Showing papers in "Hong Kong Journal of Psychiatry in 1993"

Child Sexual Abuse in Hong Kong

Abstract: SUMMARY Child sexual abuse in Hong Kong is a relatively neglected topic. Present article attempts to address 3 related issues--the definition, reporting and recognition. some of the hotly debated issues are reviewed. Recommendations are suggested to deal with the raised questions. INTRODUCTION The apparent rarity of child sexual abuse in local territory is in marked contrast with those reported in the west. In the United Kingdom and United States, the annual incidence have been reported as 0.3 (Mrazek et al, 1983) to 0.7 (NCCAN, 1981) per 1,000 children. The prevalence rate is 12%-62% for females and 8%-31% for males (Baker & Duncan, 1985; Peters et al, 1986). These figures are mainly restricted to white Caucasian population. Across ethnic groups, the rate has been reported to be higher among Hispanics (Kercher & McShane, 1984), same among Afro-Americans (Wyatt & Peters, 1986) and lower among Asians and Jews (Russell, 1986). Little can be said about the prevalence of child sexual abuse among Chinese. Most publications were limited to case studies (Kok, 1984; Li, 1987; Ho & Kwok, 1991; Lau, 1992). Some were retrospective recall in an adult population suffering from mental disturbances (Kok, 1984; Li, 1987). An earlier study by Law (1979) described 183 victims of children molesters over 10-years' period. However, the focus of the article was on the description of offenders. A search of local communities dealing with child abuse revealed only 134 sexual abuse cases in 4-years' time (Ho & Lieh-Mak, 1992). The small number of cases in a 1.26 million population under 15 (Census and Statistic Dept., 1990) is far lower than the western counterparts. However, the rarity of reported cases does not necessarily mean absence of the problem. Experience-in the United Kingdom and the United States in the past 15 years have well demonstrated that true prevalence is a function of public awareness and professional attention to the problem (Kercher & McShane, 1984; Finkelhor & Baron, 1986). This article attempts to explore the issue from 3 perspectives: cultural variation of the criteria of child sexual abuse. professional reporting and recognition. DEFINITION OF CHILD SEXUAL ABUSE Before tackling the issue of prevalence rate, the problem of what constitute a case have to be addressed. Another thorny issue will be the cultural variation in the definition of child sexual abuse. Early studies did not specify or only give a global description of what constitute a sexual abuse. One of the frequently quoted definition is given by Schechter and Roberge (1976) and it referred to ".... the involvement of dependent, developmentally immature children and adolescents in sexual activities that they do not fully comprehend, are unable to give informed consent to, and that violate the social taboos of family roles." It leaves too many loopholes for subjective judgement. Recent work tends to operationalize the definition which consists of at least 2 components (Mrazek, 1980). Firstly, what behaviours constitute sexual abuse and, secondly the developmental level of the victim. Wyatt (1985) has demonstrated that by varying the four areas of definition, namely upper age limit for sexual abuse; criteria to define a given sexual experience as abusive; inclusion or exclusion of peer experience; use of different criteria for incidents occuring during adolescence, a 14% difference in prevalence rate was found. Garbarino (1980) suggested the intention of the perpetrator should be considered in the definition. It would help in discriminating between acts performed for the sexual gratification of the perpetrator or for conveying feelings of affection. While it has a clear relevance in terms of management, in practice, it may be very difficult to judge. The perpetrator may not be willing or able to tell his or her intention. It could be a mixture of both. Neither do we have empirical data to support our inference from behaviour to intention. …

Psychological Effects of Physical Illness and Hospitalisation on the Child and the Family

Abstract: SUMMARY Physical illnesses are common happening in the case of children, yet they can have profound impact on the children. With the increasing trend of admitting young children into hospital for inpatient care, the problem of separation from their parents has emerged. The short-term and long-term sequelae on these children and their families are discussed. The present article also records some observations made in the children's wards as regards the related psychological effects in the Chinese families in Hong Kong. Recommendations concerning measures to improve the situation and to ameliorate the effects are made, such that those requiring hospitalisation will not suffer unnecessary psychological trauma in due course. INTRODUCTION The importance of the family as a formative influence on a child's personality growth needs no arguing. Particularly in early childhood, it is the matrix within which the child develops, the area where his strongest emotional ties are formed and the background against which his intense personal life is enacted. From the moment a child is born, the family governs the early experience that permeates the course of physical and mental development. Small children, particularly in infancy, need adequate maternal care to avoid the risk of serious maldevelopment of intellect and personality. Maternal care does not necessarily imply the biological parent. More favourable developments may come from the exclusive maternal care of the infant ('monomotic') in comparison with care shared with extended family or friends ('polymotic'). Mother is normally the source of stimulation to verbal behaviour, play, and the like. She provides for the nutritional, material and security needs of her child (Hill, 1976). The normal growth of children is dependent on the mother's full-time occupation in the role of child-rearing (Baers, 1954). To the extent that such needs can be provided by other agencies, the impact of separation is diminished. EFFECTS OF ACUTE ILLNESS Any acute illness, with its physical discomfort and emotional stresses, can be quite upsetting to the child and his parents. Even the small child is so organised psychobiologically that pain or the threat of pain, the loss of a bodily part or the threat of bodily mutilation, an particularly the awareness of the possibility of impending death precipitate a series of defensive reactions initiated by the arousal of anxiety. An impairment of physical strength or a loss of physical control or of the autonomy of behaviour may also result in damage to the child's self-image and self-esteem and thus may lead to feelings of loss of identity and continuity. While a small child's sense of security may be undermined by some loss of confidence in the omniscience and omnipotence of his parents, a sudden feeling of becoming different from his peers may stimulate increased anxiety in the older child. This anxiety may be complicated by other unpleasant feelings, such as feelings of guilt and anger from the assumption that painful medical or surgical procedures are hostile attacks or that the illness is punishment for past misbehaviour. Illness also draws attention to the parts of the body affected, thus making bodily sensations loom up in the child's mind, increasing his sensitivity to bodily sensations, altering, perhaps, his body and self-image, evoking repressed infantile experiences and fantasies, and suggesting the patterns for the later utilisation of illness for secondary gains. It is now known that when ill, children may show their anxiety in different ways. Infants and small children usually give vent to their feelings by crying and sometimes by vigorously resisting all medical procedures. Some children regress in their behaviour, becoming overly pliant, apathetic, or withdrawn. Loss of hope may result in loss of interest in the environment, increased self-preoccupation, and sometimes in either depression or a flight into fantansy. …

Study of Life Stress in Children with Psychiatric Disorders in India

Abstract: SUMMARY Life Events Scale for Indian Children (LESIC) was developed and standardized for use on Indian children. Life stress was measured using LESIC in 80 children with psychiatric disorders and 100 normal children. The findings revealed that the sick group encountered more serious life events as reflected in their having greater stress score in the one year preceding the onset of symptoms. Sick children also experienced greater stress in younger age (4-7 yrs), and more undesirable events as compared to normal controls. This study focuses on issues of measurement of stress. Its role in psychiatric disorders and cultural factors. INTRODUCTION The role of life events in the causation of psychiatric disorders was recognized long back by Adolf Meyer (1951) who suggested that even the most normal and essential events in life could contribute to psychiatric disorders Literature concerning life events and stress in childhood is sparse in contrast to that in adults. In the last decade there have been few measures of stress in childhood (Compas, 1987; Johnson, 1986). Classical life events approach of Holmes & Rahe (1967) was used in Coddington's Social Readjustment Rating Scale (Coddington, 1972 a & b, 1984). Limitations of the life events checklist approach to studs of stress in childhood have been discussed in various reviews (Goodyer, 1990 a & b, Rutter & Sandberg, 1992). mainly extrapolating from relevant literature on adults. However, Coddington's Social Readjustment Rating Scale or its modifications have been widely used in many studies (Monaghan, Robnison and Dodge 1979, Hurme 1981. Wertieb, Weigel and Feldstein 1987, Jensen et al, 1991). Till the alternative methodology of interview technique for assessing life stress is standardized and validated, studies using the checklists we likely to continue for some time. Psychopathology in childhood has been found to be associated with many environmental factors and life events such as adverse family circumstances (Rutter, 1985 & 1989, Shaw and Emery, 1989, Goodyer, Wright Altham, 1988), maternal separation or deprivation (Bowlby, 1969 & 1980, Rutter, 1981 & 1989, Wolkind end Rutter, 1985), birth of a sibling (Dunn & Kendrick, 1982, Dunn, 1988), parental diverce (Hetherington, 1988), bereavement (Van Eerdewegh et al, 1982), physical handicap (Wasserman & Allen. 1985), urbanism) (Quinton. 1988), maternal depression (Mills at al, 1985). It has been found that these events assume etiological significance in a particular such-cultural context. Brown & Harris (1989) emphasized that the significance of these events should be interpreted in the social context of its occurence. Another way of approaching this question of cultural relativity of stressful events can be via0 studying the same event in socio-culturally different populations and to examine and compare directions and strength of their relationships to psychopathology. No studies have been reported from India on stress and psychiatric disorders in children and there is no assessment measure developed for Indian population. Only one study in India (Rangaseami & Kamakshi, 1983) on adolescent hysterics, used Coddington's Social Readjustment Rating Scale and reported that majority (85%) of hysterics had a significant life stress before the onset of symptoms. Present study was planned to examine the relationship between stress and psychiatric disorders in children in India in a case-control study design. Being the first systematic study in this area, it was necessary to develop a measure of stress applicable to Indian population. MATERIAL AND METHODS LIFE EVENTS SCALE FOR INDIAN CHILDREN British Life Event Inventory (Monoghan, Robinson & Dodge, 1979) which was an adaptation of Coddington's SRRS (Coddington, 1972) was adapted for use on Indian papulation). The process of adaptation involved evaluation of the British Inventory by experienced professionals in terms of relevance of items and appropriate stress score, keeping in mind the Indian socio-cultural context. …

Suicide among Children and Adolescents in Hong Kong

Abstract: SUMMARY This study aims at exploring the problem of suicide among children and youths under 21 in Hong Kong in the past 10 years (1981-1990) by reviewing the coroner's reports. The suicide rate for age group 10-20 is found to be 2.2 per 100,000. Although the phenomenon is not as serious as in other countries such as Japan and the U.S.A., it has caused great concern to the public. Unfortunately, the nature of the problem, especially its causes, has been in a certain extent distorted by the public. Certainly, the school should not be the only system in which various kinds of effort are to be put to prevent suicide among children and youths. The deteriorating family structure in Hong Kong deserves equal and even more attention. INTRODUCTION Various means of escape from the unpleasant reality have been learned by people in their upbringing. Suicide, the most irreversible escape, appears to have increased disturbingly among teenagers during the past two or three decades in most countries. A teenager's suicide if, always shocking. It will distress those who know trim and very often ii captures headlines, Relatives and journalists would often depersonalize the death and seek an explanation for it by blaming the changing society or attribute it to a deteriorating educational system. The publicity given to individual incident may lead many to conclude that childhood and adolescent suicide is an overlooked and growing phenomenon. Although such conclusion has gained empirical support in the West, statistics in Hong Kong tin hardly be found. The present study aimed to explore the scope of the problem in Hong Kong during the past ten years. LITERATURE REVIEW DURKHEIM'S CLASSIC STUDY The study of suicide against its social background may be dated from the classic research of Durkheim, first published in 1897. He defined suicide as death resulting from behavior that the individual knows will lead to his own demise. Whether death is desired is immaterial and only the individual's awareness of the consequences of his behavior is relevant (Durkheim, 1951). Durkheim investigated not suicides per se but social suicide rates. His study focused on comparisons and tried to explain why the rate was higher for one group than the other. With the support of the rates he collected, Durkheim argued that suicide rate was a measure of the health of the health of the social body. He also generated a. strictly sociological theory of suicide by identifying two major explanatory variables, integration and regulation, that created his four types of suicide; egoistic, altruistic, anomic, and fatalistic. He observed that whenever integration or regulation was strong or weak, the suicide rate was high; whenever moderate, the rate was low as shown below in Figure 1. [FIGURE 1 OMITTED] CONCEPT OF DEATH AMONG CHILDREN AND YOUTHS There is a fundamental question before one goes on to make any further enquiries concerning suicide among children and adolescents; what do children know of death? Children's views of life and death differ sharply from adult views. In an early study on this subject, Gesell and Ilg (1946) presented a dynamic approach that considered both cognitive change and the parallel emotional reactions. The central conclusion was that the main bulk of development in grappling with death occurred by age seven, and by age twelve, there was is clear understanding of the distinctive appearance of the dead compared to the living. Similarly, Kane (1979) also described the development of the concept of death among children in three stages. Initially, a child could only perceive death as a separation and lack of movement. Secondly, all aspects of death seemed to be understood but only in concrete terms. Finally, during the last stage, these aspects would be known on a more abstract level. Despite popular beliefs, children's suicide does not seem to be the result of misunderstanding. …

The Pathways of Childhood

Abstract: The pathways from childhood to adulthood are multiple, tortuous and often fraught with problems. It is a period of fife characterized by continuous development and changes. There are different developmental tasks and needs for different age groups. To realize the full potential of children and to bring them up to become normal adults, parents and teachers need to understand and fulfill these developmental tasks and needs. Parents need to provide a stable and loving home and to devote time and efforts to their children. In addition, an enabling environment providing well designed and co-ordinated educational, social, physical, artistic and recreational opportunities are also essential. If the child is like a seed then a loving home is like good soil and an enabling environment is like sufficient sunshine and rain; it is the combination of good soil, sufficient sunshine and rain that will ensure that the seed will grow healthily and bear fruit. Research in Hong Kong has shown that there is gross misunderstanding among parents and teachers about the needs of children. Educational achievements are often regarded as most important. Children's emotional, physical, social and recreational needs are often grossly under-estimated. Many children are living a very unbalanced life. While most children spend a great deal of their time on homework, their leisure hours are often engaged in un-stimulating activities. Hong Kong does provide a tange of services for children and families. However, many of these services are either insufficient In quantity, inadequate in quality or fragmented in coordination. Take education as an example, it is a fair statement to say that Hong Kong basically provides an average education for the average child. Many children with learning disorders are not given any help at all. Even when some assistance is available, the input is still insufficient. On the opposite end, very little has been done to help intellectually gifted children to realize their potential. Between these two extreme ends on the continuum of normal intelligence are many children who are talented in specific areas. Again very little has been done to discover and develop these talents. Many children are less fortunate. They may be born with physical and intellectual handicaps. Some may suffer from neuro- developmental disorders such as developmental language and speech disorders, hyperkinetic disorders and childhood autism. More-over, based on many well designed child psychiatric epidermilogical studies done in many different parts of the world (Branderburg et al., 1990; Gould, Wunsch-Hitzig & Dohrenwend, 1980; Offord et al., 1987; Rutter, 1989), including several studies done in Hong Kong (Luk et al., 1991; Shek, 1988; Wong & Lau, 1992), it is estimated that at least 1096 of Hong Kong children are suffering from significant behavioural disorders, most usually the results of longstanding abnormal psychosocial environments. Translated into actual numbers, there are about 150,000 cases, based on the estimation that there are 1.5 million children and adolescents in Hong Kong. These children and their families require psychiatric intervention, remedial education, training and rehabilitation. But how much has Hong Kong done for these unfortunate children? Not a lot. Assuming that the expressed demand for child psychiatric service is only 5%, that still gives a figure of 75,000 children and adolscents as requiring child psychiatric service. But there are only a few child psychiatric units in Hong Kong. Take the school as another example, the existing school social work provision is one school social worker per 2,000 secondary school students. The average secondary school in Hong Kong accommodates 1,000 students. Thus one school social worker is shared by two schools. In some areas, because of shortage of staff, one school social worker has to look after three schools. According to the prevalence of 109% there are about 100 psychiatrically disturbed students per school. …

A Review of the Drug Treatment of Alzheimer's Disease *

Abstract: SUMMARY A high interrater diagnostic reliability and objective measurements of therapeutic response are essential in drug trials of Alzheimer's disease (AD). Most therapeutic trials on AD are based on the cholinergic hypothesis. Although only modest clinical improvements are observed, future developments in cholinergic therapy have a great potential. Some of the other therapeutic strategies such as the use of metabolically active compounds also produce small but consistent responses. Investigations on these drugs might provide other hints for the neuroendocrinological aspects of the aetiology of AD. Psychosocial aspects of management are also important and much of the load will rest on the primary health carers. INTRODUCTION It is estimated that from the year 1986 to 2006, the life expectancy in Hong Kong will improve from 74.0 years in men and 79.8 years in women to 77.3 and 82.9 respectively (Tam. 1990). The population of those aged 65 or over will increase from 8% to 13% of the total population, or from 0.42 to 0.81 million in the same period (Census and Statistics Department, 1987). Of such a geriatric population, about 10% will suffer from mild to moderate dementia (Hollisters, 1985). And approximately 50-60'% of this patient population are presently believed, at least in western countries, to suffer from senile dementia of the Alzheimer's type (Alzheimer's disease of AD) (Rogers, 1986). Caring for AD patients will also produce a huge burden on the community unless effective therapies are identified. Management of AD patients includes social, psychological and drug approaches. Many different categories of drugs are being tried recently and show variable degrees of effectiveness in improving the cognitive functions of AD patients, This article thus aims to review the mechanisms proposed and clinical efficacy observed of the many types of drugs that have been tried. One possible therapeutic strategy that has been investigated extensively is based on the hypothesis that AD is associated with decreased central cholinergic transmission. There are large reductions in the activity of choline acetyltransferase in the cortex and hippocampus of brains from AD patients (Roberts, 1989). Thus the potentiation of central cholinergic function by cholinergic drugs might ameliorate the cognitive impairment in AD. DRUGS ACTING ON THE AUTONOMIC NERVOUS SYSTEM DRUGS ACTING ON THE PARASYMPATHETIC SYSTEM (1) Acetylcholinestemase inhibitors 9-ANMINO-1, 2, 3, 4TETRAHYDROACRIDINE (THA) One of the major chemical changes in AD is the decrease in activity of choline acetyltransferase in the cerebral cortex and hippocampus, leading to an impairment of acetylcholine syntheses (Katzman, 1986). THA was originally developed as a partial antagonist of morphine, appears to have acetylcholinesterase inhibiting effects (Kaul, 1962) and has been tried in various studies as a potential treatment of AD. Other than being an enzyme inhibitor. THA was found to have other mechanisms to explain its cholinergic effect. In electrophysiological studies with neurons of Lymnaea stagnalis. THA inhibits the slow outward [K.sup.+] current and consequently increases the duration of the action potentials (Drukarch, 1987). Moreover, THA concentration-dependently inhibits the uptake of noradrenaline, dopamine and serotonin. Such uptake inhibition does not seem to occur at the level of the axonal membrane, but at the level of the monoaminergic storage granules (Drukarch, 1988). Thus THA might well have some monoaminergic effect. The initial report by Summers et al (1986) that combined oral treatment of THA and lecithin improves the condition of patients with AD has attracted considerable interest. Later studies, however, failed to demonstrate such marked improvements. A study using THA 125mglday showed that when compared to placebo, THA does not improve either the Mini-mental State score nor the Stockton Geriatric score except a slight but statistically significant improvement in the physician's score on the Visual Analogue Scale (Chatellier, 1990). …

Temperament of Children of Addicts: A Preliminary Report

Abstract: SUMMARY The temperament characteristics of 20 children of psychoactive substance dependent fathers were studied and compared with those of 119 emotionally disturbed children as well as with the general population norms. The children of addicted fathers were found to be generally low in rhythmicity, adaptability and distractibility. They also displayed negative emotionality, withdrawal and lower threshold of responsiveness as compared to the norms for general population. The differences were further enhanced on rhythmicity and distractibility in subjects whose parents had greater severity of substance dependence. Sex and birth order of the child, duration of exposure of child to father's drug abuse, degree of psychosocial dysfunction in the father, and depression in the mother did not show any significant relationship with the temperament characteristics of the children. This study highlights the usefulness and need for research in this area. INTRODUCTION Several studies in the past few years have shown that certain temperament traits measured in childhood are associated with an increased risk for psychiatric disorders in adolescence (Thomas and Chess, 1977) and young adulthood (Thomas and Chess, 1984). There is also evidence in literature to suggest that temperament deviations in childhood may increase the risk for alcoholism in adulthood (Tarter, Alternan and Edwards, 1985). High behavioural activity (Tarter et al., 1985; Jones, 1968) and other characteristics such low as attention, high emotionality and low sociability (Tarter et al., 1985) appear to comprise features of vulnerability to alcoholism in boys. Tarter et al. (1990a) reported high activity level in biological offsprings of alcoholics. These temperament deviations might indicate a behavioural-genetic marker for alcoholism. Similar search for a behavioural marker for substance abuse in general had concerned researchers. However, there is hardly any literature on relationship between temperament and substance abuse other than alcoholism. Tarter et al. (1990b) in their study on substance abusing adolescents reported them to be distinguishable from normal controls on a variety of temperament dimensions, e.g., higher on activity and lower on flexibility, mood stability. eating rhythm, daily rhythm and task orientation. Since children of substance abuse parents constitute a high risk group predisposed to development of psychiatric disorder in general or substance abuse in particular, it would be worthwhile to explore into the temperament patterns of these children. AIMS AND OBJECTIVES The present study was carried out with the aim of examining whether (i) the temperament profile of children of addicts differs from that of normal children or of emotionally disturbed children, and (ii) the children's temperament correlates with their parents' pattern of substance abuse (severity and duration), psychosocial dysfunction in the sick parent and depression in the well parent. This preliminary study had an exploratory descriptive study design. MATERIAL AND METHODS SUBJECTS The index sample consisted of 20 children whose fathers were diagnosed as suffering from psychoactive substance dependence (not abuse) using DSM-111 criteria (APA, 1980) attending the Drug De-addiction and Treatment Centre (DDTC), Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh. The child had the following criteria for inclusion and exclusion: Inclusion criteria: 1. Age 5-15 years. 2. Minimum exposure to parent's drug taking behaviour: 2 years, and the child staying with the parent for the best 1 year at least. 3. Both parents staying with the child. 4. Only one child per family was included. Exclusion criteria: 1. Substance abuse or mental retardation in index subjects. 2. Significant physical or mental illness in the mother. …