Refugee Women's Health Screening in Massachusetts one Shot Deal-Paroma Mitra

Although women and children face the maximum brunt of war and strife, they are a small part of the overall picture of refugee health. Approximately 80% of the refugees are women or children. Refugees are persons who are outside their country of nationality and who are unable or unwilling to return to that country due to persecution or a well-founded fear of persecution because of race, religion, nationality, political opinion, or membership in a social group.(5) The current system does not emphasize on the specific needs of health care in female refugees. Female refugees are at maximum risk since in countries of conflict, they play more traditional roles and are dependent on their families for all types of support, namely physical, monetary, mental and emotional support. During times of conflict, losing or being separated from their families’ leaves them susceptible to all forms of injuries. Female refugees are also extremely vulnerable to sexual violence in the form of rape, genital mutilation and violation of other reproductive rights due to racial and ethnic discrimination Also, they tend to be overcrowded in camps which are unsanitary and hence they are extremely vulnerable to multiple diseases. When they enter a new country of refuge, they come with special needs of their own namely human needs namely physiological, psychological, social and spiritual.

Currently, the Massachusetts Department of Public Health carries out a basic physical examination of refugees. The primary aim of this physical check up is to ensure that refugees don not have any diseases that would prevent them from entering the United States. These exclusions would include certain communicable diseases and mental health associated with violence. The refugees are further divided into Class A and Class B where Class A deals with communicable diseases and Class B deals with physical deformity and violence leading to Mental Health (5). Whereas, there is provision for treatment including follow up for Class A there is no provision for help for Class B refugees. The current refugee and immigrant program is currently conducted under the Department of Public Health in Massachusetts effective since July 1995. According to the current figures, the number of immigrants entering the state is 1100 annually primarily from Africa and central and east Europe especially from regions of strife. (5) Looking at the background these women come from, a physical examination seems inadequate, real emphasis must be paid on issues like mental health, malnutrition, gynecologic health which forms the bulk of the needs of refugee women.

Current Refugee Physiological Care in Massachusetts
Physiological issues like access to health care and diet and nutrition are overlooked in the current Massachusetts outline. Physiology concerns the normal functioning of the human body hence correct physiological care essential to the well being of these women. When refugee women come in for their first physical examination in most of the cases an interpreter is provided to explain the procedure. An interpreter could also help explain the new health care system they are to become a part of. There are language barriers, limitations regarding transportation, the refugee health finances which women traditionally are not trained to understand in their country of origin. Most women are taught not seek formal care but culturally are expected to treat themselves at home.(1) Therefore, an effort must be made to set up interpreters who not only speak the language but understand the cultural background these women come from and provide with tools to access health care. Interpreters can also counsel about topics like diet and nutrition to women as in a study looking a refugee camps it was reported that particularly prone to diet related malnutrition therefore they must be counseled and given correct diet in regard to their status as women who are menstruating or women at child bearing age as current data shows in a lot of refugee camps there is food shortage hence countries of second asylum must make arrangements for adequate nutrition.(3) Mostly women in refugee camps suffer from some form of malnutrition as during times of conflict there is shortage of food supplies and males tend to be fed first. Also, the food supplies often land up being inadequate in essential nutrients leading to large number of diseases. Dehydration is also another common occurrence seen in women as the water shortage is quite common and lack of clean water is very frequent resulting in a lot of cases of dehydration and diarrhea. Efforts must be made to ensure correct nutrition which does not lead to further exacerbation of disease and pre- existing dehydration must be treated with adequately.

Mental Health as a Vital Factor
Mental Health problems are a part and parcel of every group of society but particularly seen in refugee women. Pre-existing mental disorder may already be present in women which may be triggered by stress due to their surroundings. Other women may be stressed due to what happened in their home country, their flight to a new one and relocation. A study measuring health variables of refugee women for resettlement (10) included biopsychosocial factors such as depression and anxiety as important primary variables as they are seen in about 58% and 24% of women refugees .The most common disorder seen is PTSD (post traumatic stress disorder). (3)In a Yugoslavia study 65% women developed post traumatic stress disorder due to physical and sexual torture. (Kang et all 1965) .Separation from their families leads to additional stress which may exacerbate PTSD. Mental health examination carried out in detail must be mandatory while dealing with refugees and they have special needs that must be addressed adequately to ensure their well- being and they must be followed up on as well by specialists who can deal with the particular sort of stress disorders seen in refugees.

Refugee Women and History of Sexual Abuse and Rape

There is a high prevalence of sexual abuse and rape in refugee women. (1) Especially seen in third world countries, women are traditionally expected to submit to the needs of men and men may take advantage of women already weakened by war for personal abuse and pleasure. It is often reported that soldiers are at the fore front of sexual abuse and often use it as a tool for controlling a population already weakened by war and strife. A study investigating basic women’s right has shown that limitation of sexual and reproductive rights may affect health. (7) It has also been reported that men in second country of asylum may take advantage of frightened and susceptible immigrant women.

Adequate measures must be taken to address this part of mental health and a country or a state granting asylum must provide adequate counseling and support in regard to this. Also health care providers must understand privacy issues and the question of chastity in these women; they may not be able to trust male health care providers completely. It is also important to understand that seeing violence towards others or seeing acts of violence increases sense of vulnerability amongst women.

Refugee Women and Gynecological Issues
Refugee women suffer genital trauma in terms of various degrees of female circumcision which lead to various gynecological and obstetric problems later. (3) There are three different kinds of circumcision, Type 1(seen in Niger, Eritrea, Uganda) which is removal of the clitoris and prepuce, Type 2(seen in Kenya, Somalia, Egypt) deals with excision of clitoris and prepuce along with part of labia minora and type 3(Northern Sudan, Somalia) deals with removal of clitoris and prepuce and sewing up the labia minora with thread and leaving a little gap for urine and menstrual blood. (3)

A lot of countries in Africa namely Somalia and northern Kenya both currently involved in internal strife have high prevalence rates of type 2 & 3 type of circumcision. A large concern of female genital cutting (FGC) is the environment in which it is done in. A lot of the time, a non- sterile blade is used to perform the procedure on young girls by a mid- wife. There is high incidence of hemorrhage and septicemia (3) leading to death. Also a major concern in women who have undergone a type 3 FGC, urinary system infections are very common due to stagnation of urine and they face a large number of urologic as well as gynecological problems. In older women who have undergone the procedure, increased cases of pyometritis, dysmenorrhea, dysparenuia, pelvic inflammatory disease and chronic cervicitis are seen.(3) There is also increased aversion regarding sexual activity leading to different psychological problems from ones discussed above. In addition to this, there is increased incidence of HIV and HBV transmission.

Gynecologic care must be provided to prevent these diseases as far as possible. Women must be regularly checked for gynecologic diseases, regular pap smears and health care surrounding care of the genital region must be given. Also, refugee women have a higher incidence of parity leading to increased cervical prolapse and stress urinary incontinence. Also, special prenatal care must be given to women who have undergone FGC. These concerns if raised by women must be addressed correctly and health care providers must be able to respect the values and needs of women.

Refugee Women and Social Interaction and Expectations
Women are expected to fulfill the “family role” and expected to recreate an atmosphere equivalent to the old home and country putting additional stress on them. (3) They have to adjust to a foreign country and society and are expected to adhere to the ways of the old society as well as cultural traditions in their homeland casting them into particular roles. Role strain occurs when individuals are expected to conform to a form of behavior expected of them which leads to increased amount of stress. (3) It is commonly known that foreign ways are rarely valued by the larger society. This causes excessive strain and burden on women. According to the social networking theory, the surroundings influence the behavior however a new environment does not always necessarily assure of change of behavior. To address this role strain, support groups consisting of members of the same background & society nay help new immigrants to adjust to the ways of a new country and life style. Women should be encouraged to mingle and work in the new society they are in. They are also expected to adjust to a new system in terms of facilities new home and away from parts of their family. The concept of resettling is not addressed currently a high- quality tools are required to measure relevant concepts required for resettling like education. (10)

In other states, the Baylor nursing home ( near Dallas, Texas) uses community outreach services and centers that is driven by human needs and serves the refugee communities nears Dallas, Texas that comprises of many different societies of refugees such as South- east Asians, refugees from Central America , refugees from Mexico and Saudi Arabia. 70% of the people serving in these communities speak the language of the refugee community and it gradually introduces concepts of all forms of health care. (4) Students are encouraged to mingle in the community they serve and teach basic health care prevention. Massachusetts may also incorporate a similar method of care. In another state, Ohio, the system talks about interlinking between various departments to provide for physical, mental and social care of refugees. (2) It has also paid some emphasis on different needs of women refugees and talks about coordinators that not only address physical examination but set up agencies to help refugees to understand the new system they are now a part of. . It can serve as a basic framework for a revised model of the current Massachusetts system. Based on the Social Learning Theory where modeling may cause behavioral change, having other refugee women to help counsel the incoming women may cause a change in their behavior and attitude towards a new system.

A simple electrical system which we take for granted may seem new and foreign to refugee women. Language too becomes a burden. Electrical appliances, laundry and other things we take for granted may not be as prevalent in third world countries. Women particularly may be overwhelmed as children tend to pick up these modes faster and hence they must be specially taught to use the facilities available in the new country. Women in particular according to a study(9) reveal themes of leaving the good life behind, worrying about their children, feeling ambivalent about marriage and lacking hope in the future. These concerns must be addressed to ensure their well-being.

There is a role change that is seen in refugees as in women may get jobs before their husbands and become the primary bread- winner of their families creating a new gender role. If this causes a strain on familial ties, it leads to additional stress on the women concerned. A way to deal with the stress may be via prayer and worship for many. Religion is a key part of life for many women and religious practices may be a part of everyday living for many. It may be a source of strength for many and religious beliefs must be respected in every aspect of care. A new society may not always compliment the old hence the well-being of the individual is compromised. A social advocacy approach is needed with both individual and collective strategies for responding to the lack of sensitivity shown many times. (8)

Conclusion

Refugee women deserve to be treated with special sensitivity and careThe more we learn and study about them the better we can address their issues. (9) They each have varying needs that must even be assessed at an individual level if possible. Women form the back bone of the family in most places and can become contributors to society if given the opportunity to do so. The best way to address the needs of female refugees is to increase the knowledge and sensitivity regarding special health care. One must understand that these women come from often a tragic and violent past to an unknown and uncertain future. The feeling of being degraded, dismissed or ignored may have serious repercussions on these fragile lives. Massachusetts has a large number of refugees many of whom come from violent pasts and it is in integral part of society’s responsibility to ensure their well being. The Commonwealth could modify their clinical program on a more needs based assessment and follow up rather than a purely physical assessment. This must also contain special assessments of women’s needs separately. New proposals are being made currently to incorporate women’s health into the main framework of the current refugee and immigrant health program. The Massachusetts government and Department of Public Health must look into providing health care as well as addressing the other issues describe above. It is imperative and urgent that the community act to provide basic needs to refugees (6). One routine physical examination is not enough to assess the needs of many of these women, mental, psychological and spiritual health must also be addressed simultaneously.


REFERENCES:-
1 http://www.theirc.org/special-report/rape-in-congo.html
2http://jfs.ohio.gov/refugee/docs/NEW%20HEALTH%20SCREENING%20PROTOCOL.pdf
3 http://www3.baylor.edu/~Charles_Kemp/refugee_health_problems.htm
4http://www3.baylor.edu/~Charles_Kemp/refugee_health_models.htm
5 http://www.mass.gov/dph/cdc/rhip/wwwrihp.htm
6. http://refugees.org/uploadedFiles/Investigate/Publications_&_Archives/WRS_Archives/2007/SilentSurge.pdf

7. Basic health, women’s health, and mental health among internally, displaced persons in Nyala Province, South Africa, Sudan. Kim G, Torbay R, LawryL. Massachusetts Veterans Epidemiology Research and Information center, Veterans Affairs Boston Health Care System, Boston, MA.Jan, 2005.
8. Listening to different voices. Hrycak N, Jakubec SL. Faculty of Nursing, University of Calgary, Calgary, Alberta, Jun 2006.
9. Pavlish C. Narrative inquiry into life experiences of refugee women and men. International Nursing Review. 54(1):28-34, 2007 March
10. Gagnon AJ. Tuck J. Barzun L. A systematic review of questionnaires measuring the health of resettling refugee women. Health Care for Women International.25 (2): 111-49, 2004 Feb.

Painting the True Picture of Pediatric Bipolar Disorder-Megan Aleardi

Over a decade ago, documentation in scholarly journals and published statements from the National Institute of Mental Health (NIMH), acknowledged that Pediatric Bipolar Disorder (BPD) was a controversial area of mental health that had been neglected for a considerable amount of time. A review of the publications up to that point concluded that more studies of treatment, course and outcome on Pediatric BPD were urgently needed (1). In 2001, the NIMH held a meeting in the form of a roundtable discussion comprised of 19 of the top researchers and clinicians in the field of Child Psychiatry who were invited because they all agreed that the diagnosis of Pediatric BPD was equivocal and should be further defined. While smaller details about how cycling and/or irritability played a role in the distinction between which category of pediatric bipolar disorder a child would be classified, the larger agenda was successful in that all participants concluded the disorder did indeed exist and could be diagnosed in pre-pubertal children (2).

A Federal Award which would provide funding for the implementation of an annual conference for the following five years was granted to one of the roundtable participants. The goal of the funding, similar to that of the roundtable meeting, was to get their agenda regarding Pediatric BPD on the map. This was to be done by gathering clinicians of all kinds, parents of children with BPD, and representatives from advocacy groups together to set the final agenda; that being the dissociation of the stigma with, and eventual acceptance of, the diagnosis of Pediatric BPD to the public.

Why the Disconnect?

Child Psychiatry has been ineffective as a unified field in its ability to properly develop and disseminate their agenda to the public. The particularities of the phenotype on which researchers do not agree have prohibited the agenda from being fully developed. This shift in agenda has effectively left an opening for the media to misrepresent the diagnosis by framing the disorder as one that does not exist. The stigma associated with the diagnosis of Pediatric BPD not only effects the ability of the parents to accept the label, but it also prevents practicing clinicians from having the confidence to properly diagnose and treat the disorder.

Agenda Setting Gone Wrong.

In her book, “Team of Rivals”, Doris Kearns Goodwin spoke of the strength of Abraham Lincoln‘s political career as one in which he had the sense of the large picture, the sense of timing, and the patience to endure internal or public scrutiny until what it was he was trying to accomplished was ready, complete, and the timing was right for him to announce it to the world (3). Lincoln’s campaign for presidency is an example of the “Agenda Setting Theory” carried out successfully.

Unfortunately, Child Psychiatry as a field has yet to be successful in properly following the Agenda Setting Model. At this time, the field should be presenting itself as one united team with the agenda of dissociating any stigma that is associated with what they study with intense passion and all agree upon. The shift to individual sub-agendas occurred because of the field’s hyper focus on the phenotype. Teams of psychiatrists are putting the energy into proving that their definitions of terms like “rapid cycling,” “multiple episodes per year, “daily cycling” are the pinnacle points in defining Pediatric BPD. Contradicting theories stating that the diagnosis is based upon grandiosity and euphoria, or that irritability, distinguished by severity, is a cardinal rule in defining the disorder, are breaking down the large agenda (4-6).

Furthermore, the field has been unable to come to a conclusion as to which mechanism is the most appropriate, or most accurate in making the official diagnosis of Pediatric BPD. Studies on The Child Behavior Checklist (CBCL) and on the Convergence between structured diagnostic interviews and clinical assessments (7-8), while essential to the field, would be better received as part of the full agenda package. Making the distinctions between the different levels, variability, and outcomes in addition to figuring out the best way to make those distinctions is of utmost importance. However, until a majority of the field has come to a consensus, and until those who may not agree with the majority stop publically opposing others, the media is left to thrive on the controversy within the small details of the field, rather than portraying what the top researchers can agree on; that is, Pediatric BPD is a serious and morbid disorder.

The Media Framed Its Own Picture.

The shift from the initial agenda of disseminating the validity of the diagnosis of Pediatric BPD to the public, to the sub-agendas of individual groups trying to prove his/her methods to be superior to others, effectively left a wide opening for the media to misrepresent the diagnosis by framing the disorder as one that does not exist. They were able to do this through the portrayal of some of the leading researchers as bad doctors by misquoting what had been said and using quotes out of context. The Media’s portrayal of Dr. Joseph Biederman, the clinician who took the initiative, applied for, and received the funding to carry out the agenda as established at the initial round-table discussion is an example of how it contributed to the break down of the field’s agenda. He, like Lincoln, invited those researchers that may not have had the same views as he did to help finish what had been started at the previous meeting. He also invited representatives from parent advocacy groups such as the Child and Adolescent Bipolar Foundation (CABF), as well as actual parents who were living with a child suffering from BPD. Providing a forum to present new information from research, as well as gather opinions from those who lived with the disorder and those who advocated for them was a right step towards getting on the agenda. Unfortunately, the shift of all members of the conference to their own agendas, combined with the overdose death of a 4-year old child diagnosed with Pediatric Bipolar Disorder, left the media with room to paint their own picture. The media found the perfect opportunity to frame Pediatric BPD as a non-existent disorder that was created by the researchers and pharmaceutical companies to make money (9). By disrespectfully using the tragic death of a child to blame some of the leading researchers in the field, the media significantly slowed down any forward progress towards the original agenda of Child Psychiatry. The stigma is not only stronger, but also more associated to Pediatric BPD.

On June 17, 2007 a member of staff on the Boston Globe opened his article with the following statement: “No one has done more to convince Americans that even small children can suffer the dangerous mood swings of bipolar disorder than Dr. Joseph Biederman of Massachusetts General Hospital. From his perch as one of the world's most influential child psychiatrists, Biederman has spread far and wide his conviction that the emotional roller coaster of bipolar disorder can start "from the moment the child opened his eyes" at birth…” (10).

On June 19, 2007, Lawrence Diller wrote the following to open an editorial in the Boston Globe, “As a doctor, I did the nearly unthinkable at a recent conference on bipolar disorder in children. I charged another doctor with moral responsibility in the death last December of Rebecca Riley, a 4 -year-old girl from Hull. Naming names in medicine is just not done very often -- and I knew the personal and professional risks I was taking. Yet I felt compelled to name Joseph Biederman, head of the Massachusetts General Hospital's Pediatric Psychopharmacology clinic, as morally culpable in providing the "science" that allowed Rebecca to die... (11)”. For the record, Dr. Biederman was not ever associated with Rebecca Riley’s case, or those who had been treating her.

The blogs became filled with the majority of comments from those who accepted the media’s portrayal of the disorder and from those who were denouncing the field. Few and far between though, were posts from parents who wanted to share their success stories to show support of those clinicians who had overcome the stigma and were not afraid to diagnose and treat children. Based on the number of negative comments, it was clear that the initial agenda to dissociate the stigma was not as compelling as the way the media re-framed it. Dr. Jerrold Rosenbaum, The Chief Psychiatry at MGH published a statement in defense on the attacks on Dr. Biederman. On June 27, 2007, he said it best when he wrote, “Despite the imbalanced and sensational media coverage, and despite the attempts of misguided critics, Biederman and others must -- and will -- persevere in this field because it is the right thing to do. No, it is not Biederman who suffers most from the preposterous allegations set forth. Sadly, the greatest losers are children with mental illness and families, who, as a result of the proliferation of misinformation and the deepening of a stigma, could feel too embarrassed and ashamed to seek the life-saving help they so desperately need (12).”

The Stigma Still Exists.

The unfortunate outcome of the “Agenda Setting Theory” gone wrong in addition to the media’s ability to incorrectly re-frame the disorder, has left the current state of belief amongst the general public associating a major stigma with Pediatric Bipolar Disorder. The public generally has not accepted the diagnosis as a real disorder nor one that needs to be treated. This stigma is still in the minds of the practicing clinicians, leaving many afraid to make the diagnosis for fear of a media attack on him/her. The fact that the stigma exists at the level of the doctors doesn’t bode well for those that count on them for explanations. The parents cannot overcome the stigma if the doctor who is treating (or not treating) their child has not overcome it. We are left then, with children who are suffering, and people who want to help but are afraid to label a child as having BPD. The problem that lies beneath the label is that without a diagnosis, our children won’t receive correct treatment. If left untreated, we are doing a major disservice to these children as we are not controlling the disease and we are not preventing what can escalate into larger issues.

The proper treatment of the disorder is not anywhere near being accepted due to social stigma placed upon the medications associated with it. What people are missing is that if treated, a child is less likely to engage in risky behavior such as smoking which is a gateway to additional drug forming habits which in turn become substance use disorders (13-14). “Between 40% and 70% of people with bipolar disorder have a history of substance use disorder. A current or past comorbid substance use disorder may lead to worse outcomes for bipolar disorder, including more symptoms, more suicide attempts, longer episodes, and lower quality of life (15)”.

The parents are left to question the truth if the confidence of the doctor in making the diagnosis is lacking. The stigma prevents them from finding supportive resources to help them to accept the truth and learn what they can do to manage and maintain the quality of life their child deserves. Parents don’t want to be labeled as bad parents, nor do they want their children being labeled as bad kids (16). If a parent cannot overcome the stigma associated with something that they live with every day, the child will not have the support to overcome it either.

Implications and Conclusions

Dr. Janet Wozniak summed it up when she stated that, “Although the diagnosis of Pediatric-onset bipolar disorder is controversial, an increasing literature of systematic research has challenged the traditional view that this disorder is a rare condition” (17). Unfortunately, that “traditional view” is still quite common, even 7 years after that statement was made. The stigma is still present, and the media’s use of framing it as a disorder that doest not exist is preventing any progress towards the dissociation of the stigma and ultimate acceptance of Pediatric BPD. An article recently published in the Harvard Medical Letter restated what we knew many years ago when it said, “it’s important to understand that despite uncertainties surrounding the diagnosis childhood bipolar disorder is a real and serious illness that should be recognized and treated as early as possible (18).” The irony to this statement is that the author chose to remain anonymous. That irony summarizes the exact problem that Child Psychiatrists’ face in getting the public to accept the disorder. The general public will believe what information they obtain from the media as they can associate an actual person with what they are being told. The initial agenda of child psychiatry needs to be set and backed-up by the experts as the first step in the circulation of the truth. Until then, many children will live their lives with an untreated and tremendously morbid disorder with detrimental outcomes.

REFERENCES

1.Faedda GL. Baldessarini RJ. Suppes T. Tondo L. Becker I. Lipschitz DS. Pediatric-onset bipolar disorder: a neglected clinical and public health problem. Harvard Review of Psychiatry. 3(4):171-95, 1995 Nov-Dec.

2. National Institute of Mental Health research roundtable on prepubertal bipolar disorder. Journal of the American Academy of Child & Adolescent Psychiatry. 40(8):871-8, 2001 Aug.

3. Kearns Goodwin, Doris. “Team of Rivals”. Simon & Shuster, 2005.

4. Geller B. Tillman R. Bolhofner K. Proposed definitions of bipolar I disorder episodes and daily rapid cycling phenomena in preschoolers, school-aged children, adolescents, and adults. Journal of Child & Adolescent Psychopharmacology. 17(2):217-22, 2007 Apr.

5. Wozniak J. Biederman J. Kwon A. Mick E. Faraone S. Orlovsky K. Schnare L. Cargol C. van Grondelle A. How cardinal are cardinal symptoms in pediatric bipolar disorder? An examination of clinical correlates. Biological Psychiatry. 58(7):583-8, 2005 Oct 1.

6. Mick E, Spencer T, Wozniak J, et al.: Heterogeneity of irritability in attention-deficit/hyperactivity disorder subjects with and without mood disorders. Biological Psychiatry 58:576-582, 2005.

7. Mick E, Biederman J, Pandina G, et al.: A preliminary meta-analysis of the child behavior checklist in pediatric bipolar disorder. Biological Psychiatry 53:1021-1027, 2003.

8. Wozniak J, Monuteaux M, Richards J, et al.: Convergence between structured diagnostic interviews and clinical assessment on the diagnosis of pediatric-onset mania. Biological Psychiatry 53:938-944, 2003.

9. Groopman, J. “What’s Normal”, The New Yorker, April 2007.

10. Allen, Scott. “Backlash on bipolar diagnoses in children: MGH psychiatrist's work stirs debate”. Boston Globe, June 17, 2007

11. Diller. T “Misguided Standards of Care” Boston Globe. June, 19, 2007

12. Rosenbaurm, J. “Heroes in Mental Health.” Boston Globe. June 27, 2007.

13. Tohen M, Greenfield SF, Weiss RD, et al.: The effect of comorbid substance use disorders on the course of bipolar disorder: a review. Harvard Review of Psychiatry 6:133-141, 1998.

14. Wilens TE, Biederman J, Millstein RB, et al.: Risk for substance use disorders in youths with child- and adolescent-onset bipolar disorder. Journal of the American Academy of Child & Adolescent Psychiatry 38:680-685, 1999.

15. Ostacher MJ. Sachs GS. Update on bipolar disorder and substance abuse: recent findings and treatment strategies. Journal of Clinical Psychiatry. 67(9):e10, 2006 Sep

16. Wade J: "Crying alone with my child:" parenting a school age child diagnosed with bipolar disorder. Issues in Mental Health Nursing. 27:885-903, 2006.

17- Wozniak J, Biederman J, Richards JA: Diagnostic and therapeutic dilemmas in the management of pediatric-onset bipolar disorder. Journal of Clinical Psychiatry 62 Suppl 14:10-15, 2001.

18. Anonymous 2007: BPD in children. Difficult to Diagnosis, Important to Treat. Harvard Mental Health Letter (May2007, Vol. 23 Issue 11, p1-4, 4p)