Asperger's Syndrome - Defining Asperger's Syndrome Versus Autism and Pervasive Development Disorders

Your child may have just been diagnosed or he is showing symptoms of an autism spectrum disorders and you now wonder, What is Asperger's Syndrome? With a recent - or anticipated - diagnosis you are wondering where to turn. Perhaps you are trying to figure out what this will mean for your child and your family's future. Here you can find an overview on what Asperger's Syndrome is and what to expect in the future.

First of all, Asperger's is an autism spectrum disorder. Autism is a developmental disorder than affects the way a child...or adult...interacts with, perceives and interprets the world. A spectrum means that there are many different forms of autism, ranging from very severe to very mild. Those on the more high functioning side usually get a diagnosis of Asperger's Syndrome.

Many children as well as adults may be misdiagnosed...this is unfortunately all too common. Many are initially diagnosed with ADHD or OCD or some other condition before a proper diagnosis is reached. This is unfortunate because it delays the start of effective training and treatments that can help someone with Asperger's syndrome.

So what does this mean?

Social Aspects of Asperger's Syndrome

Asperger's Syndrome is primarily a syndrome that has to do with deficits in social functioning. Someone with Asperger's will have often have trouble both understanding language and using language in a proper way. They often have a pedantic style of talking, and are often referred to as "walking dictionaries." People with Asperger's are often very smart, and can talk about facts very easily, but have a lot of trouble with small talk or really any social connections at all, at least when they're younger.

People with Asperger's syndrome don't tend to understand sarcasm or jokes, and take everything you say very literally...even when they are adults. They have very concrete thinking, and are very rule oriented. Those with Asperger's often depend on routines to get through the day, and can be very upset if their routines are interrupted; children may have meltdowns while adults may get angry or autocratic. They are prone to emotional upset if something does not go right.

Due to their deficits in social skills, children and adults with Asperger's syndrome often have trouble making friends. When they are kids, they will not understand the concept of playing with others. They will often do something called "parallel play" where they might play next to, but not with, another kid. They have to be taught to share toys and be flexible enough to play with another child. Adults can become very isolated after years of not being able to establish long-lasting friendships.

Obsessive Interests

The interests of children and adults often deviate from their peers, especially when they are older. Those with Asperger's are often obsessive about specific subjects, such as geology, a particular sports team, or trains, and their peers find this uninteresting. This constant focus on one topic and lack of interest in topics that others bring up tends to isolate them further.

Obsessive interests are a main fabric of the cloth of Aspergers syndrome. Most kids with Asperger's have something that they are very interested in and talk about it endlessly. One child might be obsessive about cars. Another "Thomas the Train". A third with volcanoes. And so forth.

Because they are unable to truly show interest in a wide range of subjects that are of interest to their peers, they become social outcasts. This all contributes to the social isolation that is so common in kids with Asperger's especially when kids start school. While their friends are talking about baseball or video games, the Aspergers child may exclusively talk about volcanoes. It doesn't take long before his or her peers in school loose interest in both the subject of volcanoes AND in the child.

In an adult, the inability to show interests in general office politics or to chit-chat about sports or the latest TV shows can isolate a person from his or her colleagues. This lack of social integration may make the person with Asperger's seem like an "odd duck" or just "not fitting in" which can lead to lay offs and lack of promotions.

Sensory Issues Are A Common Symptom Of Asperger's Syndrome

People with Asperger's syndrome often have a lot of difficulty with sensory processing. The typical person can usually tune out extraneous noise, smells and visual stimuli, among others. They do it without even thinking about it, because that's the way their brain is set up.

People with Asperger's syndrome, however, lack a "barrier" between their brain and the sensory onslaught of the world. They are far, far more sensitive to loud noises - or even soft ones no one else notices; to smells of all kinds...from what comes from your kitchen to the perfume of a passerby on the sidewalk. They often have trouble with the feeling and texture of clothing; with how tight or loose it is, and with the tags on the back. Visual stimuli can also be quite distracting. These sensory concerns need to be minimized for a child with Asperger's to function in his or her environment, and their concerns need to be taken seriously. Many adults have difficulty holding a job because of the noise, distractions and overall sensory overload of a "cubicle farm" in which they must work. A co-worker tapping a pencil or bright fluorescent lights can overwhelm an adult with Asperger's.

Fixation On Routine Is A Common Symptom Of Asperger's Syndrome

Aspies (as those with Asperger's syndrome are affectionately called) often fixated on a routine. Following a set routine is extremely common. And any change in routine may cause a meltdown. Yet stubbornly sticking to routine helps those with Asperger's feel safe and grounded. Yet family, friends, and co-workers can feel that this fixation with routine is extreme. With kids, even small change in routine, like sitting in a different chair around the dinner table, can cause a meltdown.

A lot of children with Aspergers need to know exactly what will happen in order not to feel completely overwhelmed. A good tip is to ensure that you tell your child, in advance, if there will be any change in his or her routine (such as an upcoming vacation). A good strategy is to write down what you will do, where you will go, who will be there etc. Paint a picture in your loved one's mind so that he or she can turn the future vacation into a routine before it occurs. The more your child understand what will happen and when, the more accepting he will be of the changes and the easier he will be able to handle the new experience.

Most adults learn to handle changes in routine...if for no other reason than the world around them is never predictable and they must learn in order to survive. Nevertheless, most adults with Asperger's still feel much more comfortable following a routine. This lack of spontaneity can cause challenges in relationships...how many girlfriends want their boyfriend to always take them to the same restaurant? And once there to order the same diner time after time.

Good Things About Asperger's Syndrome

While not a comprehensive list, these are the main and most common features of Asperger's syndrome. Not to fear, though, not everything about having Asperger's is negative. People with Asperger's are often more likely to be unfailingly honest, loyal, and hard working. They are often very intelligent and can make great contributions...especially in fields that they are passionate about...when they are older. They have a unique way of looking at the world that can benefit all those around them.

Bill Gates, Albert Einstein, and some of the great thinkers of the world are suspected to have or have had Asperger's. While many aspects of Asperger's Syndrome will always remain a challenge, and while there is no question your child will have a more difficult path through the world than many others, always remember there is often benefit to thinking a little bit differently. When you think about a diagnosis of Asperger's and its associated symptoms and wonder "What is Asperger's" remember you have a choice about the way you look at it.

Once we understand how a child or adult with Asperger's thinks, and understand that sensory issues as well as the need for routine motivate their actions, we can devise treatments and training to help them cope with an ever-changing world. Many treatments allow those with Asperger's to succeed and thrive. Hopefully treatments can make life a little easier especially for those with Asperger's and the people who love them. There are many other tips and suggestions that can help your loved one live a fulfilling and happy life. A great site to find information to help both children and adults with Asperger's syndrome is the web site www.AspergersSociety.org. There you will be able to sign up for the FREE Asperger's Syndrome Newsletter as well as get additional information to help your loved one be happy and succeed in life.

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Dyadic Developmental Psychotherapy - An Evidence-Based Treatment For Disorders of Attachment

Dyadic Developmental Psychotherapy is an evidence-based and effective form of treatment for children with trauma and disorders of attachment . It is an evidence-based treatment, meaning that there has been empirical research published in peer-reviewed journals. Craven & Lee (2006) determined that DDP is a supported and acceptable treatment (category 3 in a six level system). However, their review only included results from a partial preliminary presentation of an ongoing follow-up study, which was subsequently completed and published in 2006. This initial study compared the results DDP with other forms of treatment, 'usual care', 1 year after treatment ended.

It is important to note that over 80% of the children in the study had had over three prior episodes of treatment, but without any improvement in their symptoms and behavior. Episodes of treatment mean a course of therapy with other mental health providers at other clinics, consisting of at least five sessions. A second study extended these results out to 4 years after treatment ended. Based on the Craven & Lee classifications (Saunders et al. 2004), inclusion of those studies would have resulted in DDP being classified as an evidence-based category 2, 'Supported and probably efficacious'. There have been two related empirical studies comparing treatment outcomes of Dyadic Developmental Psychotherapy with a control group. This is the basis for the rating of category two. The criteria are:

1. The treatment has a sound theoretical basis in generally accepted psychological principles. Dyadic Developmental Psychotherapy is based in Attachment Theory (see texts cited below

2. A substantial clinical, anecdotal literature exists indicating the treatment's efficacy with at-risk children and foster children. See reference list.

3. The treatment is generally accepted in clinical practice for at risk children and foster children. As demonstrated by the large number of practitioners of Dyadic Developmental Psychotherapy and it's presentation as numerous international and national conferences over the last ten or fifteen years.

4. There is no clinical or empirical evidence or theoretical basis indicating - that the treatment constitutes a substantial risk of harm to those receiving it, compared to its likely benefits.

5. The treatment has a manual that clearly specifies the components and administration characteristics of the treatment that allows for implementation. Creating Capacity for Attachment, Building the Bonds of Attachment, and Attachment Focused Family Therapy constitute such material.

6. At least two studies utilizing some form of control without randomization (e.g., wait list, untreated group, placebo group) have established the treatment's efficacy over the passage of time, efficacy over placebo, or found it to be comparable to or better than an already established treatment. See ref. list.

7. If multiple treatment outcome studies have been conducted, the overall weight of evidence supported the efficacy of the treatment.

These studies support several of O'Connor & Zeanah's conclusions and recommendations concerning treatment. They state (p. 241), "treatments for children with attachment disorders should be promoted only when they are evidence-based."

Dyadic Developmental Psychotherapy, as with any specialized treatment, must be provided by a competent, well-trained, licensed professional. Dyadic Developmental Psychotherapy is a family-focused treatment .

Dyadic Developmental Psychotherapy is the name for an approach and a set of principals that have proven to be effective in helping children with trauma and attachment disorders heal; that is, develop healthy, trusting, and secure relationships with caregivers. Treatment is based on five central principals.

At the core of Reactive Attachment Disorder is trauma caused by significant and substantial experiences of neglect, abuse, or prolonged and unresolved pain in the first few years of life. These experiences disrupt the normal attachment process so that the child's capacity to form a healthy and secure attachment with a caregiver is distorted or absent. The child lacks a sense trust, safety, and security. The child develops a negative working model of the world in which:

- Adults are experienced as inconsistent or hurtful.

- The world is viewed as chaotic.

- The child experiences no effective influence on the world.

- The child attempts to rely only on him/her self.

- The child feels an overwhelming sense of shame, the child feels defective, bad, unlovable, and evil.

Reactive Attachment Disorder is a severe developmental disorder caused by a chronic history of maltreatment during the first couple of years of life. Reactive Attachment Disorder is frequently misdiagnosed by mental health professionals who do not have the appropriate training and experience evaluating and treating such children and adults. Often, children in the child welfare system have a variety of previous diagnoses. The behaviors and symptoms that are the basis for these previous diagnoses are better conceptualized as resulting from disordered attachment. Oppositional Defiant Disorder behaviors are subsumed under Reactive Attachment Disorder. Post Traumatic Stress Disorder symptoms are the result of a significant history of abuse and neglect and are another dimension of attachment disorder. Attention problems and even Psychotic Disorder symptoms are often seen in children with disorganized attachment.

Approximately 2% of the population is adopted, and between 50% and 80% of such children have attachment disorder symptoms . Many of these children are violent and aggressive and as adults are at risk of developing a variety of psychological problems and personality disorders, including antisocial personality disorder , narcissistic personality disorder, borderline personality disorder, and psychopathic personality disorder . Neglected children are at risk of social withdrawal, social rejection, and pervasive feelings of incompetence . Children who have histories of abuse and neglect are at significant risk of developing Post Traumatic Stress Disorder as adults . Children who have been sexually abused are at significant risk of developing anxiety disorders (2.0 times the average), major depressive disorders (3.4 times average), alcohol abuse (2.5 times average), drug abuse (3.8 times average), and antisocial behavior (4.3 times average) (MacMillian, 2001). The effective treatment of such children is a public health concern (Walker, Goodwin, & Warren, 1992).

Left untreated, children who have been abused and neglected and who have an attachment disorder become adults whose ability to develop and maintain healthy relationships is deeply damaged. Without placement in an appropriate permanent home and effective treatment, the condition will worsen. Many children with attachment disorders develop borderline personality disorder or anti-social personality disorder as adults .

FIRST PRINCIPAL. Therapy must be experiential. Since the roots of disorders of attachment occur pre-verbally, therapy must create experiences that are healing. Experiences, not words, are one "active ingredient" in the healing process.

For example, one eight year old boy who had Reactive Attachment Disorder, Bipolar Disorder, and a variety of sensory-integration disorders wrote about his past therapy and attachment therapy this way (More details of this story can be found in the book Creating Capacity for Attachment, edited by Arthur Becker-Weidman & Deborah Shell):

My first therapy was with Dr. Steve. The therapy was FUN! We ate lots of snacks. I had a bottle. We played lots of cool games like thumb wrestling, pillow rides, giant walk, Superman rides, guess the goodies, eye blinking contests, hide and go seek goodies. I had to follow the rules and play the games just like Dr. Steve said.

Dr. Steve taught me how to play and have fun with my Mom. But I still didn't know how to love. I would still get real mad and try to hurt Mom and break things. Inside I still thought I was a bad boy. I was still afraid Mom and Dad would get rid of me. I had lots of tantrums at home. Sometimes I would still get out of control and break things and try to hurt Mom. I was getting even worse when I got mad.

Stuff Dr. Art Taught Me - I learned about my feeling well. Sometimes I stuff too many feelings like mad, scared and sad into my feeling well. Then the well will overflow and I could explode with behaviors. But I can stop that by expressing my feelings. Then the well can't overflow because I let some of the feelings out.

I also made pictures of my heart. I was born with a nice heart but then when I went into the orphanage I got cracks in my heart. My heart cracked because they couldn't take good care of me. I was a baby and I needed someone to hold me and rock me. But they couldn't because there were too many babies. Then I put 16 bricks around my heart. I was protecting my heart so it wouldn't get hurt anymore. But the bricks kept the love out too. I wouldn't let Mom's love in. I had lots of mad in my heart.

My hard work in therapy got rid of all the bricks. Then Mom's love got in. The love made the cracks heal. Now I have a bright red heart with no cracks.

I really liked Dr. Art now and am proud that I am strong. I still don't need therapy. I still let Mom's love into my heart! Sometimes I send e-mail's to Dr. Art. I tell him how good I'm doing.

I started missing Dr. Art and told Mom. Mom was confused and thought I wanted more therapy. I told Mom "I don't need therapy. I just want to have lunch with Dr. Art." So I sent Dr. Art an email to let him know that I wanted to have lunch with him. Then one day we had lunch together.

Sometimes it's still hard. I still get mad and sometimes I don't express my feelings well. Sometimes when Mom helps me I can express my feelings and say "I don't want to pick up my toys. It makes me mad that I have to but I will". When I say that it doesn't make me feel mad anymore. It helps me to listen to Mom. But sometimes when I get mad I pout and stomp my feet and run to my room if I forget to express my feelings. But now I let Mom help me so that I can talk about my feelings and do what she says

It's been a really longtime since I tried to hurt Mom or break things when I'm mad. I feel good about love now. I know that my Mom and Dad love me. I know that I love Mom and Dad. I don't feel like I'm a bad boy anymore.

Effective therapy uses experiences to help a child experience safety, security, acceptance, empathy, and emotional attunement within the family. A number of techniques and methods are used including psychodrama, interventions congruent with Theraplay, and other exercises.

SECOND PRINCIPAL. Therapy must be family-focused. Therapy helps the child address the underlying trauma in a supportive, safe, secure environment in "titrated" and manageable doses so that what the parents have to offer can get in and heal the child. It is the parents' capacity to create a safe and nurturing home that provides a healing environment. Being able to have empathy for the child, accept the child, love the child, be curious about the child, and be playful are all part of the "attitude " that heals. Parents are actively involved in treatment.

THIRD PRINCIPAL. The trauma must be directly addressed. Therapy helps healing by providing the safety and security so that the child can re-experience the painful and shameful emotions that surround the child's trauma. Revisiting the trauma is essential if the child is to begin to revise the child's personal narrative and world-view. It is by revisiting the trauma and sharing the anger and shame with an accepting, empathetic person that the child can integrate the trauma into a coherent self.

FOURTH PRINCIPAL. A comprehensive milieu of safety and security must be created. Traumatized children are often hyper-vigilant, insecure, and deeply distrusting. A consistent environment that is safe and secure is essential to creating the experiences necessary for the child to heal. This milieu must be present at home and in therapy. Good communication and coordination among home, school, and therapy is another important element of effective treatment. "Compression-wraps," invasive and intrusive stimulation designed to evoke rage, "re-birthing," and other provocative techniques are not part of Dyadic Developmental Psychotherapy. These intrusive and invasive techniques are not therapy, not therapeutic, and have no place in a reputable treatment program.

Fifth Principal. Therapy is consensual and not coercive. At our center we are very clear that physical restraint is not treatment and is not used in treatment in any manner. Treatment is provided in a manner consisted with the Association for the treatment and Training of Children's White Paper on Coercion in treatment.

The therapist must be well trained, licensed, and have significant experience in treating trauma-attachment disordered children. A good resource to locate such therapists is the Association for the Treatment and Training in the Attachment of Children, ATTACh. In selecting a therapist you should look for the following:

- Significant training from a recognized training program. Ask where the therapist was trained, how long ago, and for how long.

- Ongoing training. Ask when was the last training event the therapist attended and how long was the event.

- Licensure in the state in a recognized mental health discipline.

- Membership in ATTACh.

- A comprehensive informed consent document and appropriate releases.

- An initial assessment to develop a differential diagnosis and treatment plan.

DETAILED DESCRIPTION OF TREATMENT

Dyadic Developmental Psychotherapy is a treatment developed by Daniel Hughes, Ph.D., (Hughes, 2008, Hughes, 2006, Hughes, 2003,). Its basic principals are described by Hughes and summarized as follows:

1. A focus on both the caregivers and therapists own attachment strategies. Previous research (Dozier, 2001, Tyrell 1999) has shown the importance of the caregivers and therapists state of mind for the success of interventions.

2. Therapist and caregiver are attuned to the child's subjective experience and reflect this back to the child. In the process of maintaining an intersubjective attuned connection with the child, the therapist and caregiver help the child regulate affect and construct a coherent autobiographical narrative.

3. Sharing of subjective experiences.

4. Use of PACE and PLACE are essential to healing.

5. Directly address the inevitable misattunements and conflicts that arise in interpersonal relationships.

6. Caregivers use attachment-facilitating interventions.

7. Use of a variety of interventions, including cognitive-behavioral strategies.

Dyadic Developmental Psychotherapy interventions flow from several theoretical and empirical lines. Attachment theory (Bowlby, 1980, Bowlby, 1988) provides the theoretical foundation for Dyadic Developmental Psychotherapy. Early trauma disrupts the normally developing attachment system by creating distorted internal working models of self, others, and caregivers. This is one rationale for treatment in addition to the necessity for sensitive care-giving. As O'Connor & Zeanah (2003, p. 235) have stated, "A more puzzling case is that of an adoptive/foster caregiver who is 'adequately' sensitive but the child exhibits attachment disorder behavior; it would seem unlikely that improving parental sensitive responsiveness (in already sensitive parent) would yield positive changes in the parent-child relationship." Treatment is necessary to directly address the rigid and dysfunctional internalized working models that traumatized children with attachment disorders have developed.

Current thinking and research on the neurobiology of interpersonal behavior (Siegel, 1999, Siegel, 2000, Siegel, 2002, Schore, 2001) is another part of the foundation on which Dyadic Developmental Psychotherapy rests.

The primary approach is to create a secure base in treatment (using techniques that fit with maintaining a healing PACE (Playful, Accepting, Curious, and Empathic) and at home using principals that provide safe structure and a healing PLACE (Playful, Loving, Acceptance, Curious, and Empathic). Developing and sustaining an attuned relationship within which contingent collaborative communication occurs helps the child heal. Coercive interventions such as rib-stimulation, holding-restraining a child in anger or to provoke an emotional response, shaming a child, using fear to elicit compliance, and interventions based on power/control and submission, etc., are never used and are inconsistent with a treatment rooted in attachment theory and current knowledge about the neurobiology of interpersonal behavior.

Dyadic Developmental Psychotherapy, as conducted at The Center For Family Development, uses two-hour sessions involving one therapist, parent(s), and child. Two offices are used. Unless the caregivers are in the treatment room, the caregivers are viewing treatment from another room by closed circuit T.V. or a one-way mirror. The usual structure of a session involves three components. First, the therapist meets with the caregivers in one office while the child is seated in the treatment room. During this part of treatment, the caregiver is instructed in attachment parenting methods (Becker-Weidman & Shell (2005) Hughes, 2006). The caregiver's own issues that may create difficulties with developing affective attunement with their child may also be explored and resolved. Effective parenting methods for children with trauma-attachment disorders require a high degree of structure and consistency, along with an affective milieu that demonstrates playfulness, love, acceptance, curiosity, and empathy (PLACE). During this part of the treatment, caregivers receive support and are given the same level of attuned responsiveness that we wish the child to experience. Quite often caregivers feel blamed, devalued, incompetent, depleted, and angry. Parent-support is an important dimension of treatment to help caregivers be more able to maintain an attuned connecting relationship with their child. Second, the therapist with the caregivers meets with the child in the treatment room. This generally takes one to one and a half hours. Third, the therapist meets with the caregivers without the child. Broadly speaking, the treatment with the child uses three categories of interventions: affective attunement, cognitive restructuring, and psychodramatic reenactments. Treatment with the caregivers uses two categories of interventions: first, teaching effective parenting methods and helping the caregivers avoid power struggles and, second, maintaining the proper PLACE or attitude.

Treatment of the child has a significant non-verbal dimension since much of the trauma took place at a pre-verbal stage and is often dissociated from explicit memory. As a result, childhood maltreatment and resultant trauma create barriers to successful engagement and treatment of these children. Treatment interventions are designed to create experiences of safety and affective attunement so that the child is affectively engaged and can explore and resolve past trauma. This affective attunement is the same process used for non-verbal communication between a caregiver and child during attachment facilitating interactions (Hughes, 2003, Siegel, 2001). The therapist and caregivers' attunement results in co-regulation of the child's affect so that is it manageable. Cognitive restructuring interventions are designed to help the child develop secondary mental representations of traumatic events, which allow the child to integrate these events and develop a coherent autobiographical narrative. Treatment involves multiple repetitions of the fundamental caregiver-child attachment cycle. The cycle begins with shared affective experiences, is followed by a breach in the relationship (a separation or discontinuity), and ends with a reattunement of affective states. Non-verbal communication, involving eye contact, tone of voice, touch, and movement, are essential elements to creating affective attunement.

The treatment provided often adhered to a structure with several dimensions. It is pictured in Figure 1, below. First, behavior is identified and explored. The behavior may have occurred in the immediate interaction or have occurred at some time in the past. Using curiosity and acceptance the behavior is explored. Second, using curiosity and acceptance the behavior is explore and the meaning to the child begins to emerge. Third, empathy is used to reduce the child's sense of shame and increase the child's sense of being accepted and understood. Forth, the child's behavior is then normalized. In other words, once the meaning of the behavior and its basis in past trauma is identified, it becomes understandable that the symptom is present. An example of such an interaction is the following:

Wow, I see how you got so angry when your Mom asked you to pick up your toys. You thought she was being mean and didn't want you to have fun or love you. You thought she was going to take everything away and leave you like your first Mom did, like when your first Mom took your toys and then left you alone in the apartment that time. Oh, I can really understand now how hard that must be for you when Mom said to clean up. You really felt mad and scared. That must be so hard for you.

Fifth, the child communicates this understanding to the caregiver.

Sixth, finally, a new meaning for the behavior is found and the child's actions are integrated into a coherent autobiographical narrative by communicating the new experience and meaning to the caregiver.

Past traumas are revisited by reading documents and through psychodramatic reenactments. These interventions, which occur within a safe attuned relationship, allow the child to integrate the past traumas and to understand the past and present experiences that create the feelings and thoughts associated with the child's behavioral disturbances. The child develops secondary representations of these events, feelings and thoughts that result in greater affect regulation and a more integrated autobiographical narrative.

As described by Hughes (2006, 2003), the therapy is an active, affect modulated experience that involves acceptance, curiosity, empathy, and playfulness. By co-regulating the child's emerging affective states and developing secondary representations of thoughts and feelings, the child's capacity to affectively engage in a trusting relationship is enhanced. The caregivers enact these same principals. If the caregivers have difficulty engaging with their child in this manner, then treatment of the caregiver is indicated.

Children who have experienced chronic maltreatment and resulting complex trauma are at significant risk for a variety of other behavioral, neuropsychological, cognitive, emotional, interpersonal, and psychobiological disorders (Cook, A., et. al., 2005; van der Kolk, B., 2005). Children and adolescents with complex trauma require an approach to treatment that focuses on several dimensions of impairment (Cook, et. al., 2005). Chronic maltreatment and the resulting complex trauma cause impairment in a variety of vital domains including the following:

- Self-regulation

- Interpersonal relating including the capacity to trust and secure comfort

- Attachment

- Biology, resulting in somatization

- Affect regulation

- Increased use of defensive mechanisms, such as dissociation

- Behavioral control

- Cognitive functions, including the regulation of attention, interests, and other executive functions.

- Self-concept.

Dyadic Developmental Psychotherapy addresses these domains of impairment. Dyadic Developmental Psychotherapy shares many important elements with optimal, sound social casework and clinical practice. For example, attention to the dignity of the client, respect for the client's experiences, and starting where the client is, are all time-honored principles of clinical practice and all are also central elements of Dyadic Developmental Psychotherapy

In summary, therapy for traumatized children who have disordered attachments must be experiential, consensual, and provide an environment of security, acceptance, safety, empathy, and playfulness. Only an experienced and trained therapist can provide attachment therapy.

Becker-Weidman, A., (2006) "Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy," Child and Adolescent Social Work Journal. Vol. 23 #2, April 2006, 147-171.
Becker-Weidman, A., (2006). "Dyadic Developmental Psychotherapy: A multi-year Follow-up," in, New Developments In Child Abuse Research, Stanley M. Sturt, Ph.D. (Ed.) Nova Science Publishers, NY, pp. 43 -- 61.
Becker-Weidman, A., (2007) "Treatment For Children with Reactive Attachment Disorder: Dyadic Developmental Psychotherapy," http://www.center4familydevelop.com/research.pdf
Becker-Weidman, A., & Hughes, D., (2008) "Dyadic Developmental Psychotherapy: An evidence-based treatment for children with complex trauma and disorders of attachment," Child & Adolescent Social Work, 13, pp.329-337.
Craven, P. & Lee, R. (2006) Therapeutic interventions for foster children: a systematic research synthesis. Research on Social Work Practice, 16, 287-304.

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Disorders of Immune System - AIDS

AIDS is the most typical immunodeficiency disorder worldwide, and HIV infection is one from the best epidemics in human history. AIDS is the consequence of a chronic retroviral virus that produces extreme, life-threatening CD4 helper T-lymphocyte dysfunction, opportunistic infections, and malignancy.

Retroviruses include viral RNA that is transcribed by viral reverse transcriptase into double-stranded DNA, which can be integrated into the host genome. Cellular activation leads to transcription of HIV gene items and viral replication. AIDS is defined by serologic evidence of HIV virus with the presence of a range of indicator diseases related to medical immunodeficiency.

HIV is transmitted by coverage to infected body fluids or sexual or perinatal make contact with. Transmissibility from the HIV virus is related to subtype virulence, viral load, and immunologic host factors. Acute HIV virus may present as an acute, self-limited, febrile viral syndrome characterized by exhaustion, pharyngitis, myalgias, rash, lymphadenopathy, and significant viremia without detectable anti-HIV antibodies.

Following an initial viremic phase, individuals seroconvert along with a period of clinical latency is usually observed. Lymph tissues turn out to be centers for substantial viral replication during a "silent," or asymptomatic, stage of HIV virus despite an absence of detectable trojan in the peripheral blood. Over time, there's a progressive decline in CD4 T lymphocytes, a reversal from the regular CD4:CD8 T-lymphocyte ratio, and numerous other immunologic derangements.

The clinical manifestations are directly related to HIV tissue tropism and defective immune function. Development of neurologic complications, opportunistic infections, or malignancy signal marked immune deficiency. The time course for progression varies, but the median time before appearance of medical illness is about ten many years. Around 10% of individuals infected manifest rapid progression to AIDS within five many years after virus.

A minority of individuals are "long-term nonprogressors." Genetic elements, host cytotoxic immune responses, and viral load and virulence appear to effect susceptibility to virus and the rate of disease progression. Chemokines (chemoattractant cytokines) regulate leukocyte trafficking to sites of inflammation and have been discovered to play a significant role in the pathogenesis of HIV illness.

During the initial stages of virus and viral proliferation, virion entry and cellular infection requires binding to two coreceptors on target T lymphocytes and monocyte/macrophages. All HIV strains express the envelope protein gp120 that binds to CD4 molecules, but different viral strains display tissue "tropism" or specificity on the basis from the coreceptor they recognize. These coreceptors belong towards the chemokine receptor family.

Changes in viral phenotype throughout the course of HIV virus may lead to changes in tropism and cytopathology at different stages of disease. Viral strains isolated in early stages of infection (eg, R5 viruses) demonstrate tropism toward macrophages. X4 strains of HIV are a lot more commonly seen in later stages of illness.

X4 viruses bind to chemokine receptor CXCR4, more broadly expressed on T cells, and are related to syncytium formation. A small percentage of individuals possessing nonfunctional alleles for the polymorphic chemokine receptor CCR5 appear to be highly resistant to HIV virus or display delayed progression of disease. Mathematical models estimate that throughout HIV virus billions of virions are produced and cleared each day.

The reverse transcription step of HIV replication is error prone; mutations occur frequently, and even within an individual patient, HIV heterogeneity develops rapidly. The improvement of antigenically and phenotypically distinct strains contributes to progression of illness, medical drug resistance, and lack of efficacy of early vaccines. Cellular activation is critical for viral infectivity and reactivation of integrated proviral DNA.

Although only 2% of mononuclear cells are found peripherally, lymph nodes from HIV-infected individuals can include large amounts of trojan sequestered among infected follicular dendritic cells within the germinal centers.

The marked decline in CD4 T-lymphocyte counts-characterizing HIV infection-is due to several mechanisms, including the pursuing: (1) direct HIV-mediated destruction of CD4 T lymphocytes, (2) autoimmune destruction of virus-infected T cells, (3) depletion by fusion and development of multinucleated giant cells (syncytium formation), (4) toxicity of viral proteins to CD4 T lymphocytes and hematopoietic precursors, and (five) induction of apoptosis (programmed cell death).

CD8 CTL activity is initially brisk and effective at controlling viremia through elimination of trojan and virus-infected cells. Ultimately, viral proliferation outpaces host responses, and HIV-induced immunosuppression leads to disease development. Loss of viral containment occurs with lack of adequate helper T purpose and decreased IL-2 production leading to diminution of CD8+ T-cell-dependent cytotoxic responses.

Subsequently, there is an accumulation of viral escape mutations with general cytokine dysregulation detrimental to maintenance of lymphatic organs, bone marrow integrity, and effective immune responses. In addition to the cell-mediated immune defects, B-lymphocyte function is altered such that numerous infected individuals have marked hypergammaglobulinemia but impaired specific antibody responses.

Both anamnestic responses and individuals to neoantigens can be impaired. However, the role of humoral immunity in controlling viremia or slowing disease development is unclear. The development of assays to measure viral burden (plasma HIV-RNA quantification) has led to a better understanding of HIV dynamics and has provided a tool for assessing response to therapy.

It is now well recognized that viral replication continues all through the disease, and immune deterioration occurs despite clinical latency. The risk of progression to AIDS appears correlated with an individual's viral load after seroconversion. Data from a number of large clinical cohorts have shown that there's a direct correlation between the CD4 T-lymphocyte count and also the risk of AIDS-defining opportunistic infections.

Thus, the viral load and also the degree of CD4 T-lymphocyte depletion serve as important clinical indicators of immune status in HIV-infected people. Prophylaxis for opportunistic infections such as pneumocystis pneumonia is started when CD4 T-lymphocyte counts reach the 200-250 cells/ L variety.

Similarly, patients with HIV virus with fewer than 50 CD4 T lymphocytes/ L are at significantly increased risk for cytomegalovirus (CMV) retinitis and Mycobacterium avium complex (MAC) infection. Cells other than CD4 T lymphocytes contribute to the pathogenesis of HIV infection.

Monocytes, macrophages, and dendritic cells can be infected with HIV and facilitate transfer of trojan to lymphoid tissues and immunoprivileged sites, such as the CNS. HIV-infected monocytes will also release large quantities from the acute-phase reactant cytokines, including IL-1, IL-6, and TNF, contributing to constitutional symptomatology.

TNF, in particular, has been implicated in the severe wasting syndrome observed in patients with advanced illness. Concomitant infections might serve as cofactors for HIV infection, increasing expression of HIV through enhanced cytokine production, coreceptor surface expression, or increased cellular activation mechanisms.

The medical manifestations of AIDS are the direct consequence from the progressive and severe immunologic deficiency induced by HIV. Patients are susceptible to a wide variety of atypical or opportunistic infections with bacterial, viral, protozoal, and fungal pathogens. Common nonspecific symptoms consist of fever, night sweats, and weight loss. Weight loss and cachexia can be due to nausea, vomiting, anorexia, or diarrhea.

They often portend a poor prognosis. The incidence of infection increases as the CD4 T lymphocyte number declines. Lung virus with Pneumocystis jiroveci is the most common opportunistic infection, affecting 75% of individuals. Patients present clinically with fevers, cough, shortness of breath, and hypoxemia ranging in severity from mild to existence threatening.

A diagnosis of pneumocystis pneumonia could be made by substantiation from the medical and radiographic findings with Wright-Giemsa or silver methenamine staining of induced sputum samples. A negative sputum stain does not rule out disease in patients in whom there's a strong clinical suspicion of disease, and further diagnostic maneuvers such as bronchoalveolar lavage or fiberoptic transbronchial biopsy might be required to establish the diagnosis.

Issues of pneumocystis pneumonia include pneumothoraces, progressive parenchymal disease with severe respiratory insufficiency, and, most commonly, adverse reactions to the medications used for treatment and prophylaxis.

As a consequence of chronic immune dysfunction, HIV-infected individuals are also at high risk for other pulmonary infections, including bacterial infections with S pneumoniae and H influenzae; mycobacterial infections with M tuberculosis or M avium-intracellulare (MAC); and fungal infections with C neoformans, H capsulatum, or C immitis. Medical suspicion followed by early diagnosis of these infections should lead to aggressive treatment.

The improvement of active tuberculosis is significantly accelerated in HIV virus as a result of compromised cellular immunity. The risk of reactivation is estimated to be 5-10% per year in HIV-infected patients compared having a lifetime risk of 10% in those without having HIV. Furthermore, diagnosis may be delayed because of anergic skin responses.

Extrapulmonary manifestations occur in up to 70% of HIV-infected individuals with tuberculosis, and the emergence of multidrug resistance may compound the problem. MAC is really a less virulent pathogen than M tuberculosis, and disseminated infections usually occur only with extreme medical immunodeficiency.

Symptoms are nonspecific and typically consist of fever, weight loss, anemia, and GI distress with diarrhea. The presence on physical examination of oral candidiasis (thrush) and hairy leukoplakia is highly correlated with HIV infection and portends rapid development to AIDS.

Abnormal outgrowth of Candida from normal mouth flora is the cause of persistent oral candidiasis, whereas Epstein-Barr trojan is the cause of hairy leukoplakia. HIV-infected people with oral candidiasis are at much greater risk for esophageal candidiasis, which might existing as substernal pain and dysphagia. This infection and its characteristic medical presentation are so common that most practitioners treat with empiric oral antifungal therapy.

Should the patient not respond rapidly, other explanations for the esophageal symptoms should be explored, including herpes simplex and CMV infections. Persistent diarrhea, especially when accompanied by high fevers and abdominal pain, might signal infectious enterocolitis.

The list of potential pathogens in such cases is lengthy and includes bacteria, MAC, protozoans (cryptosporidium, microsporidia, Isospora belli, Entamoeba histolytica, Giardia lamblia), and even HIV itself. HIV-associated gastropathy and malabsorption are commonly noted in these individuals.

Because of their reduced gastric acid concentrations, individuals have an increased susceptibility to virus with Campylobacter, Salmonella, and Shigella. Co-infection with viral hepatitis (HBV, HCV, CMV) can lead to end-stage liver disease, but fortunately, institution of highly active antiretroviral therapy (HAART) can lead to a reduction in medical HBV illness.

Skin lesions commonly related to HIV virus are typically classified as infectious (viral, bacterial, fungal), neoplastic, or nonspecific. Herpes simplex virus (HSV) and herpes zoster virus (HZV) may cause chronic persistent or progressive lesions in individuals with compromised cellular immunity.

HSV commonly causes oral and perianal lesions but can be an AIDS-defining sickness when involving the lung or esophagus. The risk of disseminated HSV or HZV virus and the presence of molluscum contagiosum appear to be correlated using the extent of immunoincompetence.

Seborrheic dermatitis caused by Pityrosporum ovale and fungal skin infections (Candida albicans, dermatophyte species) are also commonly observed in HIV-infected patients. Staphylococcus including methacillin-resistant S aureus can cause the folliculitis, furunculosis, and bullous impetigo commonly observed in HIV-infected individuals, which require aggressive treatment to prevent dissemination and sepsis.

Bacillary angiomatosis is a potentially fatal dermatologic disorder of tumor-like proliferating vascular endothelial cell lesions, the result of infection by Bartonella quintana or Bartonella henselae. The lesions might resemble those of Kaposi's sarcoma but respond to treatment with erythromycin or tetracycline. CNS manifestations in HIV-infected patients consist of infections and malignancies.

Toxoplasmosis frequently presents with space-occupying lesions, causing headache, altered mental status, seizures, or focal neurologic deficits. Cryptococcal meningitis commonly manifests as headache and fever. Up to 90% of patients with cryptococcal meningitis exhibit a positive serum test for Cryptococcus neoformans antigen.

HIV-associated cognitive-motor complex, or AIDS dementia complex, is the most frequently diagnosed cause of altered mental status in HIV-infected patients. Patients typically have difficulty with cognitive tasks, poor short-term memory, slowed motor purpose, personality changes, and waxing and waning dementia. Up to 50% of patients with AIDS suffer from this disorder, perhaps caused by glial or macrophage infection by HIV resulting in destructive inflammatory changes within the CNS.

The differential diagnosis can be broad, including metabolic disturbances and toxic encephalopathy resulting from drugs. Other causes of altered mental status consist of neurosyphilis, CMV or herpes simplex encephalitis, lymphoma, and progressive multifocal leukoencephalopathy, a progressive demyelinating disease caused by a JC papovavirus.

Peripheral nervous system manifestations of HIV virus include sensory, motor, and inflammatory polyneuropathies. Almost 33% of individuals with advanced HIV disease develop peripheral tingling, numbness, and pain in their extremities. These symptoms are likely to become due to loss of nerve axons from direct neuronal HIV infection.

Alcoholism, thyroid disease, syphilis, vitamin B12 deficiency, drug toxicity (ddI, ddC), CMV-associated ascending polyradiculopathy, and transverse myelitis also cause peripheral neuropathies. Less commonly, HIV-infected patients can develop an inflammatory demyelinating polyneuropathy similar to Guillain-Barre syndrome; however, unlike the sensory neuropathies, this inflammatory demyelinating polyneuropathy typically presents before the onset of clinically apparent immunodeficiency.

The origin of this condition is not known, although an autoimmune reaction is suspected. Retinitis resulting from CMV virus is the most typical cause of rapidly progressive visual loss in HIV virus. The diagnosis could be difficult to make because Toxoplasma gondii virus, microinfarction, and retinal necrosis can all cause visual loss. HIV-related malignancies commonly seen in AIDS include Kaposi's sarcoma, non-Hodgkin's lymphoma, primary CNS lymphoma, invasive cervical carcinoma, and anal squamous cell carcinoma.

Impairment of immune surveillance and defense and increased coverage to oncogenic viruses appear to contribute towards the development of neoplasms. Kaposi's sarcoma is the most typical HIV-associated cancer. In San Francisco, 15-20% of HIV-infected homosexual men develop this tumor during the progression of their disease.

Kaposi's sarcoma is uncommon in women and children for reasons that are not clear. Unlike classic Kaposi's sarcoma, which affects elderly men within the Mediterranean, the illness in HIV-infected individuals may present with either localized cutaneous lesions or disseminated visceral involvement.

It is often a progressive disease, and pulmonary involvement could be fatal. Histologically, the lesions of Kaposi's sarcoma consist of a mixed cell population that includes vascular endothelial cells and spindle cells within a collagen network.

Human herpesvirus 8 is associated with Kaposi's sarcoma in patients with AIDS. HIV itself appears to induce cytokines and growth factors that stimulate tumor cell proliferation rather than causing malignant cellular transformation. Clinically, cutaneous Kaposi's sarcoma typically presents as a purplish nodular skin lesion or painless oral lesion.

Sites of visceral involvement include the lung, lymph nodes, liver, and GI tract. In the GI tract, Kaposi's sarcoma can produce chronic blood loss or acute hemorrhage. In the lung, it often presents as coarse nodular infiltrates bilaterally, frequently related to pleural effusions.

Non-Hodgkin's lymphoma is particularly aggressive in HIV-infected individuals and usually indicative of substantial immune compromise. The majority of these tumors are high-grade B-cell lymphomas with a predilection for dissemination. The CNS is frequently involved either as a primary site or as an extranodal site of widespread disease.

Anal dysplasia and squamous cell carcinoma are also more commonly found in HIV-infected homosexual men. These tumors appear to become related to concomitant anal or rectal infection with human papillomavirus (HPV). In HIV-infected women, the incidence of HPV-related cervical dysplasia is as high as 40%, and dysplasia can progress rapidly to invasive cervical carcinoma.

Adherence to multidrug regimens remains a challenge, but clearly antiretroviral therapy improves immune purpose. For reasons that are not clear, HIV-infected patients have an unusually high rate of adverse reactions to a wide variety of antibiotics and frequently develop severe debilitating cutaneous reactions.

Drug hypersensitivity and toxicity can be severe, potentially life-threatening, and limiting with certain agents. Immune reconstitution syndrome is really a described reaction occurring days to weeks following initiation of HAART.

Medical relapse or worsening of mycobacterial, pneumocystis, hepatitis, or neurological infections occurs as a result of a resurgence of immune activity, causing paradoxical worsening of inflammation, possibly as residual antigens or subclinical pathogens are attacked.

Other issues of HIV-infection include arthritides, myopathy, GI syndromes, dysfunction of the adrenal and thyroid glands, hematologic cytopenias, and nephropathy. Since the illness was first described in 1981, medical knowledge of the underlying pathogenesis of AIDS has increased at a rate unprecedented in medical background.

This knowledge has led towards the rapid improvement of therapies directed at controlling HIV virus as well as the multitude of complicating opportunistic infections and cancers.

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