LETTERS TO THE EDITOR
fluoxetine and the neuroleptics. Twin A, an inpatient, had his fluoxetine discontinued after 4 days. His symptoms persisted. Twin B, an outpatient, continued on fluoxetine as his parents did not report the adverse affect immediately. The agitation and aggression subsided in approximately 5 days, and a significant improvement occurred within 3 weeks. Twin A was restarted on fluoxetine in light of Twin B's improvement, and he, too, improved after 2 weeks. We report our experience because we feel that it is important for clinicians to be aware that there may be a synergistic effect when fluoxetine and neuroleptics are used concurrently. Both neuroleptics were discontinued when fluoxetine was started. P. Matthews, M.B ., M.R.C. Psych., F.R.C.P.(C) D. Quinn, M.B ., F.R.C.P.(C) Gene S. Marcoux, Resident IV Konnie Falkenberg, Resident IV University Hospital Saskatoon, Saskatchewan, Canada
Discussing Adoption in Therapy To the Editor: Adopted children are reported to be overrepresented in psychiatric populations. Schecter (1960) was perhaps the first to report such a phenomenon, and we have also found an increased incidence, with 11.7% of an inpatient population of children and adolescents being adopted (Dickson et aI. , 1990). While there have been many attempts to explain these findings , there have been few studies of treatments aimed at resolving adoption issues, and most of the literature has focused on individual case reports (Brinich, 1980; Mackie, 1982). We designed a study to assess whether the reports in the literature have had any impact on the treatment of adoptive children in a psychiatric setting. This study had two parts. In the first, 44 children in a private, university-affiliated, free-standing psychiatric hospital were identified as adopted from a chart review of all 375 children and adolescents discharged between August, 1982 and June, 1986. Adoptees, therefore, represented 11.7% ofthe total population . A review of the records demonstrated that some mention of adoption was made in 22 of the cases, and no mention past the intake process was made in the other 22 cases. Several variables were explored to determine if any increased the likelihood of adoption being mentioned . Most significant was the length of stay, where the mean length was almost twice as long in those cases in which adoption was mentioned (160.8 days versus 84.7 days, p < 0.05, Student's r-test), Adoption was more likely to be mentioned in younger children, in females, and in those adopted past I year of age. In addition, those who were discharged after the hospital had been open a few years were more likely to have discussed it, perhaps reflecting the maturation of the staff and its programs. Nurses were most likely to discuss adoption, with 19 patients discussing adoption with nurses; whereas psychiatrists discussed adoption with seven patients and other workers one or two times each. In only five cases did the family discuss adoption , and in four it was only during admission. There was essentially no evidence in the record that adoption was a topic of family therapy sessions. The second part of the study consisted of an adoption survey being distributed to 120 staff members, of whom 36 (30%) responded. Of those responding, 16 were nurses, nine were psychiatrists, three were social workers, with the remaining respondents distributed among several specialty fields. Two respondents knew the incidence of adoption in the general population; whereas four were able to guess an answer close to the hospital's incidence. Nine respondents described some personal experience with adoption, ranging from being adopted, having adopted a child, or having worked with an adoption agency. When
J .Am. Acad. Child Ado/esc. Psychiatry, 30 :1, January 1991
asked their opinions regarding adoption in therapy, most respondents saw adoption as an important issue in development and therapy, but they did not endorse it as increasing the risk of behavior or psychiatric problems. Psychiatrists saw adoption as a more important issue than nurses (mean Likert score of 3.7 versus 2.5 on a I to 5 scale, with 5 being very significant). Ninety percent of respondents believed the child or parents should initiate discussion of adoption, but at least 50% ofthe same respondents indicated that others could initiate the discussion. Seventy percent of the respondents endorsed the idea that discussion of adoption should proceed even if the child or parents are reluctant; whereas only half agreed with pursuing the discussion if the therapist is reluctant. Some of these suggested that another therapist take over. Interestingly, 97% of respondents expressed comfort talking about adoption, and 78% reported discussing adoption; all 36 expressed an interest in knowing more about adoption. While this study had serious limitations in the small number of patients, the problems with retrospective chart reviews, and the low response rate to the survey, it does suggest that adoption is not addressed in a systematic way in the inpatient setting. Thus, 30 years of reporting increased incidences of distressed adoptees does not seem to be making an impact in the clinical setting. There may be several explanations for this, including the lack of knowledge of the literature by the staff, the individual staff members being unaware of the adoptive status of the patient since it was frequently only mentioned on intake forms, and the reluctance of the patient and family to discuss adoption. It is also possible that discussions of adoption were never recorded, but this seems unlikely to be the total explanation. In addition, other issues, such as drugs and family disruption, may have predominated in treatment, thus pushing adoption into the background . Since longer stays increased the likelihood of adoption discussions, it would seem adoption was addressed as other issues abated. Alternatively, longer stays suggest that pathology was more severe and necessitated a more in-depth look at sources of the problems, which may include adoption. The ability and willingness of the staff to discuss adoption is also important. There is some indication that the staff of this young hospital showed some increased awareness with time since more recently hospitalized children were more involved in discussions of adoption . The survey would suggest that many staff members see adoption as an important issue but are uncertain of its impact, and the records indicate they are uncertain about what to do. Most important is that every respondent expressed a desire to know more, and it would be interesting to know what impact some recent conferences and in-service meetings have had on the attitudes and therapy of the staff members. Lesley R. Dickson , M.D. William M. Heffron , M.D. Suellen Stephens, M.D. University of Kentucky College of Medicine REFERENCES
Brinich, P. (1980), Some potential effects of adoption on self and object representations. Psychoanal. Study Child, 35:107-133. Dickson, L. R., Heffron, W. M., & Parker, C. (in press) . Children from adoptive and disrupted homes on an inpatient unit. Am . J. Orthopsychiatry. Mackie, A. J. (1982), Families of adopted adolescents. J. Adolesc., 5:167-178. Schecter, M. (1960), Observations on adopted children. Arch. Gen. Psychiatry, 3:21-32.
Trichotillomania and Depression To the Editor: Trichotillomania is characterized by impulses to pull out one's own hair, in the absence of psychosis or scalp disease, resulting in hair
155
fluoxetine and the neuroleptics. Twin A, an inpatient, had his fluoxetine discontinued after 4 days. His symptoms persisted. Twin B, an outpatient, continued on fluoxetine as his parents did not report the adverse affect immediately. The agitation and aggression subsided in approximately 5 days, and a significant improvement occurred within 3 weeks. Twin A was restarted on fluoxetine in light of Twin B's improvement, and he, too, improved after 2 weeks. We report our experience because we feel that it is important for clinicians to be aware that there may be a synergistic effect when fluoxetine and neuroleptics are used concurrently. Both neuroleptics were discontinued when fluoxetine was started. P. Matthews, M.B ., M.R.C. Psych., F.R.C.P.(C) D. Quinn, M.B ., F.R.C.P.(C) Gene S. Marcoux, Resident IV Konnie Falkenberg, Resident IV University Hospital Saskatoon, Saskatchewan, Canada
Discussing Adoption in Therapy To the Editor: Adopted children are reported to be overrepresented in psychiatric populations. Schecter (1960) was perhaps the first to report such a phenomenon, and we have also found an increased incidence, with 11.7% of an inpatient population of children and adolescents being adopted (Dickson et aI. , 1990). While there have been many attempts to explain these findings , there have been few studies of treatments aimed at resolving adoption issues, and most of the literature has focused on individual case reports (Brinich, 1980; Mackie, 1982). We designed a study to assess whether the reports in the literature have had any impact on the treatment of adoptive children in a psychiatric setting. This study had two parts. In the first, 44 children in a private, university-affiliated, free-standing psychiatric hospital were identified as adopted from a chart review of all 375 children and adolescents discharged between August, 1982 and June, 1986. Adoptees, therefore, represented 11.7% ofthe total population . A review of the records demonstrated that some mention of adoption was made in 22 of the cases, and no mention past the intake process was made in the other 22 cases. Several variables were explored to determine if any increased the likelihood of adoption being mentioned . Most significant was the length of stay, where the mean length was almost twice as long in those cases in which adoption was mentioned (160.8 days versus 84.7 days, p < 0.05, Student's r-test), Adoption was more likely to be mentioned in younger children, in females, and in those adopted past I year of age. In addition, those who were discharged after the hospital had been open a few years were more likely to have discussed it, perhaps reflecting the maturation of the staff and its programs. Nurses were most likely to discuss adoption, with 19 patients discussing adoption with nurses; whereas psychiatrists discussed adoption with seven patients and other workers one or two times each. In only five cases did the family discuss adoption , and in four it was only during admission. There was essentially no evidence in the record that adoption was a topic of family therapy sessions. The second part of the study consisted of an adoption survey being distributed to 120 staff members, of whom 36 (30%) responded. Of those responding, 16 were nurses, nine were psychiatrists, three were social workers, with the remaining respondents distributed among several specialty fields. Two respondents knew the incidence of adoption in the general population; whereas four were able to guess an answer close to the hospital's incidence. Nine respondents described some personal experience with adoption, ranging from being adopted, having adopted a child, or having worked with an adoption agency. When
J .Am. Acad. Child Ado/esc. Psychiatry, 30 :1, January 1991
asked their opinions regarding adoption in therapy, most respondents saw adoption as an important issue in development and therapy, but they did not endorse it as increasing the risk of behavior or psychiatric problems. Psychiatrists saw adoption as a more important issue than nurses (mean Likert score of 3.7 versus 2.5 on a I to 5 scale, with 5 being very significant). Ninety percent of respondents believed the child or parents should initiate discussion of adoption, but at least 50% ofthe same respondents indicated that others could initiate the discussion. Seventy percent of the respondents endorsed the idea that discussion of adoption should proceed even if the child or parents are reluctant; whereas only half agreed with pursuing the discussion if the therapist is reluctant. Some of these suggested that another therapist take over. Interestingly, 97% of respondents expressed comfort talking about adoption, and 78% reported discussing adoption; all 36 expressed an interest in knowing more about adoption. While this study had serious limitations in the small number of patients, the problems with retrospective chart reviews, and the low response rate to the survey, it does suggest that adoption is not addressed in a systematic way in the inpatient setting. Thus, 30 years of reporting increased incidences of distressed adoptees does not seem to be making an impact in the clinical setting. There may be several explanations for this, including the lack of knowledge of the literature by the staff, the individual staff members being unaware of the adoptive status of the patient since it was frequently only mentioned on intake forms, and the reluctance of the patient and family to discuss adoption. It is also possible that discussions of adoption were never recorded, but this seems unlikely to be the total explanation. In addition, other issues, such as drugs and family disruption, may have predominated in treatment, thus pushing adoption into the background . Since longer stays increased the likelihood of adoption discussions, it would seem adoption was addressed as other issues abated. Alternatively, longer stays suggest that pathology was more severe and necessitated a more in-depth look at sources of the problems, which may include adoption. The ability and willingness of the staff to discuss adoption is also important. There is some indication that the staff of this young hospital showed some increased awareness with time since more recently hospitalized children were more involved in discussions of adoption . The survey would suggest that many staff members see adoption as an important issue but are uncertain of its impact, and the records indicate they are uncertain about what to do. Most important is that every respondent expressed a desire to know more, and it would be interesting to know what impact some recent conferences and in-service meetings have had on the attitudes and therapy of the staff members. Lesley R. Dickson , M.D. William M. Heffron , M.D. Suellen Stephens, M.D. University of Kentucky College of Medicine REFERENCES
Brinich, P. (1980), Some potential effects of adoption on self and object representations. Psychoanal. Study Child, 35:107-133. Dickson, L. R., Heffron, W. M., & Parker, C. (in press) . Children from adoptive and disrupted homes on an inpatient unit. Am . J. Orthopsychiatry. Mackie, A. J. (1982), Families of adopted adolescents. J. Adolesc., 5:167-178. Schecter, M. (1960), Observations on adopted children. Arch. Gen. Psychiatry, 3:21-32.
Trichotillomania and Depression To the Editor: Trichotillomania is characterized by impulses to pull out one's own hair, in the absence of psychosis or scalp disease, resulting in hair
155
