African Journals Online
Southern African Journal of Child and Adolescent Mental Health

Volume 13, number 2, 2001 
Abstracts

(1)THERAPEUTIC SPIRAL MODEL FOR PSYCHODRAMA WITH TRAUMA SURVIVORS. 
Vivyan Alers 

Psychodrama can provide a safe place to conciously re-experience unprocessed trauma and bring hope of new possibilities to people whose lives and famlies have been impacted by overwhelming catastrophe. Kate Hudgins and Peter Felix Kellerman, in 'Psychodrama with Trauma Survivors.'

(2) AUTISTIC DISORDER: A CONSEQUENCE OF DISRUPTED ATTACHMENT
A. Berg
UCT Parent-Infant Mental Health Service
Child & Family Unit, Red Cross Children's Hospital
Cape Town, South Africa

The advancement of neuroscience during the last decade has made significant contributions to the understanding of the links between parent-infant interactions, brain development and social relatedness. The first attachment relationship impacts positively or negatively on the structural organisation of the brain, making maturation "experience-dependent". Security of attachment has been found to be the most important factor in fostering right brain capacities such as affect regulation, empathy and the development of a theory of mind.
Conversely, traumatic attachments negatively affect brain development and infant mental health. In this paper the hypothesis is made that disrupted attachment during sensitive periods could lead to structural impairments resulting in pervasive developmental disorders. This notion is supported by the term "Autistic Post-Traumatic Developmental Disorder" as proposed by Reid. 
The case of a three-year old boy who presents with symptoms of autism will be presented in order to illustrate the above assertions. The attachment bonds to this child's mothering figures were disrupted during two crucial phases of his development, at ages 9 and 13 months. His presenting symptoms could be seen as manifestations of Autistic Post-Traumatic Stress Disorder.
The profound impact on the developing brain of disrupted attachment during infancy makes early detection and intervention particularly relevant and urgent.

(3) GENERALISED ANXIETY DISORDER: A COGNITIVE BEHAVIOURAL INTERVENTION
L. Carew
City Park Two
Cape Town, South Africa

Generalised Anxiety Disorder is a relatively common and disabling condition in childhood. Proposed aetiological mechanisms have included biological factors, psychodynamic and learning theory.
The Cognitive-Behavioural model of childhood anxiety organises around the central principle of the perception of threat and anxiety. It addresses the relationship between physiological alerting and arousal, negative cognitive appraisal and behavioural avoidance. Treatment is aimed at managing anxiety, reducing personal distress and enhancing coping skills and mastery of the environment.
This presentation of clinical material will illustrate the practical application of the Cognitive-Behavioural model in the treatment of a 7 year old boy with Generalised Anxiety Disorder.

(4) WHEN CHILDREN ARE THE CENTER OF THE STORM: Psycho-legal issues involving children (custody and access)
L. Carr 
Suite 265
Private Bag X 5
Norwood, 2117
email: [email protected]

This workshop will begin with a brief introduction to the mechanics of the legal process in South Africa insofar as it relates to children. The description of these mechanics will be placed in a historical and international context. Terms like the adversarial system and the inquisitorial system will be explained. The development of parental preference in deciding matters of family law will be critically discussed in historical context. The standard of the best interests of the child will be critically examined. The dynamics of the legal process will then be described in terms of power relationships, where children are viewed as the site of power relations rather than as subjects of family law. Current issues like fathers rights and parental alienation will be examined to exemplify issues dealt with the workshop in terms how they reflect changing power relationships in the legal system. 

(5) THE EUREKA EXPERIENCE - A CHILD PSYCHIATRIC CLINIC WITHIN A SCHOOL 
H.M. Clark
Child, Adolescent and Family Unit, 
Chris Hani Baragwanath Hospital
Department of Psychiatry, 
University of the Witwatersrand

Eureka school is a special school in Vereeniging, Gauteng that comprises 430 learners, ranging in age from 6 to 21 years, of which 140 live in the school hostel facility. To qualify for admission a learner should be mentally handicapped - IQ less than 55, or higher if comorbid behaviour problems present. All learners must have been exempted from mainstream schooling. Eureka is a state funded school and, whilst it draws learners from all socioeconomic and cultural backgrounds , many of the children are from very disadvantaged, chaotic and even rejecting home backgrounds. For many of the children who are patients in the clinic, the school is by far the most positive and containing structure they know and also the place where the impact of their difficult backgrounds becomes most evident as they struggle with their intellectual limitations, their own emotional insecurities, their all too frequent psychiatric comorbidity as well as the challenges of forging a developmental path as individuals and as social beings.
The Eureka child psychiatric clinic was started in June 1998 when it was realised that significant numbers of the children were being transported to the three overloaded regional child psychiatric clinics on a weekly basis. Out of their familiar environment, the children were often difficult to contain and there was no access to information on their functioning in said environment. Starting with about 15 children, the clinic ran on a monthly basis staffed by the author and the school nursing sister who at the onset had had no formal psychiatry training. This paper looks at the development and functioning of this clinic over the past three years. At this stage there are 65 patients on file. Children are referred by staff of the school , their parents or by outside treating agencies. Information is gathered on a regular basis from family (if available), teachers, hostel staff and other parties such as social workers. The child is seen individually as well as within the classroom setting. The presentation will review the range of diagnostic entities presenting and as well as a range of medication and behavioural treatment modalities in use.

(6) CONVERSION DISORDER : A CHRIS HANI BARAGWANATH PERSPECTIVE 
H.M. Clark 
Child, Adolescent and Family Unit, 
Chris Hani Baragwanath Hospital
Department of Psychiatry , 
University of the Witwatersrand

Conversion disorder is a common diagnosis of referral to the Child Psychiatry Clinic at Chris Hani Baragwanath Hospital. By DSM IV definition the disorder refers to a child or adolescent who presents with symptoms or deficits affecting voluntary motor or sensory function that suggests a neurological or other medical condition, which is either not present or does not fully account for the symptoms or deficits. The condition is believed to arise from conscious or unconscious conflicts or anxiety which presents in a conscious form as a physical symptom thus allowing the patient not to directly experience the anxiety or to avoid the anticipated anxiety provoking stimulus.
Common forms of conversion disorder seen in the clinic are pseudoseizures, fainting, and loss of sensory or motor function in a particular part of the body. Our experience also includes a case of conversion blindness and one of conversion ptosis. This presentation will review ten cases of conversion disorder across the range of forms seen in this unit over the past three years. It will look at aspects of commonality and describe a phenomenon that has become quite typical in our patients.
One of the accepted constants in child psychiatry is the presence of comorbidity. What emerges in this series of cases is that patients who, whilst they fulfill DSM IV criteria for conversion disorder at some point, have a clinical presentation that presents over time with a complex of overlapping disorders and is thus at first glance atypical for said disorder. The complex includes organic disorders, hysteria and a factitious component - in addition to conversion disorder. This hypothesis will be presented diagrammatically and it will be shown that the patient's position within the complex is not fixed but changes over the time frame thus allowing for a changing presentation. It will be proposed that it is only with understanding of the physical, psychological and social makeup of the child as well as the structure and functioning of the interrelated systems in which the child exists that one can understand the placement in said complex and effectively approach management in a consultation-liaison setting.

(7) THINKING ABOUT THE NEUROPSYCHOLOGICAL ASSESSMENT OF CHILDREN WITH HEAD INJURIES
A. Cramer
PO Box 3049
Knysna, 6570

As opposed to the neuropsychological assessment of adults, there seems to be much less information available about such assessments with children. Psychologists are frequently asked to assess the nature and severity of cognitive impairment of a child following a head injury, for the purposes of diagnosis and treatment or in the case of a civil claim. In such cases the administration of a children's intelligence test or a single screening indicator, is insufficient or even inappropriate. The aim of this presentation would be to briefly:
· Identify the possible problems with such assessments, and suggest ways in which to overcome some of the problems associated with testing children
· List the areas of focus in a thorough assessment (as opposed to mere testing)
· Suggest a method of thinking about the assessment of young children based on the development of perceptual abilities
· Provide a list of possible neuropsychological tests suitable for the assessment of children.
This presentation is intended to be practical in nature and provide some guidelines for thinking about the neuropsychological assessment of children, for psychologists who do not usually perform this function. 

(8) WHO NEEDS IN-PATIENT PSYCHIATRIC TREATMENT ?
W. de Jager 
Therapeutic Learning Centre, 
Child and Family Unit
Red Cross Children's Hospital

In-patient psychiatric care for children has two unique functions:
It allows for assessments through observation of cases difficult t diagnose and can attempt the treatment of patients refractory to out-patient treatment. Although many problems surround this form of treatment (costs / removal from home), it is currently being re-evaluated worldwide and acknowledged to be an important component of a sound Child Mental Health Treatment system.
The Therapeutic Learning Centre at Red Cross Hospital in Cape Town, is one of the few such units in South Africa. This paper will present an audit of admissions of the last two years in order to ascertain how useful this form of treatment has been to children who place a severe burden on out-patient resources. Two short case examples will be presented to illustrate successful and unsuccessful treatment. Reasons for outcome will be postulated. The need for such units within a South African context will be discussed.

(9) HEROIC ASPIRATIONS - A CHILD'S STRUGGLE IN PLAY THERAPY
M. Donaldson
Clinical Psychologist

This paper describes work done with a five year-old boy suffering from a genetic degenerative disease - MPS 6 - that causes increasingly severe deformity, sight and hearing problems and gross motor skills disabilities, while mental capacity remains unaffected. Drawing on play therapy material, the child's battle to come to terms with his disability, disfigurement and general trauma related to his illness is described. The paper further illustrates the parallel developmental process taking place within - that of mastery and autonomy from internal figures and an internal world deeply affected by the external difficulties. While no complete "cure" or solution or resolution can be expected, the paper makes a case for therapeutic intervention with very sick or disabled children. Expression through play of the difficult and sometimes unmanageable feelings and thoughts has provided containment and relief.

(10) PSYCHOANALYTIC THINKING APPLIED TO WORK WITH CHILDREN
J. Green
E. Echstein
S. Peeke

Psychoanalytic psychotherapy, rooted in psychoanalytic theory, explores the impact of experience, both internal and external on the development of the individual. In this paper, we aim to demonstrate the value of this detailed exploration of a person's experience as a way of understanding the workings of the mind and in so doing offering the hope of change in the individual. Case material from individual psychotherapeutic work with children will be used to show how an understanding of these early processes assist the child in dealing with anxieties that may obstruct normal development. The material will also demonstrate how interpretation of unconscious processes can result in early symptom relief for the child.

(11) SCHOOL AS COMMUNITY: IMPLEMENTING SUPPORT PROGRAMMES IN EDUCATIONAL INSTITUTIONS
L.M. Eskell-Blokland 
Vista University, 
Dept of Psycholgy, 
Private Bag X1311
Silverton, 0127

A.M. Steele
Private practice.

The workshop presentation presents a project which has been developed within the notion of school as centre of community. The philosophy holds that schools can be utilised to serve the broader needs of the local communities other than simply "school" the children in core curricula. Education is viewed as multi-dimensional and needing to address values, personal and inter-personal skills in order to empower individuals and communities to identify and address their own particular needs.
The project draws on the ecosystemic paradigm in a design that focuses on process rather than content. The ecosystemic approach recognises that the organization of community affects the individual who is part of various social structures. It is the transactions between these structures and the individuals which co-evolve adaptation and coping. Groups such as churches, neighbourhoods and schools serve as mediating structures between individual and community. 
Educational institutions give a natural access to the learners and their families, thus holding the potential for forming the centre for community networking. In this way educational institutions could become the key to community upliftment and development. 
The presence of these programmes in the schools provide skills for the various stakeholders so that community involvement is encouraged and persons are empowered to discover ways to address the specific needs of the communities in which the institutions are embedded. Skills imparted by these programmes go beyond pure counselling and stimulate thinking around particular needs of the immediate communities.
In the past parents have regarded schools as bearing the responsibility of the pupils for formal education and remain relatively uninvolved in personal primary care of the learners. Educational institutions give a natural access to the learners and their families, thus holding the potential for forming the centre for community networking. In this way educational institutions could become the key to community upliftment and development.
These programmes train and monitor peer support for pupils, teachers and parents of senior high schools. Pupils are selected from a volunteer group as suitable candidates to enter the training in basic listening, helping and referral skills. Parents and teachers are drawn into the programme as trained helpers and resident and casual monitors.
The programme is currently addressing concerns in the schools such as substance abuse, physical and emotional abuse, divorce in families, relationship problems between parents and children, sexual concerns of teenagers, depression and suicide among teenagers, discipline issues of parents, establishing a climate in the school where there is acknowledgement of psychological, personal and emotional issues, inter-cultural and -racial understanding and tolerance.
The project was established in 1997 at Willowridge High School in the Eastern suburbs of Pretoria. Currently the programme runs at Willowridge High School and Crawford College, both in Pretoria. Negotiations are underway to establish the project at more high schools.

(12) CHILD HOMICIDE IN A FORENSIC PSYCHIATRIC CONTEXT:
A COMPARISON BETWEEN MOTHERS, FATHERS AND NON-PARENTS WHO KILL CHILDREN
W. Friedlander

BACKGROUND
Accounts of parents who kill children date to the beginning of recorded history. Current rates of infanticide are 9 per 100 000 live births in the USA. In the UK, 90% of maternal filicides have a relationship to psychiatric illness.
AIMS
This study describes the patterns of parental homicide seen in a population of patients referred for psychiatric observation after being charged with the murder of their children. The characteristics of the perpetrator and the murder itself are compared and the role of psychiatric illness explored. Potential risk factors for infant homicide are extracted from this allowing preventive strategies to be implemented.
METHOD
The study is of a retrospective descriptive design. All observation patients admitted to the forensic unit at Sterkfontein Hospital from 1 January 1993 to 31 December 1999 with a charge of murder, where the victim was younger than 18 years old, were included in the study population. This population was then divided into 3 groups: the mother as perpetrator, the father as perpetrator and a group where the perpetrators were not the biological parents of the child. Clinical and demographic parameters were recorded from the patient records. For each patient, the mental status findings, fitness to stand trial and criminal responsibility were arrived at after assessment by a multi-disciplinary team. Diagnostic assessment was made according to the clinical information contained in the files.
RESULTS
Fathers who killed their own children were significantly older than mothers who killed their own children. There was a high prevalence of substance abuse particularly in the group of patients who killed children who were not their biological offspring. The age of the victim was older when alcohol abuse was involved. The prevalence of past psychiatric illness was equal in all three groups of observation patients but did not influence a psychiatric diagnosis being made during the observation period. Fathers who killed their children were most likely to kill other members of their family in the same attack. One third of all murders were carried out in a manner suggesting that the perpetrator was psychotic at the time. 
DISCUSSION
Common characteristics of people who murder their own children that distinguish risk groups in the general population could not be found. Substance abuse and past psychiatric illness do, however, play a significant role.
CONCLUSION
Like in other research on crime perpetrated by the mentally ill, people who kill children do have a high incidence of psychiatric illness and substance abuse but defy categorization both in terms of their diagnosis and predisposing factors. 

(13) A SOUTH AFRICAN JOURNEY: WORKING IN A MULTICULTURAL MILIEU
R. Gericke 
Gauteng Mental Health

This paper will describe the story of cognitively challenged, 11-year-old Ntombi's disappearances from home during postictal confusion due to complex partial seizures with bilateral foci effecting the left temporal and right parietal lobes, and her calling to be a sangoma. The case is presented as it unfolded over approximately a twelve-month period during the interventions by different agencies as this will show how the family and wider system struggled to hold this child. But Ntombi's journey also called, and continues to call, members of the mental health team at a child psychiatric clinic to find a way home in a transitional, multicultural space in South Africa where we may get lost should we only wear the Western paradigmatic lens. Ntombi's journey therefore invites us onto a journey, and many questions are raised en route. Perhaps in finding the road between the 'Western' and the 'African' we can better aid Ntombi, and South Africa, in finding our own way home.

(14) EVALUATING SOUL BUDDYZ, A MASS MEDIA INTERVENTION FOR 8-12 YEAR OLD CHILDREN IN SOUTH AFRICA 
S.J. Goldstein, E. Scheepers, A. Maker, G. Japhet
Soul City: Institute for Health and Development Communication,
Ms Scheepers is an Independent Consultant 

Although 8-12 years old is a relatively healthy time of a person's life, there are important health promotion issues, which seem to have been neglected in this age group. Trauma both intentional and unintentional, are the major causes of morbidity and mortality in this age group. The potential for health education, which will carry children through the rest of their lives is also critical at this age. It is an age where cognitively children are well developed, and emotionally they are starting to mature, and they are keen to learn. Soul Buddyz is a multi media intervention, which dealt with three issues for children of this age group. The three issues are AIDS and sexuality; trauma, which includes traffic trauma, burns drowning as well as intentional trauma, bullying and abuse; and the third issue was disability.
The Soul Buddyz series consisted of:
Television: a 26 part, half hour television drama was aired on SABC1 from August 2000 to February 2001. The drama is driven by the child characters and centers around a group of children who meet up in a park in an urban area after school each day. The group is from varied socio-economic, race and language backgrounds. Each episode is told from the perspective of one of children in the format of a voice over narrative. Children deal with issues that confront them in their everyday life according to topics covered in the Soul Buddyz message brief (mentioned above). 
At the end of each episode there is a two-minute 'reality check' (Buddyz Buzz) which consists of real children commenting on the issues raised in the episode.
Radio: twenty-six episodes of a magazine programme, was broadcast in 4 languages from February 2001 to April 2001. The programme consists of a 10-minute drama with similar content to the television, but with different characters, there is also a 10-minute information slot and a 30-minute phone programme to discuss the issues raised in the drama. 
Print material: a Grade 7 life skills book with 11 units focusing on the issues in the electronic media was distributed to all grade 7 students in the country (900 000). Each unit has a photo comic of one page telling the television story, a set of activities to do. There are stories that real children tell about the issues and an educator's page with teaching information and support contacts.
A parenting booklet was distributed through the Sunday Times (650 000) and NGO's. The book has information in an easy to read format about basic parenting skills like discipline, and communication as well as information about the particular issues dealt with in Soul Buddyz, like sexuality and AIDS.
The whole project was framed in a children's rights framework and emphasised the following principles:

(15) ETHICS OF RESEARCH IN CHILDREN
M. Groenewald, 
Department of Paediatrics, 
Allergy and Research Clinic, 
I Military Hospital, 
Pretoria, South Africa

Highly controlled clinical studies are essentially a phenomena of the latter part of the 20th Century. Much of the significant progress in medicine we all enjoy today would not have been possible without them. Scientific research is essential to advance knowledge of all aspects of childhood disease. Such research however, may be performed only when the information sought cannot in practice be obtained by other means.
All research must be based on sound scientific concepts and must be planned and conducted in such a fashion as will reasonably ensure that definite conclusions will be reached. Some programmes may offer direct benefit to the individual child, while others may have a broader community purpose. In appropriate circumstances both may be ethical.
The Research Ethics committee has the responsibility to consider all aspects related to the trial process i.e rights / welfare, risks / benefit and placebo arm.
In the last 20 years or so, there has been a growing recognition of the importance of listening to children's views and wishes. In all issues relating to children, the best interest of the child is paramount (SA Constitution section 28). 
One of the major shifts in child law is that from parental authority to parental responsibility. Earlier research tended to be on children, regarding children as subjects of the research. Increasingly, research is conducted with children, who are being involved as active participants.
The thorny question of children, consent and research via questionnaires or interviews at schools also needs be addressed.
This paper will highlight some of the legal and ethical issues to consider in undertaking research with children, which apply both to archiving data to the research process itself, using practical examples.

(16) CHILD ABUSE: ASSESSMENT AND TREATMENT APPLYING GARBARINO'S FIVE FORMS OF PSYCHICALLY DESTRUCTIVE BEHAVIOUR. 
S.F. Hammerschlag, 
Clinical Psychologist. (Private Practice)

The assessment and treatment of child abuse appears to need more research and greater refinement with regard to each unique case. 
The Mental Health Worker needs to look at every form of child abuse in terms of the unique effect that it may have on the child's psyche.
The emotional elements are the core in understanding and treating abuse in children. Using case study material, Garbarino's five behavioral forms of emotional abuse are applied in order to achieve more individual and effective assessment and treatment of child abuse. 

(17) THE RECOGNITION OF PARENT ALIENATION AS EMOTIONAL CHILD ABUSE. 
S.F. Hammerschlag, 
Clinical Psychologist. (Private Practice)

Parent alienation, without a rational just cause, is emotional child abuse. 
Parental Alienation may not have the concrete consequences seen in Physical Abuse, however, it has indicative emotional and psychological consequences for the child.
Parent alienation is becoming more prevalent due to changes in our social context.
The Mental Health and Legal professions need to protect children from these emotional and psychological consequences.
Based on literature and clinical experience, proposals are made on assessment, treatment and professional ethics. 

(18) HOLISTIC MANAGEMENT OF EARLY ONSET PSYCHOTIC DISORDERS IN SOUTH AFRICA
S.M. Hawkridge, L. Keyter, J. Schrönen, E. Seale, R.A. Emsley
Department of Psychiatry, University of Stellenbosch

We present a brief overview of the optimal comprehensive management of early onset schizophrenia and bipolar disorder, including detection, hospitalisation, acute treatment, maintenance pharmacotherapy, family intervention and occupational/academic rehabilitation, as derived from a review of the international literature. The possible long-term consequences to patients, their families and their communities of inadequate treatment are outlined. We then describe the resources available to adolescents with these disorders in the various regions of South Africa, based on previously presented data and personal communications with colleagues, and outline areas of deficiency. Our finding is that even in the best-resourced provinces, insufficient accommodation has been made for the special needs of children and adolescents presenting with early onset schizophrenia and bipolar disorder, frequently resulting in contravention of the constitutional rights of children and youth. In some provinces, children and adolescents are simply admitted to adult wards in psychiatric hospitals. Arguments are presented as to the cost-efficiency of capacity expansion for the management of these disorders in young patients, including early detection in schools, dedicated short and medium term admission facilities, availability of appropriate pharmacotherapeutic agents, specific training for clinical personnel, follow up and family support resources and reintegration/rehabilitation programmes. Reference is made to the clinical experience of the child and adolescent psychiatry unit at Tygerberg Hospital, and suggestions are offered as to relatively low cost interventions to improve the holistic management of young patients with psychotic disorders in South Africa. These include dissemination of information on prodromal symptoms/risk factors to educational and primary health care personnel, dedication of physically separated beds in adult units or general hospital wards, in-service training of clinical staff, motivation for appropriate pharmacotherapeutic agents, establishment and involvement of support/consumer groups, intersectoral co-operation in the establishment of rehabilitative facilities and the collection of national data.

(19) WHEN THE CHILD'S FIRST MEMORY IS FEAR: THE USE OF ART THERAPY IN HELPING CHILDREN WHO HAVE BEEN EXPOSED TO SEVERE TRAUMA
G. Hlophe

In this paper, the author will use a case study to illustrate the use of art therapy to facilitate the therapeutic process of helping children who have been exposed to severe traumatic experiences.

(20) UPDATE ON ATYPICAL NEUROLEPTICS AND PSYCHOSTIMULANTS IN PAEDIATRIC PSYCHIATRY.
L. Holford, 
Department of Psychiatry, 
University of the Witwatersrand, 
Johannesburg, South Africa

Objective: 
This workshop will review data from recent clinical trials on 
(i) the safety and efficacy of atypical neuroleptics
(ii) slow release psychostimulants. 
These medications are relatively new to South African paediatric psychiatry and are in wide spread use. There is interest and a need for information especially about possible adverse effects.
Methods/Results:
A review of the recent literature will be described.
There are few well controlled studies of atypical neuroleptics in childhood. From these reviews the data on dosage, efficacy, extrapyramidal side effects, tardive dyskinesia, raised prolactin levels and weight gain will be discussed.
Slow release methylphenidate will be reviewed as to efficacy and advantages and disadvantages over standard methylphenidate.
Conclusions: Atypical neuroleptics appear to be efficacious in a wide variety of paediatric mental disorders. However much further research is needed before firm conclusions can be reached.
Slow release methylphenidate has particular benefit where frequent dosing is problematic.
Time will be allowed for questions and discussion.

(21) CHALLENGING THE JUSTICE SYSTEM TO DEAL WITH THE DISABLED CHILD
L.B. Jacklin and L. Lamprecht
The Memorial Institute for Child Health and Development (Assessment Clinic) 
and The Teddy Bear Clinic for Abused Children

The investigation was initiated through the combined work of the assessment and child abuse clinics. The child abuse clinic saw a dramatic rise in the number of cases involving disabled children. These children's cases appeared to not progress adequately through the criminal justice system and the authors began investigating why this was the case. Preliminary interviews and readings showed that the law still named certain categories of mentally disabled persons as 'idiots and imbeciles". The question then arose as to how such an insensitive law can meet the needs of the disabled person, and more specifically the disabled child. There are a number of other laws that require the child's evidence to be viewed with caution. Finally, within South Africa's accusatorial judicial system language is the main vehicle by which cases are heard and the child who is disabled is doubly compromised in this regard.
The clinic has collected statistics over the past four years with the average yearly caseload of four hundred. The authors then went back to the statistics for 1997 and took a random sample of 92 non-disabled children whose cases were analysed in terms of the outcome of the criminal proceedings. The sample was then measured against a disabled population of 19 children presenting to the clinic for the year 2000. The aim was to look for conviction rate and reason for the failure of the criminal justice system in the two groups respectively.
Year No. Guilty Verdict 

1997 92 23 
2000 19 0 

Total Children 111 25 Percentage Guilty (Non-Dis)
Disabled % 17.11712 0 Percentage Guilty (Dis)
The conclusion reached by the authors is that the current criminal justice system is ignorant of the needs of the disabled child. As a result they are unable to play a part in the protection of one of a child's most basic rights 'not to be abused'. The further marginalisation of the disabled child makes them more susceptible to abuse as they are often unable to protect themselves. Once violated they are afforded no protection by the state. The authors are calling for the reform of the law, as it relates to the disabled, as well as training and procedural reform in the courts themselves.

(22) UNDERSTANDING, AVOIDING AND MANAGING CHALLENGING BEHAVIOURS IN ASDS
R.R. Jordan 
The School of Education, 
The University of Birmingham

Autistic spectrum disorders (ASDs) are currently diagnosed at a behavioural level, but the autism does not lie in the behaviour itself; difficult or challenging behaviour in ASDs is a secondary consequence of the ASD, rather than a feature of it. All behaviour has meaning, but explanations of behaviour need to take account of the autism and not depend on 'normal' assumptions of its causes. Only through understanding the function and ontology of the challenging behaviours seen in ASDs, can they be avoided or managed effectively. This paper analyses challenging behaviour in ASDs in terms of the biology of the disorders, the developmental consequences, and the life experiences that give rise to it. It then enumerates a number of strategies that underpin effective approaches to preventing and managing challenging behaviour.
Among the techniques discussed are
· functional analysis within the context of ASDs
· developing communication
· reducing overall and context specific stress
· teaching relaxation and 'escape'
· coping with panic
· managing phobias
· providing proximal control
· developing understanding
· teaching alternatives to challenging behaviour'
· teaching consequences
· alternatives to 'punishment'
A positive educational approach is more humane and more effective. Short-term strategies often result in long-term worsening of the behaviour; yet 'emergency'measures may be needed to 'buy time' while more long-term effective approaches are developed. This is true of drug treatments, which are seldom effective in total, but may help by breaking behaviour patterns and allowing time for more educational approaches to take effect.
Conclusion: As with so much else in ASDs, behaviours can be misleading, and need to be interpreted within the context of the autism. The nature of ASDs and the situations that arise from them, give rise to behaviours that are often seen as challenging but there are a range of strategies that can be adopted to minimise these effects on the individual with the ASD and those who live and work with him/her. A positive approach, focusing on education not control, is more humane and more effective.

(23) COMMUNITY BASED CHILD PROTECTION PROGRAMMES: REALITY/FANTASY?
V. Khoza
KwaZulu-Natal Programme for Survivors of Violence
1214 Sangro House
417 Smith Street
Durban 4001, South Africa.
email: [email protected] 

The KwaZulu-Natal Programme for Survivors of Violence is a non-profit, non-governmental organisation based in Durban South Africa. This is the organisation that is concerned with the effects of violence and the abuse of children in violence attacks in communities of KwaZulu-Natal. The focus of our intervention is community-based, targetting communities who have been particularly severely affected by violence. This is because violence tends to break down and disrupt relationships within communities, and the aim of our programme is to rebuild and strengthen relationships between people within communities. Our model of intervention is a systematic one. We work with women, children, youth and leaders in communities. We work with children from these communities separately at our first encounter. We then move to the second phase of reconciliation because this group of children come from areas which were previously in conflict. We run and facilitate weekly groups with the children and the caregivers on different dates.
The plight of the children in the so-called township and rural areas of KwaZulu-Natal, South Africa, is an increasingly worrying one. Amidst adversity including poverty, malnution, HIV/Aids, poor educational facilitieschildrens needs receive little attention at all. We work with children who have witnessed violence, suffered from criminal and political violence, sexual abuse or domestic violence and have been used to perpetuate ciolence acts. The challenge for our organisation has been to take care of the environmental adversity, socio-cultural needs of the children.
In my paper I will be presenting the systematic model of intervention we are using as an organisation. The model of intervention used in the work with children has to shift several times in accommodating the changes in the environment and in ralising successes and mistakes made. We observed that children were not exposed to single traumatic experiences but were exposed to multiple stressors. Beside working with children directly we then work with the caregivers to bolster the coping and empowering because this has long-term impact on the child's development. This also has the advantage of reaching more children indirectly, as caregivers are in most cases responsible for the care of the children.
I will also look on coping mechanism for children who live under violent conditions. I will also expand on the positive effects on children's adaptation and development. The attributes of the individual: for example resilient temperament, good social skills, supportive family environment: such as attachment to an adult family members, low family member, low family conflict and supportive family relationships. Environmental support: such as encouraging coping efforts, recognising and rewarding competence, education and health facilities. 

(24) THE ZIMESELENI RESEARCHERS: THINK DEEP 
J. Kistner

Using participatory research as intervention with 'hard to reach' boys 
The Zimeseleni project involves 12 to 16 year old "hard to reach boys" (who would otherwise be labeled as "as conduct disorders") from Katlehong and Thokoza in exploring the reality of children living in a context of poverty, deprivation and criminalisation. The research engaged in by these boys in itself becomes a therapeutic process and creates a model for effective intervention into their lives. Recently the project has been extended and adapted to the needs of another 15 boys in the Zonkezizwe community.
The project is a joint project between Ekupholeni Mental Health Centre and Clacherty and Associates.
Ekupholeni Mental Health Centre is an NGO offering innovative and comprehensive mental health services to the communities of Katlehong, Thokoza and Vosloorus. These include individual and family interventions, a wide range of support and therapy groups and a number of community healing projects. The Zimeseleni Group is a group of 15 boys who have been referred to Ekupholeni because of behavioural problems. They range in age from 12 to 16. When the group started about half of the group was in school and the other half out of school. All of them live in extreme poverty and all come from difficult and deprived home situations. Most of the boys are involved in crime. This ranges from petty crime to rape and gang involvement, though those involved in gangs are still on the edge of criminal gang activity because of their age. The criminal activities these boys are engaged in have, in most cases, not yet been identified and/or acted on by the law enforcement authorities. Some of the boys are also involved in substance abuse. 
The boys represent a microcosm of boys around South Africa who are on the edge of criminal activity and are likely to become fully part of it in a few years time. The boys themselves acknowledge this fact sometimes with a sense of powerlessness and a sense of the inevitability of their journey in life. 
The group was established by Ekupholeni in the middle of 1999 but struggled for months to achieve a sense of identity, purpose and cohesiveness. The Ekupholeni team was desperately looking for a way of reaching and assisting these children to grow through the emotional difficulties that were pushing them into the criminal underworld.
The idea of creating a research project that would at the same time develop into a therapeutic intervention was born in early 2000 when the Ekupholeni staff met with a specialist in participatory research with children. This researcher wanted to explore the realities of boys living on the edge of crime and to use their experiences and perceptions to make child-centred recommendations to policy makers and service providers alike. 
The researcher, the psychologist and the lay counsellor began to brainstorm creative ways of reaching these very defensive, yet vulnerable and emotionally extremely needy children and undertake research into the lives of boys at risk. The idea of using a participatory research approach to reach the boys therapeutically seemed worthwhile exploring. The staff at Ekupholeni knew, however, that the boys were too guarded to talk about their own lives so the decision was made to make the focus of the research 'the lives of boys in Kathorus'. What emerged as the project developed was a powerful model for intervention based on the idea of children as researchers. 
From a psychological point of view, it was evident that all the boys had had severely traumatic experiences in primary relationships (parents), and, as a result, had defended themselves against any kind of meaningful relationships, which in their experience, had only let them down. 
This defence against meaningful relationships, coupled with severe and long term socio-economic deprivation was one of the main reasons why the boys became involved in criminal activities and also one of the main reasons why they resisted any therapeutic intervention. The research approach provided a unique approach to overcoming this defence mechanism. 
By making the boys researchers into the 'lives of boys in Kathorus' they were able to explore and discover their own difficulties and processes from a relatively safe distance. While looking at the realities of other children, the group would really explore it's own, without unduly threatening the defensive structures that have been built up over the years and have effectively helped the children to survive. 
This approach is aligned to the narrative therapy paradigm which recognises the importance of helping children, in particular, to view their problems from a distance, to depersonalise them and find active means of reasserting control over their own behaviours and experiences. In this way the child is freed from the label of "problem child". Instead he/she is seen as an active agent who labels, confronts and deals with the problem behaviour.
Using disposable cameras, the boys took photographs that illustrated the 'lives of boys in Kathrorus'. Time was spent labelling the photographs, talking about them, discussing them, all the time in the role of 'objective' researcher. All this discussion was taped and became the qualitative data that the adult researcher used to develop a picture of the reality of boys on the edge of crime and what pushed them into crime. The research was 'real' research and this fact was reinforced when the boys presented their findings at an academic conference of psychologists. In the past year the boys have presented their research to educators ( on why children are out of school) and to Soul City film makers ( on the use of drugs by children). They are currently doing research for Gunfree SA on the availability and use of fire arms among boys in Katorus.
The research process captured the boys' attention and fascination and created the space within which therapeutic interventions could take place without alienating the boys. The research provided insight into their lives own and the context they live in. The cameras and role of researcher provided the distance they needed to 'see' their own problems. Through a gradual process of exploration and analysis the boys began to reclaim ownership of the problem in a way that was free of the fear of judgment and rejection. "Think deep" and "I know because I have experienced it" have become permanent maxims of both the research and the therapy process. In preparing the presentations, problem-solving processes emerged. The positive feed back from peresentations and the actual commissioning of research projects from Soul City and GunfreeSA helped the boys see themselves and each other in an increasingly more positive light. The relationships that evolved with the adults facilitators as well as the older youth assisting with the group has created opportunities for re-parenting as well as alternative role-models. All except one of the boys are currently back at school. 
As the process continues the boys and the facilitators continunally face new challenges. We see the project as a long term intervention with many facets. The boys have suffered long term and profound emotional damage and continue to remain at risk. Easy answers are not available. However, a useful model of intervention has emerged which we are currently adapting to another group of youths in a peri-urban settlement.

(25) CHILD AND ADOLESCENT MENTAL HEALTH SERVICES IN GAUTENG - A REVIEW OF POLICY'
R. Lazarus and R. Thom
Gauteng Health Department, 
Directorate: Clinical and Service Development, 
Subdirectorate: Special Clinical Standards and Audit - Mental Health.

A business plan for Child and Adolescent Mental Health Services in Gauteng was commissioned by the then Mental Health Directorate of the Gauteng Health Department in 1996. This plan was produced by the Centre for Health Policy in 1997. It was considered important to review this business plan this year, five years after it was produced, in order to assess whether it has been possible to implement the proposals in the plan, to identify obstacles to its implementation, and possible solutions or alternative proposals for the improvement of these services. It has not been possible to implement the business plan in its entirety, and some of the problems identified include: a failure to implement adequate primary level services for children and adolescents, difficulties in inter-sectoral collaboration (particularly with the Education and Welfare Sectors) and a lack of suitable in-patient services for children in need of acute intervention. The presentation will include a review of the current services provided and initiatives that have been developed around child and adolescent mental health care, as well as the outcome of a focus group discussion with relevant role-players which will be held in August 2001.

(26) PRIMARY PARENTAL PREOCCUPATIONS REVISITED
J.F. Leckman
Child Study Center, 
Yale University, New Haven, CT

Objectives: This presentation reviews recent developments in the phenomenology, neurobiology, genetics, and epigenetics of maternal behavior in humans and animal model systems from an evolutionary perspective. This viewpoint posits that the evolutionary events that have led to the emergence of the human species and our particular set of conserved behavioral and mental capacities has also left us vulnerable to certain forms of psychopathology. Maternal behavior is an example of a highly conserved set of behavioral and mental capacities.
Methods: The results of several prospective longitudinal and cross-sectional parenting studies in human populations are reviewed. In addition gene knockout studies, in which aspects of maternal behavior have been disrupted, are critically reviewed in the context of our emerging knowledge base of the neural circuitry needed for the expression of maternal behaviors from one generation to the next.
Results: Studies of early parental preoccupations and behaviors have documented the presence of anxious intrusive thoughts and associated harm avoidant behaviors that resemble some forms of obsessive-compulsive disorder and that peak at the time of birth. Knockout gene studies in combination with classical lesioning and track tracing studies in mammalian model systems have explicated aspects of the neural circuitry that underlies maternal behavior. In addition variations in the timing and nature of stressful circumstances and fostering conditions during the immediate postpartum period have been shown to have dramatic effects on maternal behavior and stress responsivity and remarkably, some of these effects can be transmitted non-genomically to the next generation.
Conclusions: A detailed understanding of the interplay of genetic and environmental factors and the resulting neural circuits required for the expression of maternal behavior may be valuable in understanding some forms of developmental psychopathology and may guide the development of preventive interventions with high risk families.

(27) APPROACHES TO CARING FOR HIV/AIDS ORPHANED AND VULNERABLE CHILDREN: ESSENTIAL ELEMENTS FOR A QUALITY SERVICE.
T. Wilson
H. Loening-Voysey 

The growing numbers of orphaned and vulnerable children in South Africa represent a grave concern for education, health, and social development organizations. The HIV/AIDS epidemic is the primary contributing factor to these increasing numbers as South Africa experiences one of the worst HIV/AIDS epidemics in the world.
It is well documented that AIDS illnesses and deaths adversely affect households. Children are orphaned and the majority of them lose their right to a decent and humane existence. Traditional means of caring for children have had to adapt. However, it is clear that responses to the plight of these children are struggling to cope with the escalating HIV/AIDS epidemic.
The objective the of this study was to develop a framework for evaluating the quality of service and for assessing the feasibility of each approach to caring for orphaned and vulnerable children.
A reference group and extensive literature studies were used in compiling a set of indicators for quality care. Sites were then chosen and visited for a few days at a time. The indicators were used as a check list and information was collected from multiple sources in a variety of ways. Case studies were written on each site visited. Findings were checked with representatives from sites and the reference group was called again to refine the list of essential elements. The researchers went back to their findings and developed a matrix of responsibilities for different duty bearers - household, community, NGOs / CBOs and the state.
Our findings confirmed many other writings on the subject, but with South African evidence - that a multi layered and integrated response is essential, that communities need to be mobilized and supported in their efforts to take care of their children, that regulatory frameworks need to be adapted to acknowledge and support caregivers and that a comprehensive safety net needs to be established to protect the vulnerable children. 
The reference team at the start of the study identified poverty and political leadership as being the critical stumbling blocks to quality care for orphaned and vulnerable children. The clarion call of most of the respondents in this study was for the alleviation of hunger and the need for functioning state services - only then could they begin to talk about quality services.

(28) IN SEARCH OF LEGISLATION TO PROMOTE CHILD WELLBEING
J.M. Loffell
Johannesburg Child Welfare Society
PO Box 2539
2000 Johannesburg

For the past four years a multidisciplinary project committee of the SA Law Commission has been conducting a consultation and study process aimed at producing a draft Children's Code for South Africa. Such a Code would be a comprehensive statute designed to protect and promote the rights and interests of children in an holistic manner. This initiative arose from awareness on the part of national policy-makers that children's legislation as inherited from the pre-1994 dispensation is seriously inadequate and often counterproductive when it comes to meeting the needs of children in practice. In the first place it has taken its cue from western child protection models which assume that the basic survival and developmental needs of most children have been provided for, and that a range of protective mechanisms are in place and functioning adequately. The realities of life for the majority of South African children are not taken into account. Further, it is fragmented between a range of laws which focus on specific aspects of a child's life to the exclusion of others, and separates these aspects between different courts and administrative structures, often to the detriment of the children it is supposed to protect. Transformation of the legislation requires not only a rethinking of these approaches, but also attention to the various types of law which shape the lives of South African children, including those emanating from our diversity of cultural and religious traditions. The overriding question of what type of resourcing is and can be made available for the realisation of children's rights is a key question which has to be addressed at every turn. 
The author is a member of the SA Law Commission's Project Committee on the Review of the Child Care Act, but will be speaking in her personal capacity and from her perspective as a social worker.

(29) EXPLORING A DEVELOPMENTAL PROFILE OF HIV+ CHILDREN: A FOLLOW-UP STUDY USING THE REVISED EXTENDED GRIFFITHS SCALES OF MENTAL DEVELOPMENT
D.M. Luiz, A. Barnard, N. Kotras & H. Kotras
University of Port Elizabeth, 
Psychology Department, 
PO Box 1600, 
Port Elizabeth 6000, South Africa 

The study is aimed at exploring a developmental profile of HIV infected children (18 months to 8 years) in the Eastern Province of South Africa (SA), utilising the Revised Griffiths Scales of Mental Development (GSMD). The study can be described as capacity building in that it will involve professionals, para-professionals, as well as researchers from previously disadvantaged backgrounds. HIV infected children will be compared against a follow-up assessment 6 to 8 months later. A non-probability purposive and convenient sampling method will be applied. Despite SA being a country where a significant number of infants and children are infected with the AIDS virus, little developmental research is conducted in this country. To date no South African research has been conducted on HIV infected infants and children profiling their general development. And for this reason it is necessary to accumulate knowledge about their cognitive, psychological and personal-social growth so as to assist them as they are surviving to a school-going age. The child who is perinatally infected by HIV suffers a variety of infections, and this in turn may manifest as a developmental delay. This study will contribute to HIV/AIDS research in SA, and more specifically it will contribute to the current state of child health in this country for numerous reasons. Furthermore, from the findings of the study assistance, which focuses on the children's areas of developmental weakness, will be made possible to them, as well as to other children infected with the virus. That is, therapeutic programmes will be developed so as to allow for appropriate stimulation in all areas of concern.

(30) CHILDHOOD SEXUAL ABUSE AMONG A SAMPLE OF FEMALE UNIVERSITY STUDENTS IN SOUTH AFRICA AND POSSIBLE MENTAL HEALTH IMPLICATIONS FOR VICTIMS
S.N. Madu
Department of Psychology, 
University of the North, 
Private Bag X1106, 
Sovenga 0727, 
Email: [email protected] 

Childhood sexual abuse can cause a lot of psychological and behavioural problems to the victim. Some of the possible problems, according to Finkelhor and Browne (1986), come as a result of traumatic sexualisation (e.g., aversion to sex or intimacy, compulsive sexual behaviours, and aggressive sexual behaviours), stigmatisation (e.g., isolation, drug or alcohol abuse, self-mutilation, and suicide), betrayal (e.g., depression, aggressive behaviour, and delinquency), and powerlessness (e.g., anxiety, fear, nightmares, phobias, somatic complaints, eating and sleeping disorders, and dissociation). Childhood sexual abuse and rape against females are some of the social problems that call for urgent attention in South Africa (Collings, 1992, 1993, 1995, 1997; Magwaza, 1994; Sonderling, 1993; Haffejee, 1991; Levett, 1989a, 1989b; Madu & Peltzer, 2000). Thus, the author decided to make an investigation into childhood sexual abuse among a sample of female university students in South Africa, and indicate some possible mental health implications for victims.
Four hundred and sixty five female undergraduate students attending psychology courses at the University of the North, South Africa (mean age = 23.8 years, SD = 5.28), filled in a retrospective self-rating questionnaire in a classroom setting. The questionnaire is an abbreviated and modified form of the Child Maltreatment Interview Schedule (Briere, 1993). It asked questions about childhood sexual forms of abuse experienced by the participants, victim-perpetrator relationships, whether participants perceive themselves as sexually abused during childhood, and their overall self-rating of childhood. 
Result shows a childhood sexual abuse prevalence rate 23.7%. 19.1% were kissed sexually, 14.1% were touched sexually, 9.5% were victims of oral/anal/vaginal intercourse. The prevalence for sexual kiss by force is 8.6%, for sexual touch by force is 6.1%, and for oral/anal/vaginal intercourse by force is 5.5%). The highest number of perpetrators is found either among family/extended family members of victims (sexual kiss: 40.9%, sexual touch: 27.2%, oral/anal/vaginal intercourse: 42.5%) or among people entrusted with care of the participant as a child (sexual kiss: 20.4%, sexual touch: 40.7%, oral/anal/vaginal intercourse: 45%). Most of the perpetrators are people known to the victims (sexual kiss: 73.4%, sexual touch: 61.1%, oral/anal/vaginal intercourse: 77.5%). Many victims (83% of the victims) perceived themselves (possibly in line with their societal or traditional perceptions and attitudes towards child abuse) as not sexually abused during childhood; and most rated their childhood as either as "average" (41.3% of the victims) or as "very happy" (41.3% of the victims).
The author calls attention to the possible adverse psychological and behavioural (health) implications of childhood sexual abuse for the victims (as indicated above) and calls for more research, publicity, and campaigns against childhood sexual abuse of females in the Northern Province of South Africa.

(31) "THIS IS IT": HOW YOUNG VIEWERS READ YIZOYIZO
S. Maslamoney (SABC Education), 
J. Gultig (SAIDE) and 
S. Marshall (CASE)*

YizoYizo is a thirteen-part television series commissioned by SABC Education Television in support of the Department of Education's Tirisano (Let's Work Together) campaign. The second series, broadcast in the first half of 2001, was immensely popular, breaking viewership records across the country. This paper is based on an evaluation of the second series and suggests that young people are more sophisticated and discerning in their reading of television than many adults give them credit for.

(32) THE USE OF THE DBD RATING SCALE IN SOUTH AFRICAN PRIMARY SCHOOLS
A. Meyer
Department of Psychology
University of the North
Private Bag X1106
Sovenga, 0727

The cultural appropriateness of the DBD rating scale comprising 42 DSM-IV symptoms of Disruptive Behaviour Disorders (ADHD, ODD and CD) will be discussed. The aims of the study were twofold: to investigate whether the DBD measures the same constructs in South Africa as in Western cultures across samples of children from six language groups, and to explore the differences in scale sores and prevalences between subgroups as a function of language, gender and age. For all language groups, the results were consistent with a four-factor model of Disruptive Behaviours (ADHD-H/I, ADHD-I, ODD and CD) with correlated factors. There were gender and age effects on all scales. The prevalence rates were similar to Western ones in all language groups. The translations of the DBD rating scale can be used as a screening instrument for Disruptive Behaviours in South Africa. Separate norms for different language groups are not indicated.

(33) ACTIVE LEARNING TOY LIBRARIES: AN AFRICAN RESOURCE FOR EARLY CHILDHOOD DEVELOPMENT 
C. Morrison, National Chairperson, 
South African Toy and Leisure Libraries Association
PO Box 22450, Helderkruin, 1733

An active learning toy library is a service that lends toys, games, puzzles and educational aids to individual families and, in disadvantaged areas, to groups such as home-based day care centres, nursery schools and primary schools.
Play helps children to develop mentally, physically, socially and emotionally. In Africa, where many families live in poverty, buying toys to stimulate children is not a possibility. Furthermore parents from disadvantaged backgrounds do not know how to play with the commercial toys that stimulate cognitive and technological skills.
Active learning toy libraries create an opportunity for children to learn through imitating, exploring, inventing, creating, co-operating, negotiating and solving problems. Educators, including parents, learn how to use the toys effectively.
Toy libraries are a valuable resource for young children who are "at risk". Early intervention in the form of outcomes-based stimulation can minimise later problems. These libraries can also cater for different types of special needs e.g. mental or physical disability, slow developers, children with a visual impairment and children with reading difficulties. There is no doubt that, after consultations with professionals in the field, the toy library service can be extended to children with other types of special needs e.g. children with emotional problems, abused children, street children and children with HIV-Aids.
There are toy libraries in 42 countries worldwide. South Africa has over 80 toy libraries. The majority of these cater for ECD centres / schools and exclude the general community / families. The rest of Africa has none that we are aware of. England, a country the size of Gauteng, has over 1000 toy libraries that provide quality stimulation in the formative years to the children of deprived families and to children with disabilities. 
It is important for medical / health professionals and the national and regional departments of social development and health to be aware of the valuable role that toy libraries can play. According to our statistics, only four hospitals in South Africa offer a toy library service. No primary health care clinics have a reference toy library where children waiting for services can play and learn while they wait and parents can be taught how to stimulate their children at home using toys made from waste material. Partnerships between government, funders, NGO's and volunteers in establishing toy libraries in all our communities can help to create an environment of equal opportunity for all children to develop to their potential.

(34) PSYCHOLOGICAL INTERVENTION FOLLOWING A NIGHTCLUB DISASTER
P. Naidoo
Community Psychiatric Services
P O Box 56977
Chatsworth, 4030

During March 2000, approximately 800 children aged 11-17 years attended an end of term disco at a nightclub. A teargas canister was detonated resulting in children stampeding towards the exits and a wall collapsing on some of them. Thirteen children were killed and an unknown number injured. 
This paper reviews the psychological services that were provided to about 450 children. The chief intervention strategy appears to have been a single debriefing session for the majority of the children. Fifty five were identified as requiring further intervention and were referred to Psychologists for individual assessment and therapy. 
The questionable efficacy of psychological debriefing in preventing PTSD; the absence of adequate follow-up services, and the need for a well trained and ready mental health intervention team in the event of disasters, is discussed. 

(35) GROUP THERAPY AS A THERAPEUTIC INTERVENTION FOR PREADOLESCENTS
B.M. O'Farrell 
Private practitioner
Tamboerskloof, 
Cape Town, South Africa

P. Olckers 
Child and Family Unit
Red Cross Children's Hospital
Cape Town, South Africa

J. Snyman
Child and Family Unit
Red Cross Children's Hospital
Cape Town, South Africa 

The authors will discuss the treatment of preadolescents struggling with emotional and behavioural difficulties by looking at an alternative intervention to individual treatment namely, group therapy. Having reviewed this developmental stage as described by Erikson and Piaget, the relevance and therapeutic value of group therapy as an appropriate intervention will be evaluated. The groups which have been run over the past five years are implemented with the rational that the development and adaption of children of this age can be influenced by direct participation, observation, listening and identification with peers in a group setting. This is an activity based group in which the therapists use cognitive behaviour therapy techniques, and also provide an opportunity for reflection and discussion with peers, allowing the therapists to maintain a psycho-dynamic understanding of the process.
The issues around maximising therapeutic value in terms of length of treatment, group content and process will be explored based on Yalom's theoretical perspective on group work. The effectiveness of a parent support group running parallel to the aforementioned treatment will be discussed
The significance of resolving conflicts at this developmental stage will be highlighted in an attempt to change attitudes and behaviours which otherwise may tend to persist into adult life.

(36) SUPPORT PROGRAMME FOR ABUSE REACTIVE CHILDREN (CHILDREN WHO MOLEST CHILDREN)
S.B. Omar & B. Mrwetyana
The Teddy Bear Clinic for Abused Children
Department of Paediatrics (WITS)

This study is about sexual offenders, No, not the ones who sniff glue or who hang out on street corners. This study is about the young ones, the non-yet-adolescents, and the kids to whom none of us want to see labeled in the pejorative terms like "offender or perpetrator." However, these children's behaviour can only be defined by these terms.
The fact is that we don't yet know what to call them, or what to do with them. Most of them are too young for criminal justice solutions, too high risk for foster homes with other children and too unsettling to ignore. They make all of us uncomfortable we've had to deny their existence and or minimise their behaviour until now. We've called their behaviour "exploration" and "curiosity" until they are old enough for us to comfortably call it what it is; sexual abuse of other children. The children are not out to explore the wonders of the human anatomy. They aren't even old enough to engage in legally consensual sexual relations, yet their sexual behaviour can involve force, coercion, intimidation and secrecy. Their victims, whose participation is usually obtained through threats or trickery, are younger, smaller and weaker or in some way disadvantaged in relation to themselves. Their behaviours include acts of violence, rage, sexual gratification and the abuse pf power. Who are the children and why do they do the things they do.
Objectives: This is an investigation about these children who molest children and what makes them do the things they do. Data comes from group work experiences with these youth in a group (SPARK) run at the Protea Court in Soweto.

(37) TOWARDS YOUTH RISK REDUCTION IN SOUTH AFRICAN RURAL SCHOOLS
Onya, HE1; Kekana, MR1; Kekana, ATK1; Masipa P2; Maluleke n. D3.
1 University of the North
2 Dept. of Health & Welfare
3 Shihlobyeni Primary School

This presentation discusses lesson learnt in reducing risk behaviour among children attending Shihlobyeni primary school, (a rural school adopted by the University of the North as a health promoting school in the Northern Province, South Africa). Methodology used, strategies adopted and problems encountered and how they were resolved will be highlighted. Risk behaviours such as inappropriate water use and hygiene practices unprotected sexual relations, traditional alcoholic beverage use and bullying were included. The role of the school governing body (SGB), parents, teachers, learners, transitional council, tribal authority as well as inter-sectoral committee including non - governmental organisations (NG0s) will be discussed. This experience is intended to assist policy makers in transforming other schools in South Africa into "health promoting school".

(38) BETWEEN WORDS AND MUSIC: CO-CREATIVITY IN GROUP MUSIC THERAPY WITH HIV/AIDS ORPHANS. 
M. Pavlicevic, 
Music therapy Programme, 
Department of Music, 
University of Pretoria.
Pretoria, South Africa

Children with HIV/AIDS who live in residential care centres carry additional social, psychological, emotional and physical burdens from having been abandoned or orphaned, often as a result of their HIV status (or that of their mother's). As well as having to manage with their physical illness, the residential care places its own demands: children need to manage multiple relationships that are not always predictable, consistent, or nurturing - with care staff themselves often over-stretched and having to deal with their own exhaustion and burnout. Added stresses come from the complex residential dynamics - and uncertainties - of possible fostering and / or adoption, which impact on staff as well as children.
Weekly group music therapy sessions offer a 'playful' environment through spontaneous musical activities, within which the music therapist and children co-create emotional - musical relationships. All group members experience the complex and subtle nature of social roles and relating, and experience individual and group agency, even where there is no common verbal language between children and therapist. 
This presentation uses a psychodynamic framework to 'make sense of the sessions, to explore the dynamics of health and illness, and of group chaos and creativity. Group music therapy is presented as a powerful tool for enhancing children's experience of mental, social and emotional 'health' and 'agency'.

(39) SOCIAL MATURITY IN RURAL AND URBAN CHILDREN WITH MENTAL RETARDATION
A.L. Pillay
University of Natal & Midlands Hospital, 
P O Box 370, 
Pietermaritzburg 3200

The investigation sought to compare social maturity levels in rural and urban children with mental retardation. Specifically the magnitude of discrepancy between the children's IQ's and their Social Quotient's (SQ's) were examined by way of an SQ:IQ ratio. Samples of rural (n=25) and urban (n=25) mentally retarded children between the ages of 8 and 12 years, having IQ's between 40 and 70 points were drawn. The Raven's Coloured Progressive Matrices (CPM) and the Vineland Social Maturity Scale (VSMS) were used to measure IQ and SQ respectively. Neither instrument is dependent on the subject's English language proficiency. As expected, IQ was positively correlated with SQ (r= 0.66, p< 0.01). Although the IQ scores of the rural (mean=49.8) and urban (mean=51.6) groups did not differ significantly (z= 0.98, n.s.) the SQ scores of the rural subjects (mean=56.6) were significantly higher than those of the urban subjects (mean=52.9) (z=1.98, p<0.05). The rural sample had a significantly higher SQ:IQ ratio than the urban one (F=15.70, p<0.0005). No significant gender difference was found. Age was positively correlated with the SQ:IQ ratios (r=0.28, p<0.05). The rural children's higher social maturity relative to their IQ's is likely a result of the hardships and challenges of rural life where they have increased social, community and household responsibilities from an early age, e.g. cooking, laundry, minding younger siblings and fetching water and firewood from distant areas. Also, the lack of special schooling in rural areas means intellectually disabled children are even more absorbed into the domestic routine. The findings lend support to the idea that, despite cognitive deficits, children with mental retardation have the capacity to enhance their social maturity beyond that ordinarily expected in more protective environments. Of course, it would be preferable if such gains could be made without the hardships that characterise rural life. 

(40) MANAGEMENT OF HYPERACTIVITY IN CHILDREN
S.T. Rataemane
Department of Psychiatry, 
University of the Free State,
Bloemfontein

Hyperactivity in children can be one of the many symptoms of various syndromes that are found in childhood. In most cases, children are often exposed to medication that is targeted for the treatment of Attention Deficit Hyperactivity Disorder (ADHD). This may lead to worsening of symptoms in some cases and lack of response in others. The syndrome of ADHD needs careful diagnosis so as to avoid mismanagement. In doing so, various presentations of the disorder have to be understood so as to plan appropriate interventions. Guidelines for assessment of hyperactivity in children will be discussed followed by general guidelines of management of ADHD specifically. 

(41) THE UNMET MENTAL HEALTH NEEDS OF JUVENILE PERPETRATORS OF SERIOUS VIOLENT CRIME
B. Robertson, C. Zissis, C. Ward, W. Mukoma, H. Sauls, U. Meys
Dept Psychiatry & Mental Health, 
University of Cape Town
Cape Town, South Africa

Organised mental health services for juvenile perpetrators of serious violent crime have traditionally not been provided by mental health professionals in the state health sector. The authors decided to investigate their unmet mental health needs by doing a literature survey, by conducting a local study in a Place of Safety and the Youth section of a prison, and by drawing on the findings of their recent situational analysis of violence-related services in the Western Cape.
The literature survey highlighted the major economic costs of serious juvenile crime, partly due to congestion in the criminal justice system leading to an increasing number of incarcerated juveniles in South Africa (approx. 2500 under 18s awaiting trial in 1998). Although genetic and neurological factors are considered to contribute in a proportion of cases, most studies point to psychosocial factors as the main causative agents.
Our own study of 14-18 year old perpetrators of serious violent crime revealed a very high rate of psychiatric disorders and substance abuse, cognitive impairment, school-related problems, family dysfunction and exposure to gangs.
The situation analysis found that many NGOs provide preventive or rehabilitative services to urban juvenile perpetrators and their families, but the services often focus on building skills in a relatively small number of individuals, and are not co-ordinated with each other. In Places of Safety and Prisons mental health services are minimal, and rehabilitative programmes limited.
Conclusions: Juvenile perpetrators of serious violent crime have major unmet mental health needs which should claim appropriate input from state mental health professionals. Availability of mental health professionals for consultation and training to Places of Safety and prisons is essential. School-based interventions for high-risk youth should be devised and evaluated. 

(42) A RELENTLESS JOURNEY: TRAUMATISED REFUGEE CHILDREN IN SOUTH AFRICA
M. Robertson & H. Hajiyiannis, 
Trauma Clinic, 
Centre for the Study of Violence and Reconciliation

Since the political transition in 1994, there has been an influx of refugees in South Africa. The refugee experience in South Africa is different to that of other developed countries. In South Africa, there is limited assistance provided to newly arrived refugees, most of whom are compelled to live in urban areas, without a programme of social and financial support. They live in a constant state of uncertainty regarding their refugee status, and many are legally constrained from seeking formal employment. Their ability to integrate into South African society is further complicated by high levels of crime especially incidents of xenophobia. Within this context of continuous trauma, most refugees are preoccupied with survival. Consequently, the mental health needs of refugee children are often neglected. 
This study presents findings of a psychological needs assessment of a sample of 20 children and youth, between the ages of 6 and 17 years of age, who live in a refugee shelter in Johannesburg. This study integrates information gathered through a process of conducting clinical interviews, psychometric testing, and in some instances, therapy case notes. 
Preliminary findings suggest that a large number of these children have serious emotional needs and difficulties as a result of their experience of cumulative trauma and continuous stressors. Without appropriate mental health interventions, these children are at risk for developing long term psychological difficulties which are likely to impact on their personal development. 
These findings are compared to similar studies conducted with refugee children in other countries. This study provides information that can be used in the formulation of recommendations regarding the development of appropriate mental health interventions, which address the psychological needs of refugee children, in South Africa

(43) NEW ANTI-EPILEPTIC DRUGS IN CHILDHOOD EPILEPTIC SYNDROMES. 
J.L. Rodda 
Division of Paediatric Neurology 
Department of Paediatrics 
Chris Hani Baragwanath Hospital, 
University of the Witwatersrand

The childhood epileptic syndromes consist of a wide variety of clinical seizures requiring, in most instances, specific anti-convulsant therapy. Anti-convulsant medication has remained relatively static for some time but over the past ten years there has been the emergence of newer anti-epileptic drugs. These drugs have improved therapy in that they are more target specific with less toxicity, drug interactions and side effects and have better pharmacokinetics compared to the more established forms of drug therapy. Between 1990 and 1994 there has been an explosion of new drugs on the market, including drugs like lamotrigine, topiramate, vigabatrin, oxcarbazepine, gabapentin and felbamate. Most of their modes of action have been well defined, allowing the choice of drug to match the specific epileptic syndrome more exactly. An important improvement has been in the treatment of the group of intractable epilepsies, avoiding the use of poly-pharmacy in many instances. The majority of the seizures affecting children will be well controlled on the older, more established drugs, however, some of these drugs have become important adjuncts to the paediatricians, armamentarium. A major disadvantage is the cost of these newer drugs putting them out of the reach of a large proportion of this country's population. 

(44) SAFETY AND TOLERABILITY OF CITALOPRAM IN CHILDREN AND ADOLESCENTS
D. Rodseth & J. Jayrajh

Despite a dearth of evidence to support the use of selective serotonin reuptake inhibitors (SSRI's) in children and adolescents, SSRIs are currently amongst the most commonly prescribed psychotropic medications in childhood and have become the first line treatment for a number of psychiatric conditions in this age group. In this observational study a group of South African child psychiatrists was requested to submit data on children whom they were treating with citalopram. We collected data on 76 children and adolescents (29 under 12 years of age and 37 between 13 and 18 years) who had been treated with citalopram, at doses ranging between 5 and 30 mg for a wide range of conditions. In the majority of patients citalopram was well tolerated and no adverse events were reported. Citalopram was discontinued in three patients (3.9%) and the dose was reduced in two (2.6%) because of adverse events. In the case of the other children who experienced adverse events, the severity was considered insufficient to warrant action. There were no subjects in whom the psychiatrists considered it necessary to do haematological investigations or ECGs. 

(45) THE MISSED POTENTIAL OF A CHILD LABELED HIV POSITIVE
G. Shead 
Cotlands Baby Sanctuary, 
Johannesburg, South Africa

For 65 years Cotlands Sanctuary has offered help to babies and children in need, giving them a chance for a better future. Because of the HIV/Aids pandemic, the past years has seen a rapid increase in the admission of these children. Some 6 years ago Cotlands foresaw this need and established a hospice facility. Cotlands has a Sanctuary for well children, a hospice facility catering for the terminally ill baby and child and a community pre-school. They also involved in early childhood development and community outreach.
The Sanctuary section accommodates the well HIV positive child, accounting for 35%-40% of the children. They are as involved and integrated as all the other children, attend the Cotlands pre-school, go on outings, parties and holidays. Many children have a volunteer, a person showing a special interest in the child, as placing an HIV label child into foster care is difficult. Cotlands has had to make an adjustment to accommodate the older HIV child who is of school going age. They have also grown in the experiences of coping with the death of the older long term resident. Cotlands is proud of the fact that they follow the lead of the children, they are guided by the child's emotional and medical needs. Their attitude is that all children - no matter their label - are given an opportunity to be involved, to experience and to enjoy their life however short it may be. It is the quality of their life that is of concern to Cotlands. Cotlands believes that palliative care for the terminally ill is the best management. But there are other children who are "slow progressors" and denied surgery or corrective procedures because of their HIV status. They die of an unrelated, untreated medical condition before they die of HIV. It would be of great benefit to be able to identify, from an early age, those children will mostly likely be the "slow progressors" and give them more appropriate care to enable them to reach their potential. 
Experience has shown Cotlands that they must give babies, who are initially test HIV positive, the benefit of the doubt. In 2000 many babies admitted to hospice are malnourished, dehydrated, have chest infections, thrush, gastroenteritis, skin conditions typical of a typical HIV infected baby. As these babies are given nourishment, stimulation, medial attention and love, they put on weight, their infections improve, their development blossoms and on re-testing between 8-12 months, some 10% had seroconverted. Were these babies neglected or abandoned because of their initial HIV label? What if that sick, neglected, labeled child lives for another 10 years? Cotlands wants to be able to say that they have given each child the best possible chance to reach their potential and not surrender to their HIV label. 

(46) PREDICTOR VARIABLES OF ADOLESCENT RISK TAKING BEHAVIOUR
P. Shiel, J.B. Schoeman, M. Marchetti-Mercer
University of Pretoria

The research was aimed at identifying a number of psychological variables that would enhance the understanding of involvement in risk behaviours by South African adolescents. The study focused on personality characteristics, adolescent egocentrism, and sensation seeking. The sample consisted of 508 learners from a co-educational English language school in the greater Johannesburg metropolitan region. The subjects ranged in age from 11 years to 18 years of age, with 208 male subjects and 298 female subjects. The measures used were the High School Personality Questionnaire; The Risk Involvement and Perception Scale; The New Imaginary Audience Scale; The New Personal Fable Scale; and the Sensation Seeking Scale VI. The statistical procedures performed were a factor analysis; analysis of variance (ANOVA); factor analysis of variance; and a Least Squares Means analysis. Three groups were formed: a high-risk group, a medium risk group, and a low risk group. These were then compared on the basis of significant risk group main effects and their interactions with selected classification variables. The high-risk group was found to be more outgoing, dominant, heedless, and sensitive and tender-minded, whilst scoring lowest on super-ego strength. The high-risk group also displayed a greater sense of omnipotence, invulnerability. They were also found to be significantly higher in the need for sensation. Some significant gender differences were also found. Using Jessor & Jessor's Problem Behaviour Theory as well as Blos' concept of the second individuation process, it is suggested that current intervention strategies will not be successful as they often do not take into account gender differences, personality variables, as well as an understanding of adolescence as a developmental stage. For example of the findings include that male subjects were more at risk for engaging in behaviour that would put them at risk for physical injury, whereas female subjects were more prone to engaging in social types pf risk taking behaviour. This suggests that any strategy to reduce involvement in risk behaviour will have to take variable such as these into account. 

(47) IATROGENIA IN PSYCHOTHERAPY : THE IMPORTANCE OF BEING WRONG
C. Smith
Child & Family Unit, 
T.M.I., Department of Psychiatry, 
University of the Witwatersrand, 
Johannesburg., South Africa

This paper attempts to address the issue of iatrogenia in Play Therapy and Individual Psychotherapy. The questions raised attempt to discern whether when psychotherapy is not beneficial it is merely ineffective or whether it may do harm. A brief review of the literature dealing with iatrogenic psychotherapeutic techniques and attempts to detect these is undertaken. Case material illustrating dysfunctional therapeutic styles and the clinical value of recognising errors in technique will be presented. Therapeutic difficulties that arise from rigid adherence to theory will also be addressed. Finally, suggestions will be made with regard to detection of iatrogenic practices and ways of minimising and managing their impact.

(48) TREATMENT RESISTANT PSYCHOSIS IN A 12 YEAR OLD CHILD
U. Subramaney, 
TARA, the H Moross Centre
Johannesburg

Treatment resistance psychosis is often encountered in the adult population (up to 30% of schizophrenics will be resistant to neuroleptic treatment). Whilst childhood onset schizophenia and mania does occur, all children presenting with psychosis need to be carefully examined to exclude organic factors for their presentation.
We present the case of a 12 year old Mocambican girl who was transferred from the adolescent unit at Tara Hospital to ward 7 for containment. She initially presented to Chris Hani Baragwanath hospital with a maniform psychosis. She stayed in the unit for almost a year, most of the time completely psychotic and uncontainable. 
Pertinent issues raised are he extremely poor social circumstances and complete lack of emotional support; child abuse and prostitution; and the unfortunate dreaded illness of HIV, of which she was a victim. It is likely that her HIV status contributed to her treatment resistance, and in fact was the cause of her psychosis. Her rapidly deteriorating course, culminating in a severe infection is described.
Points of discussion are the management of HIV/AIDS related psychosis in children, and placement issues.

(49) COMPLEX PARTIAL SEIZURES IN AN ADOLESCENT PSYCHIATRIC INPATIENT SETTING
C.P. Szabo1 & C. Magnus 

1 Adolescent and Eating Disorders unit, Tara, The H. Moross Centre & Department of Psychiatry, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
Complex partial seizures (CPS) represent a form of epilepsy which may manifest with a wide range of associated psychiatric presentations. The initial, clinically apparent, psychiatric presentation may obscure an underlying seizure disorder. A clinical review was undertaken so as to provide relevant data in an adolescent population.
Patients/Materials and Methods
A review of all admissions (n=360) to the adolescent unit at Tara (1990-1995) was undertaken. All patients with a definite diagnosis of CPS (according to EEG) as well as those with abnormal EEG's were reviewed in terms of associated clinical features, comparing the frequency of specific clinical parameters between the two groups. In addition, an attempt to establish features influencing the diagnosis of CPS was made. A case illustration is presented.
Results
It was found that 4% (n=16) of all admissions (1990-1995) had been diagnosed with CPS.
During the same period 36 patients had undergone an electroencephalogram (EEG), of whom 16 had definite EEG features of CPS, 12 had nonspecific abnormal EEG tracings and 8 were normal. These patients presented with a spectrum of associated clinical features in addition to those typically associated with CPS. A comparison of the frequency of these features between these groups revealed differences. In addition, a number of specific clinical features influencing diagnosis of CPS were established.
Conclusions
The diagnosis of CPS may easily be overlooked on the basis of the initial presentation which may not suggest the presence of a seizure disorder. The study provides a clinical perspective of the nature of CPS presentations in an adolescent inpatient psychiatric population with the intention of facilitating appropriate diagnosis and management of such cases. 

(50) YOUTH AT RISK: EATING DISORDERS. A REVIEW AND A SOUTH AFRICAN PERSPECTIVE
C.P. Szabo
Department of Psychiatry
Faculty of Health Sciences
University of the Witwatersrand

Eating disorders are amongst the most prevalent and deadly of all psychiatric conditions. Contemporary society has witnessed an increasing prevalence of both anorexia nervosa and bulimia nervosa. South Africa is no exception. Local data on the prevalence of either conditions is lacking. However, studies examining eating attitudes and behaviours associated with eating disorders suggest that significant numbers of adolescent and young adult females are at risk.

(51) INTERNALIZING DISORDERS IN CHILDREN WITH AUTISM AND ASPERGER SYNDROME
P. Szatmari 

Although much has been written about anxiety and mood problems among children with Autism Spectrum Disorders, there are few data on the prevalence, pattern of expression, and risk factors associated with these comorbid problems. This study attempts to follow an inception cohort of children with high functioning autism and Asperger Syndrome. In adolescence, semi-structured psychiatric interviews were carried out along with a battery of tests designed to identify possible risk factors and correlates. The adolescents were between 15-17 years at this assessment and all had nonverbal IQ's greater than 70. The results indicate that comorbid psychiatric disorders are ubiquitous in this population, poorly recognized by clinical services, and often inappropriately treated. Anxiety disorders were more common than mood disorders and had a significant impact on overall adaptive behaviour and functioning. No specific risk factors could be identified from the assessment battery. Anxiety problems thus appear to be an important aspect of the outcome of adolescents with high functioning autism spectrum disorder but current treatment methods are not able to adequately deal with these problems.

(52) DEVELOPMENTAL NEUROPSYCHIATRY; CURRENT STATUS AND FUTURE DIRECTIONS
P. Szatmari

Developmental Neuropsychiatry is the study of brain behaviour relationships with a specific focus on the psychopathology of childhood. This field has made dramatic strides from its beginnings in "minimal brain damage" and now encompasses a significant portion of child psychiatry. There are however two forces that will dramatically change the prospects for developmental neuropsychiatry in the next decades; the completion of the Human Genome Project and the implementation of population health approaches to children's mental health. This presentation will argue that the promise of developmental neuropsychiatry will be fulfilled when it disappears and is replaced by a much clearer understanding of genotype-phentoype relationships in childhood psychopathology and the influences that operate at a population level to affect children's mental health. 

(53) PEER ABUSE: A REVIEW OF RECENT RESEARCH ON THE PHENOMENON OF BULLYING
E. Thayser
P O Box 72307, 
Parkview 2122. 
Email: [email protected].  

A review of the literature will be presented, showing the current status of international research on bullying in terms of prevalence, characteristics of victims and of bullies, gender differences in expressions of bullying behaviour, family background, the bystander effect, long term consequences, and interventions. This review draws upon a variety of research sources. 
The effects of bullying on victims will be covered in discussing Hawker and Boulton's (2000) meta-analytic review of 20 years' of cross-sectional studies on the link between peer victimization and psychosocial maladjustment. These authors conclude that peer abuse has been strongly associated with depression, loneliness, anxiety, and low self-worth. Victimisation is most strongly related to depression, and least strongly associated with anxiety. They consider the most cogent implication of their conclusions to be that further cross-sectional studies of peer victimisation and psychosocial maladjustment are not needed: the distress of victims has been clearly established. It is time, they say, for research to move on and to address (inter alia) questions of risk, causation, and interventions. 
The review will show that one of the problems of the existing research is that bullying behaviour in general is seen as located within the individual or by extension in his or her family. Research typically focuses on the characteristics of victims and bullies and, to a lesser extent, on parental background and behaviour. The prevailing view is that victims elicit and reinforce their own victimisation, while bullies are aggressive, tend to manifest conduct disorder, and have dysfunctional family backgrounds. Parenting and family dynamics thus come under scrutiny, but the research tends to obscure the socio-cultural context. Two further studies are therefore relevant to a discussion on peer abuse because they emphasise the importance of peer relationships and the socio-cultural context. In particular, these studies challenge the generally accepted view of the primacy of parental influence on the personality and mental health of the child. Harris's (1995) group socialisation theory of development (for which she won an American Psychological Association award) holds, unequivocally if controversially, that children's psychological characteristics are influenced by their peers and not by their parents. She further considers that permanent marks are left on children's personalities by the environment they share with their peers, not their families. Ambert's (1994) findings in her study on the relative salience of peers and parents as key sources of happiness or unhappiness in young adults' earlier lives will be presented. She concludes that peer abuse has serious, lasting consequences on personality development, whereas such consequences are generally only attributed to parental causality in the literature. 

(54) MENTAL HEALTH NEEDS ASSESSMENT OF FREE STATE CHILDREN AND ADOLESCENTS
C.L. Thomas.
Free State Health Department

Objectives: To describe services provided for young people in relation to burden of morbidity and potential effectiveness of interventions. To identify priorities for service development. To consult stakeholders from relevant government and non governmental organisations (NGO) sectors. 
Methods: The study design was a situational analysis and needs assessment. Published literature on effectiveness of interventions, and needs assessments and policies from elsewhere, was reviewed. Data on service utilisation were obtained from provincial Social Welfare, Education and Health Departments, hospitals and clinics. Data on domestic violence were obtained from the Attorney General's office. Key informants from Free State services, including the Bloemfontein Child Psychiatry Clinic, District Psychiatry Services, the University Paediatrics Department, Departments of Social Welfare, Education, Justice and Correctional Services, the Youth Commission, and several NGO's were interviewed. Interviewees described their services and identified perceived priorities for service development and opportunities for intersectoral integration. 
Results: There are 1.3 million young people aged up to 18 years living in the Free State; epidemiological studies suggest that 10% suffer a psychiatric disorder with potential for long term sequelae- approximately 13 000. Of 700 000 learners, an estimated 70 000 with learning and behavioural problems would benefit from specialist input including educational, psychological and/or psychiatric care. 1000 women reported domestic violence to the Bloemfontein Victim Support Centre between January and March 2001, many of whom had children requiring investigation. Social Welfare reports about 2000 child protection cases annually, which informants assume to be a small proportion of actual cases of abuse. HIV/AIDS is increasing causing fatal illness in, and orphaning of, children, with attendant psychological effects. State child psychiatry services assess about 400 new cases annually, in central Bloemfontein with no outreach to other areas. Adult psychiatry services regularly visit primary care level clinics outside Bloemfontein. There are no protocols for the assessment and treatment of children and adolescents by psychiatric nurses in these clinics. Recent changes in roles of psychiatrically trained nurses at primary care level have reportedly had an adverse impact. Five child guidance clinics see 5000 learners per year. In relation to prevention and health promotion The Social Welfare and Education Departments have introduced life skills programmes to schools and creches and provide training to NGOs. 
Conclusions
Most children and adolescents with mental health problems who would benefit from services do not receive any. Most services are provided outside the health sector. Development of services at primary care level, with training of primary health care nurses in child and adolescent mental health care, is seen as a priority. Promotion of good parenting through the Integrated Management of Childhood Illness programme is a feasible preventive mechanism. Screening for distress among HIV/AIDS affected children, and provision for their mental health needs, requires development. Intersectoral planning and coordination would improve service effectiveness.

(55) POLICY GUIDELINES: CHILD AND ADOLESCENT MENTAL HEALTH (DRAFT 4)
Z. Tshotsho; B. Robertson and A. Flisher
Department of Health
Directorate: Mental Health and Substance Abuse
Sub-Directorate: Child, Youth, Women and Family Mental Health 

The presentation will cover the following areas:
1. OVERALL GOAL OF THE POLICY GUIDELINES
The overall goal is the optimal development of children and adolescents in South Africa with special focus on their mental well being. 
2. OBJECTIVES:
The objectives are as follows:
· To serve as a framework for establishing integrated, accessible and affordable mental health services for children and adolescents at all levels of health care within the Primary Health Care system.
· To protect and uphold the rights of children and promote their optimal development 
3. CONTENT OF THE POLICY GUIDELINES
A holistic approach, with special focus on optimal development of children, has been adopted for addressing the various risk and protective factors that determine the mental health status of children and adolescents. General intervention strategies for the protective and risk factors are addressed together with the levels of health care at which the strategies can be implemented. The level of personnel to render the services is also highlighted. The general intervention strategies are implemented in settings or societal institutions which are involved in the optimal development of the children and adolescents. The priority areas which constitute the common problems in children and adolescents are addressed, e.g. alcohol and substance abuse, intellectual disability as well as child abuse and neglect.

(56) THE SPEECH-LANGUAGE PROFILE OF CHILDREN WITH ATTENTION DEFICIT HYPERACTIVITY DISORDER
M. Mapaseka Tshule; 
Medunsa University 

Attention Deficit Hyperactivity Disorder (ADHD) involves, according to theory, an underlying impairment of executive function, the cognitively based control system that regulates behaviour. It is possible that this executive dysfunction would interfere with performance on certain tasks used to identify language impairment. ADHD frequently co-occurs with language impairment. This co-occurrence may range from 8% to 90% (Cohen, 1996;Tannock and Schachar, 1996) with most studies suggesting an overlap in the range of 20% to 60%. The high prevalence of ADHD in the school-aged population and the substantial overlap between ADHD and language impairment make it likely that children with ADHD will be found on Speech Language Therapists case load. 
Speech-Language Therapists therefore have an important role to play in the multidisciplinary team assessing and treating these children. This paper discusses the Speech-Language Therapy profile for this disorder and the assessment and treatment implications.

(57) THE RIGHT TO CULTURALLY APPROPRIATE HEALING
T. Mpumi
Child Abuse Treatment & Training Services 
Johannesburg, South Africa 

INTRODUCTION
Article 30 of the United Nations Convention on the Rights of the child states that "A child belonging to a minority or who is indigenous shall not be denied the right, in community with other members of his/her group, to enjoy his or her own culture, to profess and practise his or her own religion or to use his or her own language.
Furthermore, article 39 from the same convention state that "states parties shall take all appropriate steps to promote physical and psychological recovery and social reintegration of a child victim of: any form of neglect, exploitation or abuse. Such recovery and reintegration shall take place in an environment which fosters the health, self-respect and dignity of the child".
This means that families and children have a right to choose means of support and treatment, which are culturally comfortable. Perhaps this is especially important when their child's rights have been violated by abuse.
The helping professionals, i.e. doctors, social workers, health workers involved in child protection work are often not encouraging when clients and families choose to consult traditional healers for treatment and support for their sexually abused children. The prejudice becomes very clear when the inyanga's and sangoma's are labelled by professionals as "witches" who perform "blackmagic".
However, traditional healers remain popular and trusted in black communities mainly because they are accessible and affordable. Furthermore, they are able to communicate effectively with their ancestors and those of the client, thus intregrating the spiritual, mental and physical wellbeing of the client.
It is for the reason that when we at CATTS (Child Abuse Treatment and Training Services) were excited when we were approached by the Izifozonke Traditional Healers Association from Soweto. They expressed their concern about the increasing problem of sexually abused children and wanted us to work together. Part of the problem was that they would refer sexually abused children to clinics, but the families often did not follow through.
This was the beginning of a partnership journey, which started off looking like social workers training sangomas, inyanga's and spiritual healers (traditional healers) and developed into a journey of mutual discovery of the many commonalties between the western and traditional ways of healing.
This paper aims to share our experience of this journey which still continues and allows children and families to make these Rights (article 30 and 39 of the UN Convention on the Right of the Child) a reality. 

(58) CHILDREN'S RIGHTS AND THE MEDIA
S. Usdin, 

The media has a vital role to play in the promotion and protection of children's rights. It can help raise awareness of children's rights and responsibilities and should hold government and society accountable to the commitments made and goals set to promote and protect children's rights. It needs to report on failures and neglect as well as highlighting successes. By providing children with opportunities to speak for themselves of the impact of adult behaviour and decisions on their lives, media professionals can improve the representation of children's issues. This paper examines the media's performance in this regard and, using both local and international guidelines, makes recommendations for improved coverage.

(59) PSYCHOPHARMACOTHERAPY IN AUTISM SPECTRUM DISORDERS: A RATIONAL APPROACH BASED ON CURRENT KNOWLEDGE OF THE UNDERLYING ETIOLOGICAL PROCESSES
R.J. Van der Gaag
Veldwijk Research Institute Meerkanten GGZ
PO 1000
NL 3850 BA Ermelo
The Netherlands& University Medical Centre Utrecht
e-mail [email protected] 

Autism spectrum disorders are pervasive developmental disorders. They are characterised by a heterogeneous clinical presentation and known to be caused by a spectrum of different organic causes with a very strong evidence for genetic components. Individuals with autism spectrum disorders present with a wide range of intellectual abilities varying from high functioning to profound learning disability. Yet all seem to have in common some information processing deficit that makes them blind or extremely short-sighted with regards to the understanding of the mind of the other. This primarily cognitive deficit affects the development of reciprocal social relations and hinders sound communication. Individuals with autism spectrum deficits engage in a variety of repetitive stereotype activities. Moreover they display a range of co-morbid conditions especially affective (anxiety and depression) and behaviourally (aggression and hyperactivity). Though it is well established that the core approach to autism should be educational and that there is to date no drug known to influence the underlying primary deficits in autism, pharmacotherapy based on the current knowledge of the neurochemistry in autism can prove to be very worthwhile in addition to the educational support. In this presentation the drugs treatments affecting serotonergic, noradrenergic and dopaminergic neurotransmission will be discussed. A rational algorithm to approach co-morbidity will be presented. Finally the usage of drugs affecting the peptidergic system and other less rational approaches will be critically reviewed.

(60) COGNITIVE BEHAVIOURAL THERAPY IN CHILD & ADOLESCENT PSYCHIATRY
R.J. Van der Gaag
Veldwijk Research Institute Meerkanten GGZ
PO 1000
NL 3850 BA Ermelo
The Netherlands& University Medical Centre Utrecht
e-mail [email protected] 

The core aim of a cognitive behavioural approach is to change behaviour and emotions by influencing the cognitive schemes that are linked to them. Cognitive behavioural therapy is a well established treatment method in adults especially in the field of depressive disorders. In children and adolescents cognitive approaches are being used in a variety of both externalising (ADHD, defiant and antisocial behaviour) and internalising (anxiety, depression) conditions. But also in pervasive developmental disorders. Herbert (1987) introduced the ABC (Antecedent-Behaviour-Consequences) scheme. In this presentation this technique will be presented. The possibilities and limitations in the diverse area's of developmental psychopathology will de discussed. 

(61) TRAUMATISED CHILDREN - SUPPORT FOR FAMILIES
L.M. van der Merwe
Senior Psychologist, 
Department of Psychiatry, 
University of the Free State, 
Bloemfontein, South Africa

Understanding something is the key to dealing with it. Unfortunately many of the things we think we know about sexual abuse are not true at all. This presentation is aimed at putting this right. We will look at the prevalence of abuse, form an impression about who the offenders are and what the possible effects of abuse may be. To be able to do so, we must form an opinion about normal childhood sexual behavior and how to distinguish it from unacceptable behavior. Reality also teaches us that it is difficult for children to disclose the fact that they have been abused. We learn why and how to respond positively to such a disclosure. Our view that responsibility for abuse rests squarely on the shoulders of the offender is expressed next. It is followed by the discussion of two worrisome but unfounded fears: The fear that abused children will eventually become abusers and the fear that they may become gay or lesbian. In conclusion, a few thoughts about life after abuse will be offered.

(62) CONSENT IN CHILDREN 
M. Vorster
Associate Professor
Community Psychiatric Services
Department of Psychiatry

Obtaining consent in children is not always a straight forward issue. There can be conflict between parents, there can be religious conflict and the child may also refuse consent.
The special considerations regarding obtaining consent in children will be addressed, using practical examples. In addition there will be a brief overview of the Child Care Act.

(63) RELIABILITY OF THE LEISURE BOREDOM SCALE FOR USE WITH HIGH SCHOOL STUDENTS IN CAPE TOWN
L. Wegner (University of the Western Cape), 
A.J. Flisher (University of Cape Town), 
M. Muller and C. Lombard (Medical Research Council)

Previous studies have shown that the Leisure Boredom Scale (LBS) is a reliable and valid method of determining subjective perceptions of leisure boredom. The reliability of the LBS amongst South African populations (including adolescents) has not been established. Two studies were undertaken to document the reliability of the LBS in grade 8 and grade 11 learners attending high schools in Cape Town. Study One had a random sample of learners attending four independent (private) high schools (N = 117). Study Two used a multistage cluster design to obtain a representative sample of learners (N = 621) from 39 government high schools. In Study One, the LBS was administered 10 to 14 days apart to determine test-retest reliability, using Cohen's Kappa and the observed agreement. Cohen's Kappa was in the moderate range for 9 items (41% - 60%) and in the fair range for 2 items (21% - 40%). The observed agreement was used for the remaining 5 items. It was in the moderate range for 4 items and in the substantial range (61% - 80%) for 1 item. In both studies the internal consistency was calculated using Cronbach's alpha. Cronbach's alpha coefficients for the total scale were .76 (Study One, administration one), .87 (Study One, administration two) and .76 (Study Two). We conclude that the LBS has satisfactory reliability when used to document perceptions of leisure boredom among high school students in Cape Town. 

(64) EMOTIONAL DISTRESS REFLECTED IN DRAWINGS OF CHILDREN FROM ALEXANDRA TOWNSHIP.
J.A. WILLIAMS
University of the Witwatersrand
Department of Psychology
PO Box 919
Florida, 1710

A review of the relevant assessment of exposure to violence literature indicated that there is a large amount o f research into the detection of sexual abuse by means of the Draw-A-Person drawings, however there is little research into the detection of the witnessing of violence by means of drawings. The present research study examined the levels of and types of distress found in the drawings of female latency aged children from Alexandra Township who were exposed to different forms of violence. The study quantitatively compared the Koppitz (1968) emotional indicator scoring system scores for the drawings of 24 girls who had been sexually abused, 28 drawings of children who witnessed violence, and 71 drawings of children forming a non-clinical population. Furthermore, the drawings of the help-seeking group (the clinical group) were compared as a whole to the non-clinical population. The different groups were compared in relation to the amount of distress depicted, the types of indicators that appeared in the drawings and the underlying feelings and behaviours that were apparent in the analysis of the Draw-A-Person drawings. 
Results of the research indicated that overall, there were high levels of distress evident in the drawings of all the groups, including the non-clinical group (m=2.6). The clinical group showed significantly higher levels of distress than the non-clinical group (f=4.7720;p<0.05). The clinical group depicted different types of emotional indicators more often than the non-clinical group. The clinical group drew short arms (p<0.05), no arms (p<0.05) and no necks (p<0.05), more often than the non-clinical group. The sexually abused children drew shorter arms (p<0.05) and no arms (p<0.05) more often than the witness to violence and non-clinical populations. The witness to violence group drew no necks (p<0.05) more often than the sexually abused and non-clinical groups. Furthermore, more than half the entire sample drew shaded bodies, and a third of the sample drew short arms and hands cut off in their drawings. These items depicted different types of distress in each group, and a high level of distress in the overall group. The findings suggest that the entire sample group showed distress in their drawings, due to the various types of violence they were exposed to. The findings in this research support the notion that children in township contexts are traumatised by direct, indirect and continuous exposure to violence (Smith, 1993; Friedland 1999; Rudenberg, 1995). This study expanded on knowledge relating to the assessment of the effects of exposure to violence in children. The drawings of children in Alexandra Township illustrate that these children are emotionally distressed, and their experiences are differently projected onto their drawings, given the different forms of violence to which they are exposed. There is a need for psychological intervention in the context of Alexandra Township, which addresses exposure to violence in all children, not only children who present at clinic settings.

(65) CHALLENGES IN CARING FOR CHILDREN WITH BEHAVIOUR AND EMOTIONAL PROBLEMS
N. Xintolo, B. Nombaca, 
Child and Family Unit, 
Rondebosch, 
Cape Town, South Africa

This paper describes the stumbling blocks and stepping stones experienced at the Therapeutic Learning Centre with the challenge of caring for and helping families to deal with emotional and behaviour problems in children.
As part of the comprehensive health care approach, the work at the Therapeutic Learning Centre which is a day and in-patient unit, based at the Red Cross Children's Hospital, is focused on a behaviour modification programme and functions within the educational parameters. The method of descriptive case study with examples will be used.
The paper explores the discharge programme, problems experienced with the welfare and justice system for continuity of comprehensive work desired by health needs of children, and the solutions thereof. 
Conclusions will be drawn by looking at recommendations to address the gaps that exist in the above mentioned systems, while securing the educational, and welfare placements as based on identified health care needs of children as developing human beings.

(66) IMPROVING ETHICAL STANDARDS IN PSYCHIATRIC RESEARCH
T. Zabow 
Department of Psychiatry and Mental Health 
University of Cape Town

Research ethics has achieved a high profile in international and national circles in recent years. The decisions by the Ministry of Health to establish a national Research Ethics Council, the MRC update guidelines for medical research and the examples of research fraud locally and elsewhere further illustrate the importance of research ethics in South Africa.
The Declaration of Helsinki in October 2000 re-established ethical principles for human research. Psychiatric patients and children are specifically addressed as well as research undertaken in developing countries.
Ethical dilemmas are multiple and need to be highlighted in relation to the use of placebos, controlled trials, health priorities, informed consent and standards of care.
There is a need to review policies and to provide education in relation to research committees and ethical requirements. A level of accountability must be attained within the public expectations of ongoing audit and review. Ethical principles must be strictly adhered to in all psychiatric research especially in the monitoring of drug development programmes.
This paper will present and illustrate the guidelines and principles for improving ethical behaviour in clinical research in vulnerable patient groups

(67) SELECTIVE SEROTONIN RE-UPTAKE INHIBITORS FOR CHILDREN AND ADOLESCENTS
C.F. Ziervogel
Department of Psychiatry
University of Cape Town

Objectives: 
1) To briefly review the scientific basis for the use of selective serotonin re-uptake inhibitors (SI's) in children and adolescents. 
2) To review the current data on the efficacy, safety and tolerability in children and adlescents. 
Method: 
A Medline search back to 1990 was conducted. Review articles and double blind, placebo controlled trials were critically reviewed. Additional hand searches were performed with key journals and in specific areas of interest for this paper. 
Results: 
Most of the published papers are from North America. There is an increasing use of SSRI's in child and adolescent psychiatry. The main disorders studied are mood and anxiety disorders. The data supporting efficacy is still limited. The most robust data is in the treatment of OCD and depression. 
Conclusion: 
Taking the limited data together with clinical experience and with adult studies, there is a valuable role for SSRI's as a component of treatment for various child and adolescent psychiatric