L EITER S TO THE ED ITOR
Sys temat ic co mprehe ns ive diag nos tic eva luations of burn ed children are , we believe , need ed to design good treatment studies . Wh at is to be trea ted? Her protocols were des igned to lessen helpl essness and increase control as suggested by Dr. Jerr y Shuc k , a surgeon , as we ll as Dr. Kavan agh . Other well-designed proto cols have targeted co nfusion , anxiety, depression , or pai n as the symp tom to be treated . It is our experience, su pported by our resear ch , that diffe rent patient s require different ind ividua lized inter vent ion s acc ording to their spec ific nceds - and in this study we assessed those need s by face-to-face dia gnostic assess me nt. Altho ugh re lief for pain , increased co ntrol over dressings , and othe r treatm ent interventions ma y be ve ry helpfu l, we have not fou nd any single treatment to add ress all psyc hiat ric sequelae of bur ns. The time has not passed for a thorough assessment of chi ldre n and adolescent s , burn ed or not , due to acute needs for treatment. A weakness of her study is the abse nce of suc h asses sments , altho ugh it prob ably docs not invalidate the usefulness of the results of her treatment study. Of course we arc aw are of her wo rk , but did not cite it becau se it was a treat ment , rath er than diagn ostic study. Dr. Kavana gh ' s qu estio ns regarding sampling ha ve more merit , but the sampling was met icul ou s eve n if onl y briefl y repor ted here . T hese arc not " typica l" burned children , since those at our hosp ital have larger and more disfiguri ng burns than the " typical" burned ehildtherefore , our resu lts prese nt ou tcomes for tho se who wo uld be most at risk from serious burn s. T he ran ge of time after burn was I to 17 years, w ith a mea n dur ation of ~ .4 yea rs . As stated in the title , this is an outco me study, not a study of acut ely burn ed children . Appare ntly Dr. Kavan augh did not read our stateme nt, " The obtained samp le of 3D subj ects was not signifi cantly different in age , percen t burn, or sex fro m the sampling pool of 56 subjects or the tota l 400 reconstructive (itali cs adde d) ad missio ns durin g the year." Rega rding the co mpar iso n group, the fami lies did have an ad olescent , hut also childre n age d 7 to 12 . Th e matchin g , in fact , was exact for age , sex , soci oeconomic status , and parent s ' mar ital status incl udi ng the 7 to 12 yea r olds. T he val idity and re liab ility stud ies of the Diagnostic Interv iew for Chi ldren and Adolesce nts were referen ced ; as stat ed, intcrrater relia bility was checked for six cases and was high eno ugh so that furthe r checks were no t de eme d esse ntia l.
Th is study co nfirms other studies whic h have found anx iety and dep ressive disord ers with burne d children, but adds new findin gs about Posttraumatic Stress Disorder, enuresis, and those wi th no disorders. The fact that DSM -II! crit eria arc used in thi s study of severely burned children (mean burn size 39%, ra nge 5% to 95% ) adds to the significance of these findin gs. A report on a much larger sa mple with similar, hut more detailed find ings including within -group co mpariso ns , is nea ring completion. Man y question s rema in regard ing etiology and trea tment , hu t answers such as these assist in des igni ng targeted psychiatri c care for the acutely burned chi ld , and later for the burned child , when the ef fects of scarring and so cial stigmatization have added (0 the or igina l inj ury . Frede rick J . Stoddard , M .D . Denn is K. Nor ma n , Ed .D. J . Michae l Murphy , Ed. D. William R. Beardslee , M. D.
Multiple Personality
Mult iple diagno st ic possib ilities were con sidered and we wo uld like to submit one other possibil ity tha t was not rea lly co vered in the Journal article . Based on the information that was available to us , we would like to suggest that the poss ibility of chi ldhood onset m ult iple perso nalit y disor der (MP D) be co nsidered . To bolster our point, we would like to discuss how thi s child fits som e of the non diagnostic predic tors of multiple personality developed by se veral authors in the literature . Kluft (l 984a) descr ibed 16 pred ictors deri ved from five child cases of multi ple perso nalit y , all in males . It is interesting to note that the pat ient in the article has the followi ng 10 pred ictors in her history. These incl ude : (I) history of intermittent dep ression , (2) fluct uations in abili ties , age approp riateness and moo ds , (3) amnesi a, altho ugh this might be attributed to her ECT , (4) halluc inated vo ices, (5) bein g called a liar, (6) d isavowal of beh avior that was witnesse d by othe rs, (7) inco nsistent beh avior in schoo l, part icularl y as noted in the hospital , (8) refractoriness to previous treatment, (9) the possibility of other DSM diagnoses, and ( 10) the possib ility of attenuated signs of mu ltiple person ality disorder , as ex hibited with her behavior of altern ately ro cking an d holding her head in her lap . Klu ft (1984b) cites Putn am as also having developed nondiagnost ie predi ct ors for mult iple person ality. Amon g the 13 predi ctors mention ed , the patient in the article meets six , including : ( I) sustained , repeated abuse , (2) possibly amnestic for abuse, (3) auditor y hallu cination s , (4) marked va riatio ns in ability , (5) amnesi a/denial , and (6) hys teric al symptoms. Fagan and McMann ( 1984) ha ve developed a list of 20 pred ictors and have divided them into two sec tio ns. O f the ir first five pred ictors , they feel that if the patient meet s tw o , they should be ex amined for MPD an d if they meet at least thre e of the next 15, they would also consider them to be at risk for MPD . Th e patie nt in the artic le meets two of the first five criteria: (1) sho wi ng marke d per sonality changes , and (2) odd variation s in physic al sk ills and attrib utes . O f the next 15 sympt om s , the patient meets five, including: ( I) perpl exin g professionals, (2) acc used of lyin g , (3) descr ibin g herself as lonel y , (4) man y physical co mp laints or illnesses , and (5) hysteric sym ptoms . The diagno sis of mu ltiple person ality in children is made very infrequently , and in the particular case be ing discussed , docs not seem to have bee n cons ide red as a possible d iag nos is . It is our suggestion that becau se of the complex natur e of this chi ld, and because of the history of abu se that was developed , she would have been at risk for this disorder. Kluft , in both of his art icles , sugg ests that the treatment of MI'D is more successfu l and easier to acc omplish in children who arc preadolescents. It would be our suggestion that MP D be co nsidered in patients that arc refra ctory to standard treatmen ts and in which abuse has occurre d in ord er to prevent a more chronic outc om e later on . Will iam M . Heffron , M .D . Edw ard N . Maxwe ll, M .D . Unive rsi ty of Kentu ck y REI'ERENCE S
Fagan , J . & McM ann , P. P. (198 4) , Inci pient multipl e per sona lity in children: four cases . J . Nerv . Melli . Dis., 172:26--36 . Kluft , R. P . (l 984a) , C hildhood mult iple per sonal ity disorder : pre dictors, cl inica l findin gs, and treatment results . In : Childhood Antecedents ofMultiple Personality , cd . R . P. Kluft. Washington, DC : Ameri can Psychiatric Pre ss , pp . 168- 196 . Kluft , R . P . (1984b), Multiple per son ality in childhood, fro m a Symposium on Multip le Persona lity. Psychiatr. Clin. North Am ., 7( 1)12 1135 .
To the Editor:
The authors reply :
We arc writing conce rning the Gran d Rou nds entit led , " An Abuse d Psychot ic Preadolescen t at Risk for Hu ntington 's Disease ," in the Jul y 1 9~ 9 , issue of the Journal. Th e Gran d Round s describes a very complicated case in a IO-year-old girl who has been follo wed throu gh age 13 and apparently is curren tly living in a res ide ntial trea tment faci lity .
The points made by Drs . Heffron and Ma xwell arc we ll taken . Multip le perso nali ty diso rder (MPD) should be considere d in children with a history of abu se , hysterical sy mptoms , and oth er risk factors they outlined in their lett er. Th e dia gn osis of MPD was co nside red in our pati ent , but not applied , becau se she did not appear to disp lay the
488
J.Am . A cad . Ch ild Adolcsc. Psychiatry, 29 :3 , May 1990
Sys temat ic co mprehe ns ive diag nos tic eva luations of burn ed children are , we believe , need ed to design good treatment studies . Wh at is to be trea ted? Her protocols were des igned to lessen helpl essness and increase control as suggested by Dr. Jerr y Shuc k , a surgeon , as we ll as Dr. Kavan agh . Other well-designed proto cols have targeted co nfusion , anxiety, depression , or pai n as the symp tom to be treated . It is our experience, su pported by our resear ch , that diffe rent patient s require different ind ividua lized inter vent ion s acc ording to their spec ific nceds - and in this study we assessed those need s by face-to-face dia gnostic assess me nt. Altho ugh re lief for pain , increased co ntrol over dressings , and othe r treatm ent interventions ma y be ve ry helpfu l, we have not fou nd any single treatment to add ress all psyc hiat ric sequelae of bur ns. The time has not passed for a thorough assessment of chi ldre n and adolescent s , burn ed or not , due to acute needs for treatment. A weakness of her study is the abse nce of suc h asses sments , altho ugh it prob ably docs not invalidate the usefulness of the results of her treatment study. Of course we arc aw are of her wo rk , but did not cite it becau se it was a treat ment , rath er than diagn ostic study. Dr. Kavana gh ' s qu estio ns regarding sampling ha ve more merit , but the sampling was met icul ou s eve n if onl y briefl y repor ted here . T hese arc not " typica l" burned children , since those at our hosp ital have larger and more disfiguri ng burns than the " typical" burned ehildtherefore , our resu lts prese nt ou tcomes for tho se who wo uld be most at risk from serious burn s. T he ran ge of time after burn was I to 17 years, w ith a mea n dur ation of ~ .4 yea rs . As stated in the title , this is an outco me study, not a study of acut ely burn ed children . Appare ntly Dr. Kavan augh did not read our stateme nt, " The obtained samp le of 3D subj ects was not signifi cantly different in age , percen t burn, or sex fro m the sampling pool of 56 subjects or the tota l 400 reconstructive (itali cs adde d) ad missio ns durin g the year." Rega rding the co mpar iso n group, the fami lies did have an ad olescent , hut also childre n age d 7 to 12 . Th e matchin g , in fact , was exact for age , sex , soci oeconomic status , and parent s ' mar ital status incl udi ng the 7 to 12 yea r olds. T he val idity and re liab ility stud ies of the Diagnostic Interv iew for Chi ldren and Adolesce nts were referen ced ; as stat ed, intcrrater relia bility was checked for six cases and was high eno ugh so that furthe r checks were no t de eme d esse ntia l.
Th is study co nfirms other studies whic h have found anx iety and dep ressive disord ers with burne d children, but adds new findin gs about Posttraumatic Stress Disorder, enuresis, and those wi th no disorders. The fact that DSM -II! crit eria arc used in thi s study of severely burned children (mean burn size 39%, ra nge 5% to 95% ) adds to the significance of these findin gs. A report on a much larger sa mple with similar, hut more detailed find ings including within -group co mpariso ns , is nea ring completion. Man y question s rema in regard ing etiology and trea tment , hu t answers such as these assist in des igni ng targeted psychiatri c care for the acutely burned chi ld , and later for the burned child , when the ef fects of scarring and so cial stigmatization have added (0 the or igina l inj ury . Frede rick J . Stoddard , M .D . Denn is K. Nor ma n , Ed .D. J . Michae l Murphy , Ed. D. William R. Beardslee , M. D.
Multiple Personality
Mult iple diagno st ic possib ilities were con sidered and we wo uld like to submit one other possibil ity tha t was not rea lly co vered in the Journal article . Based on the information that was available to us , we would like to suggest that the poss ibility of chi ldhood onset m ult iple perso nalit y disor der (MP D) be co nsidered . To bolster our point, we would like to discuss how thi s child fits som e of the non diagnostic predic tors of multiple personality developed by se veral authors in the literature . Kluft (l 984a) descr ibed 16 pred ictors deri ved from five child cases of multi ple perso nalit y , all in males . It is interesting to note that the pat ient in the article has the followi ng 10 pred ictors in her history. These incl ude : (I) history of intermittent dep ression , (2) fluct uations in abili ties , age approp riateness and moo ds , (3) amnesi a, altho ugh this might be attributed to her ECT , (4) halluc inated vo ices, (5) bein g called a liar, (6) d isavowal of beh avior that was witnesse d by othe rs, (7) inco nsistent beh avior in schoo l, part icularl y as noted in the hospital , (8) refractoriness to previous treatment, (9) the possibility of other DSM diagnoses, and ( 10) the possib ility of attenuated signs of mu ltiple person ality disorder , as ex hibited with her behavior of altern ately ro cking an d holding her head in her lap . Klu ft (1984b) cites Putn am as also having developed nondiagnost ie predi ct ors for mult iple person ality. Amon g the 13 predi ctors mention ed , the patient in the article meets six , including : ( I) sustained , repeated abuse , (2) possibly amnestic for abuse, (3) auditor y hallu cination s , (4) marked va riatio ns in ability , (5) amnesi a/denial , and (6) hys teric al symptoms. Fagan and McMann ( 1984) ha ve developed a list of 20 pred ictors and have divided them into two sec tio ns. O f the ir first five pred ictors , they feel that if the patient meet s tw o , they should be ex amined for MPD an d if they meet at least thre e of the next 15, they would also consider them to be at risk for MPD . Th e patie nt in the artic le meets two of the first five criteria: (1) sho wi ng marke d per sonality changes , and (2) odd variation s in physic al sk ills and attrib utes . O f the next 15 sympt om s , the patient meets five, including: ( I) perpl exin g professionals, (2) acc used of lyin g , (3) descr ibin g herself as lonel y , (4) man y physical co mp laints or illnesses , and (5) hysteric sym ptoms . The diagno sis of mu ltiple person ality in children is made very infrequently , and in the particular case be ing discussed , docs not seem to have bee n cons ide red as a possible d iag nos is . It is our suggestion that becau se of the complex natur e of this chi ld, and because of the history of abu se that was developed , she would have been at risk for this disorder. Kluft , in both of his art icles , sugg ests that the treatment of MI'D is more successfu l and easier to acc omplish in children who arc preadolescents. It would be our suggestion that MP D be co nsidered in patients that arc refra ctory to standard treatmen ts and in which abuse has occurre d in ord er to prevent a more chronic outc om e later on . Will iam M . Heffron , M .D . Edw ard N . Maxwe ll, M .D . Unive rsi ty of Kentu ck y REI'ERENCE S
Fagan , J . & McM ann , P. P. (198 4) , Inci pient multipl e per sona lity in children: four cases . J . Nerv . Melli . Dis., 172:26--36 . Kluft , R. P . (l 984a) , C hildhood mult iple per sonal ity disorder : pre dictors, cl inica l findin gs, and treatment results . In : Childhood Antecedents ofMultiple Personality , cd . R . P. Kluft. Washington, DC : Ameri can Psychiatric Pre ss , pp . 168- 196 . Kluft , R . P . (1984b), Multiple per son ality in childhood, fro m a Symposium on Multip le Persona lity. Psychiatr. Clin. North Am ., 7( 1)12 1135 .
To the Editor:
The authors reply :
We arc writing conce rning the Gran d Rou nds entit led , " An Abuse d Psychot ic Preadolescen t at Risk for Hu ntington 's Disease ," in the Jul y 1 9~ 9 , issue of the Journal. Th e Gran d Round s describes a very complicated case in a IO-year-old girl who has been follo wed throu gh age 13 and apparently is curren tly living in a res ide ntial trea tment faci lity .
The points made by Drs . Heffron and Ma xwell arc we ll taken . Multip le perso nali ty diso rder (MPD) should be considere d in children with a history of abu se , hysterical sy mptoms , and oth er risk factors they outlined in their lett er. Th e dia gn osis of MPD was co nside red in our pati ent , but not applied , becau se she did not appear to disp lay the
488
J.Am . A cad . Ch ild Adolcsc. Psychiatry, 29 :3 , May 1990
