LETIERS TO THE EDITOR mothers, but lacking any observations of the children or clinical assessments of parents or children, the researchers found significant differences between boys in intact and divorced families . These differences, which showed detrimental effects on behavior and academic .learning, were continuous with similar difficulties in the predivorce family. Accordingly, the researchers claim that, for boys, detrimental effects that have been attributed to divorce and the postdivorce family can be predicted by predivorce conditions. Limitations of space preclude my elaborating on methodological and clinical issues . There is, however, reason to belie ve from these recent studies that the market research methods currently in vogue in sociology , which typically tabulate individual behaviors and symptoms unrelated to their context within the feelings and perceptions of the child, translate poorly into the clinical domain. For example, they report that children who have lost a parent through death show no significant differences from controls, using the same behavioral measures. Moreover, their reports describing the good functioning of girls after divorce show no awareness of defensive needs of children to inhibit aggression and to conform. The children in my own research (Wallerstein and Blakeslee, 1989) were all functioning adequately or well within the predivorce family. Yet , this clinical picture changed markedly at the separation . We can surely agree that many children come to divorce already troubled and depleted . We can also agree that many of these difficulties persist or consolidate and that divorce fails to rescue many or most children (although it may well rescue one or both parents). Despite this common ground, it appears that sociologists and clinicians have sufficiently divergent methods and different ways of understanding, and it appears that they may at this time be mismatched travelling companions along the road to informed public policy and effective interventions. 3. Finally, the concept of a dysfunctional family has been used so variously and globally that I fear its usefulness as a clinical concept or a research tool is limited . Judith S. Wallerstein, Ph .D. Center for the Family in Transition Corte Madera, California REFERENCES

Cherlin, A., Furstenberg, F. Jr., Chase-Lansdale, P., Kiernan, K. , Robins, P., Morrison, D. & Teitler, J . (1991) , Longitudinal studies of effects of divorce on children in Great Britian and the United States. Science, 252:1386-1389. Wallerstein, J . (1989) , Commentary on essay review (Readings. June , 1989, pp. 4-8) of Second Chances: Men, Women , and Children a Decade After Divorce, Readings , 4:19-23 . Wallerstein, J. (1991), The long-term effects of divorce on children: a review . J . Am . Acad. Child Adolesc . Psychiatry. 30:349-360. Wallerstein, J. & Blakeslee, S. (1989), Second chances:Men, Women, and Children a Decade after Divorce . New York : Ticknor & Fields .

To the Editor: I appreciated the thoughtful review of the studies ofeffects of divorce on children by Dr. Wallerstein. They shared a weakness not addressed by the author. They lacked an accounting for preexisting, major psychiatric diagnoses in the parents, perhaps genetically passed on to the children. Psychiatric patients have high rates of divorce. Divorcees, therefore , are more likely to have a preexisting disorder. The offspring of psychiatric patients have high rates of disorder. These three factors explain the findings described in the review. ' As a pilot study, we surveyed consecutive couples granted a divorce in an Upstate Pennsylvania area . The names were obtained from the

J.Am .Acad. Child Adolesc.Psychiatry, 30:6, November 1991

court and not from clinics. Of the 500 questionnaires (to 250 couples) about their most troubled child's behavior, 75 were returned. Six came from both members of three couples. Three were randomly selected for inclusion ; for a return rate of 29% of the families from a single mailing. The mean ± SD of the age was 36.0 ± 6 .8. They had 13.8 ± 2.6 years of education, 10.2 ± 6.6 years of marriage. The mean age of the index child was 11.6 ± 6.6 . The couples were separated for a mean of 4 years, with a range of I to 11. Racially, 95% were white, 1.5% Hispanic, 1.5% Oriental. Of these, 55% had at least one child with a serious preexisting problem . In 33% of families, at least one child prompted teacher complaints about behavior. Crying spells were reported in 27%, short attention spans in 26% , depression in 24 %, aggression in 24%, hyperactivity in 22%, nightmares in 22%, and disruptive oppositional behaviors in 22%. In 12%, tics occurred, suicidal ideas in 8% , and 2% ran away . According to parental ratings , among the children without preexisting difficulties, behavior after parental separation worsened in 10%, remained the same in 74% , and improved in 16%. Among those with preexisting problems , 47% worsened, 27% remained the same, and 27% improved, (P < 0 .0003; Kramer's V = 0 .50) . The biggest impact, negative and positive, occurred in children with previous problems. This is also one of the first reports that divorce helps some children, especially those with preexisting psychiatric problems. Our sample was too small to test the possibility that removal of or increased exposure to disturbed parents after separation correlates with the direction of change. These data also indicate divorce has little impact on the behavior of most normal children. Not determining the rates of preexisting conditions limits the import of any study of divorce. David Behar, M .D. Medical College of Pennsylvania

Ritual Abuse of Children To the Editor: Drs . Nurcombe and Unlitzer (1991) are to be complimented for their attempt to assess and diagnose whether a child's allegations of ritual abuse is indeed ritual abuse or something else. The authors review the clinical picture, engage in " diagnostic reasoning," and come to the cautious conclusion that' 'virtually all the clinical features of the case are consistent with ritual sexual abuse" (p. 274) . I think the authors have displayed exemplary caution in indicating "consistent with ritual sexual abuse" rather than with the " high degree of medical certainty" often required in forensic evaluations . There are several questionable aspects of the paper that lead me to be even more cautious than the authors. First, the use of sexually explicit dolls is not only a questionable procedure (Yates and Terr, 1988), but there is no statement made as to the child's prior experience with such dolls during the previous videotaping and interviews by the Department of Protective Services, police, and other agencies . This information is crucial , because the authors themselves are aware that "some clinicians . . . employ inept interviewing techniques. As a result, these clinicians have unwittingly indoctrinated suggestable witnesses .... " (p. 275). Unfortunately , too many workers from protective service agencies and the judicial system are frequently inexperienced, poorly trained, overloaded, or may have a personal bias in favor of believing "that children don't lie ." Yates (1988), although an advocate of sexually explicit dolls, agrees : "The majority of individuals who use anatomically correct dolls are employed by public agencies and have little or no training in child development, child assessment, mental health, or human sexuality" (p. 255).

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Second, the authors' report of the interview with the child is a lengthy list of happenings and allegations. Some allegations are so fantastic on the face of it that reality testing with the child is indicated and possibly within the context of the interview. Additionally, when "a man killed a fireman with a knife" or " a man killed a horse with his knife, " -these alleged events can be reality tested by going to outside sources for (non)confirmation , a recommendation to be found in Section 9 of The Guidelines for Clinical Evaluation of Child & Adolescent Sexual Abuse (Perspective, 1988). Third, psychological testing with a specific view toward assessing the child's perception of reality, sense of reality , and reality testing would have been a useful and an important part of a forensic evaluation . A psychological examination (Rorschach, Children's ApperceptionTest) indicating good reality testing would have added greatly to the authors' section on "exclusion of alternative explanations." A child is certainly capable of confabulation and is capable of verbalizing delusions as allegations based on a folie adeux relationship with a disturbed parent (Anthony, 1970). Fourth, no history was obtained or none was noted from the foster parents or the record as to whether the child masturbated or had used vaginal insertions as part of her masturbatory practices , especially in light of her allegations that her father "put garbage into her vagina." Although each interviewer might have his or her own personal image of the garbage, I think it would have been appropriate to have asked as to the nature of the garbage and what happened to it once inserted. Fifth, the authors do not discuss the consistency of the interview allegations they obtained in comparison with the video tapes and documentation provided by the protective agencies. Although consistency and inconsistency are in and of themselves not diagnostic, the child should be interviewed concerning allegations made to others that are not made to the authors and allegations made to the authors that were never mentioned to prior interviewers (Schetky, 1989). The interview, as described by the authors seems to have consisted of recording the child's allegations and eliciting them to the fullest. There is no indication that the authors made any active attempts in their interviews of the child to confront inconsistencies, to compare allegations made to others, to confront the fantastic, to assess reality/fantasy differentiation, to follow up on the natural consequences of the allegations, etc. To merely record allegations is certainly one aspect of an interview, but unless other clinical skills are employed and their results recorded, the evaluations of allegations can be no better than ambiguous. The authors do not indicate how much time they spent interviewing the child's biological parents nor do they comment on the parents' mental health, on their reliability as informants or on information and history elicited by others in their past contacts with agencies. Nor do the authors state whether they had access to the father's foster home placements and the 10 years of "public in-patient psychiatric care. " Although there is much to suggest that the parents have a delusional paranoid system, the authors do not address this issue. Nor do they tell us if there actually is such a person as " Carl," a figure implicated by both parents and child. Sixth, the authors do not tell us when, at age four , a pediatric examination revealed scarring and dilation of the vaginal introitus, whether there was any interviewing of the child and whether that interviewing focused on ritual sexual abuse and satanism . From my own experience, specific leading questions are often asked of the young children concerning ritual abuse and satanism by protective agencies and police interrogators. When the young child is emotionally disturbed, such interrogation could easily become the nucleus of later confabulations and allegations. However, the biggest flaw in the authors' diagnostic reasoning is that they do not give sufficient weight to the possibility that the parents may indeed have a delusional paranoid system embodying many elements of fundamentalist christianity, "horror movies," and "charismatic mysticism." The authors note that when the child was with her

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parents, she appeared to be close to her father and evidenced no fear of either parent. Moreover, they openly "pressed her to tell the doctor how she had been sexually abused by 'Car l' " (p. 273). Given these findings, I find it hard to agree with the authors ' reasoning that "there is no evidence of the kind of dependency upon a deluded older person that would be associated with folie a deux as a diagnosis," which I believe, needs to be given additional consideration. Using the authors' exemplary caution, I would say that the clinical features are "consistent" with folie a deux until proven otherwise. In conclusion, the authors are to be complimented for their willingness to display their diagnostic acumen and thinking as it pertains to a very difficult and confusing clinical situation. As the authors suggest, forensic evaluation is often called upon to filter and clean up "muddy waters" that have resulted from inept or incomplete investigations. However, to my thinking the waters remain far from clear. Moisy Shopper St. Louis, Missouri REFER ENCES

Anthony, E. 1. (1970) , The influence of maternal psychosis on children-folie a deux . In: Parenthood, Boston: Little Brown & Co. eds. E. J. Anthony & T. Benedek. Nurcombe, B. & Unutzer, J. (1991), The ritual abuse of children: clinical features and diagnostic reasoning. J . Am. Acad . Child Adolese . Psychiatry , 30: 272-276 . Perspective 1988-guidelines for the clinical evaluation of child and adolescent sexual abuse-position statement of The American Academy of Child and Adolescent Psychiatry. J .Am. Acad. Child Adolese . Psychiatry , 27:655-657 . Schetky, D. H. (1989), More on sex abuse allegations (letter) J. Am . Acad. Child Adolesc. Psychiatry, 28:298. Yates, A. & Terr, L. (1988), Debate Forum 1988-Anatomically correct dolls: should they be used as the basis for expert testimony ? J . Am . Acad. Child Adolesc . Psychiatry , 27:254-257 . Dr. Nur combe replies:

Dr. Shopper 's detailed analysis of the case we presented opens the door to important questions. His willingness to entertain alternative hypotheses and to make explicit the process of his reasoning is consistent with the ultimate aim of our paper . Unfortunately, Dr. Shopper did not have the voluminous case records available to us; our case history was, perforce, selective. Nevertheless, his critical points demand close attention and will be discussed seriatim. 1. The Use of Anatomically Explicit Dolls When Hillary was first interviewed by a child protective worker (June 28, 1988), no dolls were employed . To a direct question about having been touched in a way that made her uncomfortable, she implicated a neighbor (" James" ) and spoke of a "Carl" who "whipped" children. She denied that her father had ever touched her improperly . At a subsequent interview , anatomical dolls were introduced , but Hillary resisted all questions about them and threw the dolls against a wall. No anatomical dolls were used during the pediatric examination (June 28, 1988), which revealed physical evidence of sexual abuse. No questions about ritual abuse were asked at that time. Actually , no questions about ritual abuse were asked until 6 months after the child had been removed from the parental home, because it was not suspected until that time. 2 . The Sequence of Events When she was initially placed in a foster home (June 29, 1988), Hillary was severely hyperactive. She urinated and defecated in the yard of the foster home and was exceedingly difficult to control. Three months after she was placed in the home (October 21 , 1988), she was found sexually interfering with a foster brother and volunteered to the foster mother that her father had "touched her bottom ." She comJ .Am .Acad. Child Ado/esc. Psy chiatry, 30 :6, N ovember 199J