors, or externalizing behaviors) were significantly associated with children's EF performance. Associations between child trauma exposure, symptomatology, and executive function were not moderated by parental PTSD symptomatology; and EF was not differentially predicted by type of trauma. Results suggest that, within an ethnically-diverse sample of preschool-aged children exposed to multiple traumas, associations between trauma exposure, symptomatology, and EF may be particularly nuanced. Keywords: child trauma, posttraumatic stress, executive function, preschool-age children, child mental health.

Given the importance of early prevention and intervention strategies for children exposed to trauma, detection of early risk factors for exposure to traumatic events in childhood is critical. The present study examined associations between three known prenatal risk factors that characterize environmental instability in utero-prenatal substance exposure, prenatal violence victimization, and unintended pregnancy-and child exposure to interparental violence and other adverse experiences in a sample of 198 mother-child dyads (M child age = 44.48 months) referred to a hospital clinic for treatment following exposure to trauma. Prenatal substance and violence exposure were associated with child trauma exposure, and prenatal violence victimization was also associated with maternal severity ratings of traumatic exposures. Unintended pregnancy was not associated with child trauma exposure or severity. These findings expand our understanding of prenatal risk factors for trauma exposure in childhood and, specifically, highlight prenatal substance exposure and violence victimization as risk factors for subsequent exposure to trauma in early childhood. Results suggest that prenatal prevention and intervention programs should target reducing maternal substance use and in-utero exposure to violence.Dada la importancia de las estrategias de prevención e intervención tempranas para niños expuestos al trauma, el detectar los tempranos factores de riesgo en el caso de estar expuesto a eventos traumáticos en la niñez es crítico. El presente estudio examinó las asociaciones entre tres conocidos factores de riesgo prenatales que caracterizan la inestabilidad ambiental en el útero -el haber estado expuesto a sustancias prenatalmente, la victimización de la violencia prenatal, y el embarazo no intencional -y el que el niño esté expuesto a la violencia entre progenitores (IPV) y otras experiencias adversas en un grupo muestra de 198 díadas madre-niño (edad promedio del niño = 44.48 meses) que habían sido referidas a una clínica hospital para el tratamiento que seguía al haber estado expuestos al trauma. El haber estado expuesto a sustancia y violencia prenatal se asoció con el hecho de que el niño había estado expuesto a trauma, y la victimización de la violencia prenatal también se asoció con la severidad maternal de clasificación de la exposición traumática. El embarazo no intencional no se asoció con la exposición del niño al trauma o la severidad. Estos resultados amplían nuestra comprensión de los factores de riesgo prenatales en cuanto al haber estado expuesto al trauma en la niñez y, específicamente, subrayan el haber estado expuesto a sustancias prenatalmente y la victimización de la violencia como subsecuentes factores de riesgo para estar expuesto al trauma en la temprana niñez. Los resultados sugieren que los programas de prevención e intervención prenatales deber enfocarse en reducir el uso de sustancias por parte de la madre y el estar expuesto dentro del útero a la violencia.Vu l'importance des stratégies de prévention précoce et d'intervention pour les enfants exposés au trauma, la détection de facteurs de risque précoce pour l'exposition à des événements traumatiques s'avère critique. Cette étude a examiné les liens entre trois facteurs de risque prénatals connus qui caractérisent l'instabilité environnementale in utero - l'exposition prénatale à des substances toxiques, la victimisation liée à la violence prénatale, et la grossesse involontaire - ainsi que l'exposition à la violence conjugale et d'autres expériences adverses chez un échantillon de 198 dyades mère-enfant (moyenne d’âge de l'enfant = 44,48 mois) envoyées consulter en clinique hospitalière pour un traitement suivant une exposition à un trauma. L'exposition à la toxicomanie et l'exposition à la violence étaient liées à l'exposition de l'enfant au trauma et la victimisation liée à la violence prénatale était également liée à la sévérité des scores maternels d'expositions traumatiques. La grossesse involontaire n’était pas liée à l'exposition au trauma de l'enfant ou à la sévérité. Ces résultats élargissent notre compréhension des facteurs prénatals d'exposition au trauma dans l'enfance et mettent en lumière plus spécifiquement l'exposition à la toxicomanie prénatale et la victimisation liée à la violence en tant que facteurs de risque d'exposition ultérieure au trauma durant la petite enfance. Les résultats suggèrent que la prévention prénatale et les programmes d'intervention devraient cibler la réduction d'utilisation toxicomane maternelle et l'exposition à la violence in-utero.Zusammenhänge zwischen pränataler Drogen- bzw. Gewaltexposition, ungewollter Schwangerschaft und Traumatisierung in der Kindheit in einem klinischen Setting Angesichts der Bedeutung früher Präventions- und Interventionsstrategien bei traumatisierten Kindern, ist die Aufdeckung potenzieller Risikofaktoren für Traumatisierung entscheidend. Die vorliegende Studie überprüft Zusammenhänge zwischen drei bekannten, eine Umgebungsinstabilität in utero charakterisierenden, pränatalen Risikofaktoren (pränatale Drogen- bzw. Gewaltexposition und ungewollte Schwangerschaft) und kindlicher Belastung durch zwischenelterliche Gewalt (interparental violence; IPV) sowie anderen widrigen Erfahrungen. Die Stichprobe bestand aus 198 Mutter-Kind Dyaden (mittleres Alter der Kinder = 44.48 Monate), die sich aufgrund traumatischer Erfahrungen in Behandlung begeben haben. Pränatale Drogen- bzw. Gewaltexposition wiesen Zusammenhänge zu kindlicher Traumatisierung auf. Des Weiteren wies pränatale Gewaltexposition auch einen Zusammenhang zu den mütterlichen Ratings der Traumaschwere auf. Ungewollte Schwangerschaft war nicht mit kindlicher Traumatisierung oder Traumaschwere assoziiert. Diese Ergebnisse ermöglichen es uns, pränatale Risikofaktoren für kindliche Traumatisierung besser zu verstehen. Insbesondere werden pränatale Drogen- und Gewaltexposition als Risikofaktoren für eine darauffolgende Traumatisierung in der frühen Kindheit hervorgehoben. Die Ergebnisse legen nahe, dass pränatale Präventions- und Interventionsprogramme darauf abzielen sollten, mütterlichen Drogenkonsum und Gewalterfahrungen in utero zu minimieren.胎児期の薬物暴露・胎児期の暴力虐待・予期せぬ妊娠と、臨床現場における小児期のトラウマ暴露の関連 トラウマに曝された子どもへの早期予防と介入の方法の重要性を考えると、小児期にトラウマとなる出来事に暴露される初期の危険因子を検出することは必須である。本研究は、トラウマに曝され治療のために病院の外来に紹介された198 組の母子 (子どもの平均年齢 44.48 ヶ月) において、胎内の環境不安定性を特徴づける３つの既知の出生前リスク因子−胎児期の薬物暴露、胎児期の暴力虐待、予期せぬ妊娠―と、パートナー間の暴力 (IPV) やその他の逆境体験に子どもが曝されること、との関連性を検討した。胎児期の薬物と暴力への暴露は、子どものトラウマ暴露と関連し、胎児期の暴力虐待は母親のトラウマ暴露の深刻さの評価とも関連した。予期せぬ妊娠は子どものトラウマ暴露や深刻さに関連していなかった。これらの結果から小児期のトラウマ暴露に関連する胎児期のリスク因子への我々の理解が広まり、特に胎児期の薬物暴露と暴力虐待は早期小児期のトラウマ暴露に引き続くリスク因子であると強調する。出生前の予防と介入プログラムは、母親の薬物使用と胎児期に暴力に晒されることを減らすことをターゲットにすべきであると、この結果から提案する。.產前物質使用丶產前暴力受害丶意外懷孕和兒童創傷在臨床環境中的關係 鑑於經歷過創傷的兒童早期預防和干預策略的重要性, 檢測兒童受創事件的早期風險因素至關重要。本研究在受創傷後轉診到醫院診所接受治療的 198 個母親-兒童二元組樣本中 (平均兒童年齡 = 44.48 個月), 探討三種已知的產前風險因素 - 產前使用物質丶產前暴力受害丶及意外懷孕 - 做成的不穩定環境與兒童經歷過父母間暴力 (IPV) 和其他不良經歷的關聯。母親產前物質使用和暴力經歷與兒童創傷有關, 產前暴力受害也與母親創傷的評分相關。意外懷孕與兒童創傷或嚴重程度無關。這些研究結果擴展了我們對兒童創傷的產前風險因素的理解, 特別強調產前物質使用和暴力受害, 是隨後兒童早期創傷的風險因素。結果表明, 產前預防和干預計劃的目標, 應該是減少母體物質使用和產前暴力經歷。.العلاقة بين التعرض للمواد المخدرة قبل الولادة، وإيذاء العنف قبل الولادة، والحمل غير المقصود، والتعرض للصدمات النفسية في مرحلة الطفولة في سياق إكلينيكي بالنظر إلى أهمية استراتيجيات الوقاية والتدخل المبكرة للأطفال المعرضين للصدمات النفسية، فإن الكشف عن عوامل الخطر المبكرة للتعرض للأحداث الصادمة في مرحلة الطفولة أمر بالغ الأهمية. تناولت هذه الدراسة الارتباطات بين ثلاثة عوامل خطر معروفة قبل الولادة تميز عدم الاستقرار البيئي في التعرض للمواد داخل الرحم قبل الولادة، والإيذاء أثناء الولادة، والحمل غير المقصود - وتعرض الأطفال للعنف بين الوالدين وغيره من التجارب السلبية في عينة من 198 من ثنائيات الأم والطفل (متوسط عمر الطفل = 44.48 شهراً) الذين تم إحالتهم إلى عيادة لتلقي العلاج بعد التعرض للصدمات. وترتبط المواد السابقة للولادة والتعرض للعنف بالتعرض لصدمات الأطفال، كما يرتبط الإيذاء الناجم عن العنف قبل الولادة بتقديرات الأم بشدة الصدمات. ولا يرتبط الحمل غير المقصود بالتعرض لصدمات الأطفال أو شدتها. وتوسع هذه النتائج فهمنا لعوامل الخطر قبل الولادة للتعرض للصدمات في مرحلة الطفولة، وعلى وجه التحديد، تسليط الضوء على التعرض لمواد ما قبل الولادة والإيذاء الناجم عن العنف كعوامل خطر للتعرض اللاحق للصدمات في مرحلة الطفولة المبكرة. وتشير النتائج إلى أن برامج الوقاية والتدخل قبل الولادة ينبغي أن تستهدف الحد من تعاطي المواد أثناء الحمل والتعرض للعنف داخل الرحم.

Childhood adversity can have long-term deleterious effects on adulthood mental health outcomes, but more research is needed examining how type and timing of childhood adversity affect mental health specifically during pregnancy. The current study examined the effects of total adverse childhood experiences (ACEs) on depression and posttraumatic stress disorder (PTSD) symptoms during pregnancy, unpacked effects of total adversity into childhood maltreatment versus family dysfunction experiences, and assessed age of onset effects of child maltreatment-specific experiences. Participants were 101 low-income pregnant women (M = 29.10 years, SD = 6.56, range = 18-44; 37% Latina, 22% African American, 20% White, 13% biracial/multiracial, 8% other; 26% Spanish-speaking) who completed instruments on childhood adversity, PTSD and depression symptoms during pregnancy, and demographics. Results indicated that total ACEs predicted elevated PTSD and depression symptoms during pregnancy, as did maltreatment ACEs, but not family dysfunction ACEs. Early childhood onset of maltreatment significantly predicted elevated PTSD symptoms during pregnancy, whereas middle childhood and adolescent onset did not. No age of onset of maltreatment variable significantly predicted depression symptoms during pregnancy. Findings underscore the importance of differentiating between childhood maltreatment versus family dysfunction ACEs and examining the timing and accumulation of maltreatment experiences during childhood, because these factors affect mental health during pregnancy. Findings also support universal prenatal screening for PTSD symptoms to identify at-risk pregnant women who could benefit from interventions to disrupt the intergenerational transmission of risk and give families the healthiest possible beginning. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood: Revised Edition (DC:0-5; ZERO TO THREE) is scheduled to be published in 2016. The articles in this section are selective reviews that have been undertaken as part of the process of refining and updating the nosology. They provide the rationales for new disorders, for disorders that had not been included previously in the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood: Revised Edition (DC:0-3R; ZERO TO THREE, 2005), and for changes in how certain types of disorders are conceptualized.

Intimate partner violence (IPV) victimization during pregnancy is a major public health concern, yet little is known about how risk factors for IPV during pregnancy may depend on whether women have histories of victimization dating back to early childhood (ages 0-5 years). This study examined whether risk factors for physical IPV victimization during pregnancy (a pregnancy that was not planned and prenatal substance use) differed for women with versus without early childhood victimization. Participants were 236 ethnically diverse, low-income biological mothers ( M = 30.94 years; 50.0% Latina, 16.9% Caucasian, 13.1% African American, and 16.9% multiracial) of children aged 0 to 6 years. Mothers were classified into four groups based on whether they had experienced early childhood victimization and physical IPV victimization during pregnancy with the target child. Multinomial logistic regressions, controlling for demographic characteristics, examined whether a pregnancy not planned and prenatal substance use predicted group membership. Compared to mothers with early victimization only, mothers with both early childhood victimization and physical IPV during pregnancy were more than 3 times as likely to report that their pregnancy with the target child was not planned. In follow-up analyses, mothers with early victimization and physical IPV during pregnancy also reported higher lifetime parity than mothers with physical IPV during pregnancy but no early victimization. Early childhood victimization may place women on a risk pathway to physical IPV during pregnancy, particularly if the pregnancy is not planned. Prevention and policy efforts should screen women for early childhood victimization to understand risks for physical IPV during pregnancy.

This study examined type and timing of childhood experiences – both adverse (ACEs; Felitti et al., 1998 ) and benevolent (BCEs, a novel index of childhood resources; Narayan, Rivera, Bernstein, Harris, & Lieberman, 2018 ) on several pregnancy-related outcomes. Participants were 101 low-income pregnant women (M = 29.10 years, SD = 6.56, range = 18–44; 37% Latina, 22% African-American, 20% White, 13% biracial/multiracial, 8% other) who completed the ACEs questionnaire for childhood maltreatment versus family dysfunction and the BCEs scale, including the ages when experiences occurred [i.e., 0–5 years (early childhood), 6–12 years (middle childhood), and 13–18 years (adolescence)]. They also reported on psychopathology symptoms, risky reproductive planning, stressful life events (SLEs), and demographics. Analyses supported type, rather than timing of experiences: specific experiences (i.e., maltreatment versus family dysfunction versus BCEs) predicted specific outcomes, regardless of the developmental period when they occurred. Specifically, maltreatment predicted PTSD symptoms, BCEs predicted risky reproductive planning, and family dysfunction and BCEs predicted SLEs. Experiences that began earlier were also more predictive than experiences that began later. Findings suggest that adverse versus benevolent childhood experiences are uniquely linked to adaptation during pregnancy and underscore the importance of also including BCEs in prenatal screening.

The current study investigated maternal sensitivity in a treatment-seeking sample of predominately Latina, low-income pregnant women with histories of interpersonal trauma exposure. Pregnant women (N = 52; M = 27.08 years, SD = 5.66) who enrolled in a study of a perinatal adaptation of child-parent psychotherapy reported on their posttraumatic stress symptoms and child-rearing attitudes at baseline and again at 6-months postpartum. Maternal sensitivity was measured via observational coding of a free-play episode at 6-months postpartum. Two thirds of mothers exhibited healthy levels of maternal sensitivity, M > 4.0 (range = 2.5-7.0). The results of multiple linear regression predicting maternal sensitivity, R(2) = .26, indicated that greater improvements in child-rearing attitudes over the course of treatment predicted higher levels of maternal sensitivity, β = .33, whereas improvements in posttraumatic stress symptoms over the course of treatment did not, β = -.10. Mothers' attitudes regarding parenting during the perinatal period may be a mechanism by which intervention fosters healthy mother-infant relationship dynamics. Thus, parenting attitudes are a worthy target of intervention in vulnerable families.

Parents' childhood experiences of trauma may influence their reports of their children's behavior, and this may be particularly true when children are also traumatized. The present study proposed and tested a matched trauma hypothesis, positing that compared to parents without a childhood history of witnessing domestic violence (DV), parents with a childhood history of witnessing DV may report their children's trauma-related symptomatology differently following children's exposure to DV. Of 137 included parents (M age = 32 years; 93% mothers), 81 reported witnessing childhood DV (matched group), whereas 56 reported no childhood DV exposure (nonmatched comparison group). All parents reported on their 3- to 6-year-old children's dissociation and posttraumatic stress symptoms following children's DV exposure. An analysis of covariance controlling for parental life stress, dissociation symptoms, and other childhood traumatic events revealed that parents who witnessed childhood DV reported significantly fewer child dissociation symptoms than comparison parents. No difference was found for parents' reports of children's posttraumatic stress symptoms. Exploratory analyses on a subsample of children with teacher reports of child dissociation symptoms (n = 75) revealed that the strength of the association between parent and teacher reports of dissociation symptoms was moderated by matched versus nonmatched group membership. Findings suggest the importance of considering a parent's history of trauma when using parents as informants for children's trauma symptoms.

Children who have experienced interpersonal trauma are at an increased risk of developing dissociation; however, little is known about the prevalence or correlates of dissociation in young children. The current study examined symptoms of dissociation in 140 children (mean age = 51.17 months, range = 36-72 months, SD = 10.31 months; 50.0% male; 45.7% Hispanic) who experienced trauma (e.g., witnessing domestic violence, experiencing abuse). Child dissociation and exposure to traumatic events were assessed using a clinician-administered interview with the biological mother (mean age = 32.02 years, SD = 6.13; 49.3% Hispanic; 25.5% married or cohabitating). Mothers completed measures of maternal dissociation, depression/anxiety, and child behavior problems. At least subclinical dissociation was present for 24.3% of children. Robust regression with least trimmed squares estimation showed that greater maternal dissociation was related to greater child dissociation, adjusting for child internalizing symptoms, number of traumas, and maternal depression/anxiety, B = 0.09, χ(2) = 10.47, p < .001, R(2) Δ = .04. Children who experienced direct victimization did not exhibit a significantly higher level of dissociation compared to children who experienced other traumas, F(1, 138) = 3.76, p = .054, η(2) = .03. These findings highlight the need to assess dissociation in traumatized young children.

This pilot study examined the potential impact of a perinatal adaptation to Child-Parent Psychotherapy (CPP), an evidence-based treatment for traumatized mother–child dyads, on maternal functioning 6 months post-partum among women with history of complex trauma and current intimate partner abuse. Pregnant women (n = 64) enrolled during the third trimester of their pregnancy (Mean gestational age = 27.48 weeks, range of 12 to 42) and participated in weekly perinatal CPP sessions until their infant was 6 months old. Women completed measures of trauma history, depression, posttraumatic stress symptoms (PTSS), and child-rearing attitudes at pre- and post-treatment. Results showed decreases in depression and PTSS from pre- to post-treatment assessments, as well as an increase in positive child-rearing attitudes. As hypothesized, women with low maternal-fetal attachment demonstrated the greatest improvement in depression, PTSS, and child-rearing attitudes compared to women with high maternal-fetal attachment. T...

The article discusses the impact of exposure to domestic violence on infants, toddlers, and preschoolers; the manifestations of post-traumatic stress disorder in the first years of life; and the parameters of Child-Parent Psychotherapy as a relationship-based treatment that aims at enhancing the parent's effectiveness as a protector as a means of restoring the child's momentum towards healthy development. Obstacles to the child's mental health and to the success of treatment are discussed, with particular attention to the adverse effects of parental psychopathology and of environmental stressors such as poverty, cultural marginalization, and lack of access to resources. It is argued that the infant mental health clinician working with traumatized children and their families needs to adopt a therapeutic approach that actively incorporates collaboration with other service systems, including pediatric care, childcare, law enforcement, child protective services, and the courts, in order to provide ecologically sound and culturally competent treatment.

Child-Parent Psychotherapy (CPP) is an evidence-based treatment for children age 0-5 who have experienced at least one traumatic event and/or are experiencing mental health, attachment, and/or behavioral problems. Harley, Williams, Zamora, & Lakatos (2014) use a case study approach to examine the utility of CPP for working with children with developmental disabilities. They share specific ways in which the model can be tailored for this population. In this commentary, we reflect on their work with James, a 14-month old Latino boy with global delays related to a stroke he suffered after surgery for a congenital heart defect, and Juan, a 6 year, 2 month old boy diagnosed as autistic who has also experienced multiple traumas. We highlight interventions that address core CPP goals and discuss the need to address four key topic areas when conducting CPP with children with disabilities: 1) the importance of addressing risks that present within the caregiver-child relationship, including caregivers’ unresolved grief; 2) the potential for the caregiver or child’s history of trauma to contribute to challenges in the child and caregiver’s functioning; 3) the importance of working as part of an interdisciplinary team to coordinate care and better address the complex needs of families; and 4) the importance of applying a socio-cultural lens in every aspect of the work.

Children under the age of 6 years are disproportionately exposed to interpersonal trauma. Research describing type and frequency of exposure to trauma among this young population is limited. Additionally, few studies have assessed the role of multiple indicators of parental functioning on children's behavior following trauma exposure. The current study was conducted with 216 ethnically and socioeconomically diverse mother–child dyads to examine the impact of maternal symptoms and parent–child functioning on child's behavior after trauma exposure. Children experienced an average of over 5 traumatic events prior to age 6 years, and mothers had experienced an average of over 13 traumatic events during their lifetime. With child's trauma history in the model, maternal depressive symptomatology (β = .30) and parent–child dysfunction (β = .32) each uniquely accounted for variance in children's behavioral and emotional functioning. The findings of this study underscore the need for clinical interventions that address the parent–child relationship and parental symptomatology following young children's exposure to trauma. Traditional and Simplified Chinese Abstracts by AsianSTSS 標題：孩童面對家長離世的HPA軸功能與心理及環境因素的關鍵：初步研究結果 撮要：本文檢視孩童喪親後HPA軸功能(包括皮質醇睡醒反應；CAR) 與心理困擾、應對、和另一尚存家長的悲傷反應之間的關係。樣本包括38名孩童(20名女童曾在過去6個月有家長離世)和28名尚存的孩童家長(23名女性)，他們會接受自我答問工具和半結構面談，而面談包括討論孩童對喪親的想法及感受，面談後連續三日，受訪者會提供3個在家唾液樣本(睡醒時，30分鐘後和黃昏時)。結果顯示孩童第1天CAR減退與更多焦慮症狀(r= -.45) 、 抑鬱症狀(r= -.40) 、 創傷後壓力症狀(r= -.45) 、不適應哀悼症狀(r= -.43) 和迴避性應對水平(r= -.53)有顯著關連。家長的更高不適應哀悼水平(r= -.47) 亦與孩童第1天CAR減退有關連。這些數據突出了減弱的CAR可能是累積穩態負荷和(又或)情緒上刺激的事件(與死者相關的討論)，及在家庭中相關的後續處理(或缺少處理)而導致的。這些可能對喪親兒童(已經歷高度心理困擾、迴避應對和家長的不適應哀悼)來說已是特別壓力。 标题：孩童面对家长离世的HPA轴功能与心理及环境因素的关键：初步研究结果 撮要：本文检视孩童丧亲后HPA轴功能(包括皮质醇睡醒反应；CAR) 与心理困扰、应对、和另一尚存家长的悲伤反应之间的关系。样本包括38名孩童(20名女童曾在过去6个月有家长离世)和28名尚存的孩童家长(23名女性)，他们会接受自我答问工具和半结构面谈，而面谈包括讨论孩童对丧亲的想法及感受，面谈后连续三日，受访者会提供3个在家唾液样本(睡醒时，30分钟后和黄昏时)。结果显示孩童第1天CAR减退与更多焦虑症状(r= -.45) 、 抑郁症状(r= -.40) 、 创伤后压力症状(r= -.45) 、不适应哀悼症状(r= -.43) 和回避性应对水平(r= -.53)有显著关连。家长的更高不适应哀悼水平(r= -.47) 亦与孩童第1天CAR减退有关连。这些数据突出了减弱的CAR可能是累积稳态负荷和(又或)情绪上刺激的事件(与死者相关的讨论)，及在家庭中相关的后续处理(或缺少处理)而导致的。这些可能对丧亲儿童(已经历高度心理困扰、回避应对和家长的不适应哀悼)来说已是特别压力。

Two bereavement-related disorders are proposed for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V): Adjustment Disorder Related to Bereavement, to be located in the main body of the text as an official diagnostic entity; and Bereavement-Related Disorder, including a Traumatic Death Specifier, to be located in the Appendix as an invitation for further research. These diagnoses currently do not include developmentally informed criteria, despite the importance of developmental processes in the ways children and adolescents grieve. In this article, we draw upon a selective review of the empirical literature and expert clinical knowledge to recommend developmentally informed modifications and specifiers of the proposed criteria for both bereavement disorders and strategies to improve future research. This article is derived from an invited report submitted to the DSM-V Posttraumatic Stress Disorder, Trauma, and Dissociative Disorders Sub-Work Group, and suggested modifications have received preliminary approval to be incorporated into the DSM-V at the time of this writing. Adoption of these proposals will have far-reaching consequences, given that DSM-V criteria will influence both critical treatment choices for bereaved youth and the next generation of research studies.

Children aged birth to five years are exposed to a disproportionately increased amount of potentially traumatic events compared to older children. This review examines the prevalence of traumatic exposure in the birth-to-five age range, the indicators and diagnostic criteria of early traumatic stress, and the contextual issues associated with the experience of early trauma. The article also selectively reviews the impact of trauma on the biological, emotional, social, and cognitive functioning of young children's development along with some promising clinical treatment and service interventions that target the parent-child relationship as a vehicle of trauma recovery. Despite extensive documentation of the negative impact of trauma on the normal development of young children, research, clinical, and policy efforts to address the psychological repercussions of early victimization remain remarkably limited. Future directions in research and clinical practice as well as implications for policy are discussed.

PURPOSE: Three major glaucoma trials, all using the same Humphrey visual field tests, specified different criteria to define visual field progression. This article compares the performance of these criteria with a reference standard of unanimous classifications by 3 independent glaucoma experts. DESIGN: Longitudinal, comparative study of diagnostic criteria. PARTICIPANTS AND CONTROLS: Two hundred forty-five patients with manifest glaucoma in the Early Manifest Glaucoma Trial (EMGT). METHODS: Visual field series of 1 eye of each of 245 EMGT patients were classified by 3 independent glaucoma specialists as definitely progressing, definitely nonprogressing, or neither. Field series that were classified in the first 2 categories by all 3 experts met the reference standards for the progressing and nonprogressing groups and were analyzed according to the progression criteria of the Advanced Glaucoma Intervention Study (AGIS), the Collaborative Initial Glaucoma Treatment Study (CIGTS), and the EMGT. Sensitivity, specificity, time to progression, and sustainability were calculated. MAIN OUTCOME MEASURES: Progression, nonprogression, sensitivity, specificity, time to progression, and sustainability. RESULTS: Seventy-seven field series were definitely progressing, and 95 series were definitely nonprogressing. Among progressing eyes, 45 (58%) of 77 were identified using AGIS criteria, 58 (75%) of 77 were identified with CIGTS criteria, and 74 (96%) of 77 were identified with EMGT criteria; all comparisons of sensitivities were significant, simultaneous (P

Systematic research and practice guidelines addressing preschool psychopharmacological treatment in very young children are limited, despite evidence of increasing clinical use of medications in this population. The Preschool Psychopharmacology Working Group (PPWG) was developed to review existing literature relevant to preschool psychopharmacology treatment and to develop treatment recommendations to guide clinicians considering psychopharmacological treatment in very young children. This article reviews the developmental considerations related to preschool psychopharmacological treatment, presents current evidence bases for specific disorders in early childhood, and describes the recommended algorithms for medication use. The purpose of this effort is to promote responsible treatment of young children, recognizing that this will sometimes involve the use of medications.

There is a steady accumulation of research and clinical evidence documenting the effect of traumatic events on the development of infants and young children. Trauma involves the impact of extreme physical or psychological stressors that overwhelm a child's ability to cope. Traumatic events threaten serious injury, death, or the psychological integrity of a child or another person. Young children are frequently exposed to a range of traumatic stressors, including hurricanes, near drownings, car accidents, and shootings, as well as physical and sexual abuse, domestic violence, war, and terrorism. Because young children have limited coping skills, they are particularly at risk for negative outcomes associated with traumatic events. (PsycINFO Database Record (c) 2010 APA, all rights reserved) (journal abstract)

A prenatal intervention designed to prevent the onset of major depressive episodes (MDEs) during pregnancy and postpartum was pilot tested at a public sector women’s clinic. The Mamas y Bebes/ Mothers and Babies Course is an intervention developed in Spanish and English that uses a cognitive-behavioral mood management framework, and incorporates social learning concepts, attachment theory, and socio-cultural issues. The four goals of this project were to develop the intervention, assess its acceptability, test the feasibility of conducting a randomized trial with public sector patients, and obtain estimates of its effect size. Forty-one pregnant women at high risk for developing MDEs were randomized to the Mothers and Babies Course ( n = 21) or a comparison condition ( n = 20). Assessments occurred during pregnancy and at 1, 3, 6, and 12 months postpartum. Differences in terms of depression symptom levels or incidence of MDEs between the two groups did not reach statistical significance in this pilot trial. However, the MDE incidence rates of 14% for the intervention condition versus 25% for the comparison condition represent a small effect size ( h = 0.28) that will be further examined in a larger scale study. The intervention was well received by the participants and implementation of a randomized trial appeared quite feasible as indicated by our follow-up rate of 91% at 12 months. Implications for the continuing development of preventive interventions for perinatal depression are discussed.

Fifty preschool children with varying amounts of visitation with their previously violent fathers were studied to determine if the amount of father visitation was related to their behavioral functioning. The possible association of the severity of violence witnessed and the quality of the mother-child relationship on child behaviors was also assessed. There was a significant negative relationship between internalizing and externalizing behaviors, as measured by the Child Behavior Checklist, and frequency of father visitation. Children who saw their fathers less frequently evidenced higher internalizing and externalizing scores. More severe levels of violence perpetrated by the father significantly predicted increased externalizing behavior scores but not internalizing scores. Severity of violence was more predictive of externalizing behaviors than frequency of father visitation.

(2003). The treatment of attachment disorder in infancy and early childhood: Reflections from clinical intervention with later-adopted foster care children. Attachment & Human Development: Vol. 5, No. 3, pp. 279-282.

National experts discuss culturally competent domestic violence health care responses and children who witness domestic violence. Comments address culturally competent systems, research, and clinical responses in Native American, Latina immigrant, and lesbian, gay, bisexual, and transgender communities and effects on and responses to children who witness domestic violence.

Purpose: To determine the ability of scanning laser polarimetry (GDx Nerve Fiber Analyzer; Laser Diagnostic Technologies, Inc., San Diego, CA) to separate normal eyes and those considered likely to have glaucoma in a public glaucoma screening. Methods: A 2-day public glaucoma screening program was held at two different institutions. Each subject underwent ophthalmologic examination, Humphrey perimetry (24–2 Fastpac program), and imaging using scanning laser polarimetry (GDx) in each eye for allocation into a diagnostic category: normal, ocular hypertensive, glaucoma suspect, or glaucoma. Results from the normal and glaucoma groups were analyzed, using modulation parameters calculated from a measurement band located 1.8 disc diameters from the disc, and selected parameters provided automatically by GDx software. Receiver operating characteristic curves were used to depict the sensitivity/specificity relationship at different GDx parameter cutoff levels. Results: Of 200 subjects, 197 were classified; 122 were classified as normal, 23 were classified with ocular hypertension, 30 were classified as glaucoma suspects, and 22 were classified with definite glaucoma. Three subjects had ocular diseases other than glaucoma. The maximum area under the receiver operating characteristic curve for modulation parameters was 0.935, and for the GDx software parameters was 0.901. Conclusions: Scanning laser polarimetry may be useful in glaucoma screening.

This paper discusses one family's struggle with domestic violence involving three generations. In this case, coercive negative maternal attributions interacted with parent‐to‐child projective identification, which resulted in the child's internalization of parental perceptions involving confusion around danger and protection from danger. Projective identification occurs as readily from a parent to a child as from a child to a parent. As is illustrated, when the parent's use of projective identification is excessive, it has severe implications for the whole of the child's psychic development (Lieberman, 1992, 1994, 1997, in press; Seligman 1993, 1995, this issue; Silverman, Lieberman, and Pekarsky, 1997).

This article deals with the complexities involved in making custody and visitation orders in families in which there is spousal battering. A study of preschool-aged children who witnessed domestic violence is described. The effects of witnessing violence on the emotional and behavioral functioning of these young children is detailed, and clinical material illustrating the relational dilemmas they face is presented.

Purpose: Optimal management of pathologic T3 prostate cancer is poorly defined. We conducted a prospective study of untreated pT3 patients to improve understanding of the natural history of this disease and to identify clinical parameters useful in patient selection for adjuvant therapy.Materials and Methods: Of 583 consecutive patients with clinical stage T1 to 2 disease managed by total prostatectomy, 206 had pT3 disease. Excluding patients requesting immediate adjuvant treatment or neoadjuvant therapy, 156 subjects were eligible for the study, including 34 with pT3a, 80 pT3b, 22 pT3c, and 20 pT3N + disease. Patients were followed for prostate-specific antigen (PSA) recurrence of greater than 0.2 ng./ml. and biopsy proved local or distant tumor progression demonstrated by imaging studies.Results: After a median of 45 months, PSA recurrence was seen in 29.4% of pT3a (10/34), 30% of pT3b (24/80), 27.3% of pT3c (6/22), and 80% of pT3N+ (16/20 cases). Local or distant progression was seen in 2.9% of...

Purpose To describe the late onset of sequential multifocal bleb leaks as a postoperative complication after filtering surgery with antimetabolites. Materials Retrospectively, 385 consecutive eyes (304 patients) undergoing trabeculectomy with 5-fluorouracil (5-FU) or mitomycin C (MMC) from 1989 to 1994 were reviewed. Eyes with filtration bleb leak occurring 6 months or more after trabeculectomy were analyzed, and clinical characteristics of the filtration bleb, response to treatment, and bleb histopathology from eyes undergoing bleb excision were analyzed. Results In seven (1.8%) of 385 consecutive eyes from 304 patients undergoing glaucoma filtration surgery with 5-FU or MMC, repetitive bleb leaks in different locations of the bleb were observed from 9 to 44 months (mean, 20.4 months) after the procedure. One hundred ninety-three eyes (50%) were treated with 5-FU and the remaining eyes, with MMC. All eyes had transparent, avascular, lobular, cystic blebs. Bleb leaks occurred in five eyes treated postoperatively with subconjunctival 5-FU and in two eyes in which MMC was used intraoperatively. Three eyes (all treated with 5-FU) required surgical excision, and four eyes healed with soft contact lens, cyanoacrylate glue, or intrableb injection of autologous blood. Histopathology of the bleb leak sites demonstrated focal epithelial thinning and interruption with subjacent hypocellularity and stromal collagen degeneration. Conclusion Late sequential multifocal bleb leaks may occur after glaucoma filtration surgery with administration of antimetabolites (5-FU or MMC) and are associated with epithelial breakdown, hypocellularity, and stromal collagen necrosis in the filtration bleb.

La sexualite et l'agression emergent durant la deuxieme annee d'une vie en tant que systemes importants de motivation qui organisent des aspects considerables du comportement du jeune enfant, affectant l'operation du systeme d'attachement et transformant les perceptions des parents et leurs comportements envers l'enfant. Le lien entre differents systemes de motivation chez le parent et l'enfant est discoute en tant que dimension importante dans l'elargissement de notre comprehension de l'attachement dans le contexte du systeme de mode de soin. Des exemples normatifs et cliniques sont presentes de maniere a illustrer la facon dont l'agression et la sexualite affectent l'attachement ainsi que les comportements et representations de modes de soin durant la petite enfance.