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On any given day, there are more than 400,000 children in foster care in the US (

). Children in foster care are at a higher risk for health and mental health problems.

 They are also connected to multiple systems, which require and challenge coordinated care.

 Further complicated by histories of maltreatment (Sidebar) and issues in assessment, diagnosis and treatment can be challenging-for children, their families and guardians, and their clinicians. In honor of 

, this article sheds light on these issues and provides information for psychiatrists caring for this vulnerable population.

“Joseph” is a 3-year-old in foster care. After 2 out-of-home placements, he was returned to his parents. Each removal was connected to allegations of physical abuse. His permanency goal is changing to adoption, but he still has visits with his parents. He is physically healthy but hyperactive and impulsive and has problems sleeping.

When Joseph first arrived at his current foster home, he had temper outbursts at least once a day that included screaming, hitting, kicking, and breaking things. Over the course of a few months, the outbursts decreased to weekly; the outbursts seemed connected to visits with his parents.

Joseph has a diagnosis of attention-deficit/hyperactivity disorder and oppositional defiant disorder. He was prescribed 18 mg methylphenidate ER in the morning, 0.1 mg clonidine at bedtime, and 0.5 mg risperidone twice daily, all by his primary care provider. How and when these medications were started is not clear from the records.

Upon entering treatment with a community mental health provider, Joseph’s foster mom reported “we can’t handle him without these medications.” Discussions continue about the risks and benefits of risperidone and the circumstances under which it would be possible to start tapering.

Providing psychiatric services to children and adolescents in foster care require collaboration not only with the clinical team, but also the child welfare team. Team members include parents, foster parents, and the social worker, at minimum. The team may also include representatives from courts and others engaged by the child welfare system to conduct assessments (eg, psychological, neuropsychological). Child welfare services’ organizational structure varies from state to state. State and/or local policy defines practice related to permanency and broader case planning, defining the consenting parties for health and mental health treatment, practices for obtaining informed consent for psychotropic medication, and tracking and oversight of psychotropic medication use for children in foster care.

Foster care workers typically serve 10 to 15 families. They are responsible for all aspects of case planning including monitoring placements, ensuring safety, arranging parental visitation, preparing for court, and planning for permanency. Case workers are often very knowledgeable about the youths and families they serve and can be a true partner in care. Psychiatrists and their office staff should reach out to local child welfare leadership to build collaborative relationships. In doing so, it is helpful to share office hours, emergency service policies, duration of initial assessment and follow up appointments, information needed prior to an initial assessment, and preferred pathways for communication between the office and the child welfare team. These outreach efforts are useful during usual care as well as when challenges or crises arise.

Children in foster care often experience placement changes. Maintaining continuity of care during treatment within a single organization as well as ensuring that comprehensive clinical information transfer occurs when children transition to new treatment providers presents a challenge. Psychiatrists should provide leadership in policy and practice development to accomplish this goal.

Child welfare systems present unique challenges for comprehensive psychiatric assessments. Psychiatrists must receive complete prior mental health records, including those prior to foster care placement; as such, they should establish mechanisms to obtain collateral history from parents, foster parents, and other caregivers (eg, staff in residential placement), and obtain health and school records. Psychiatrists should communicate these needs to the team, assist in developing protocols for consent for release of information documents, and maximize information transfer within systems.

Although most, if not all children, in foster care have suffered maltreatment exposure, the type, duration, and impact of such before foster care varies. Children may also experience traumatic exposures during foster care, including stress related to parental circumstances, separation from siblings, placement change, termination of parental rights, as well as illness and death of family members.

Although it may not be necessary or appropriate to ask children to recount specific experiences and/or exposures, psychiatrists should make the child and their family aware that they know that stressful events have occurred and provide psychoeducation on the impact of ongoing stressors in the context of maltreatment. Exposures need to be considered when conducting assessments. Doing so may include asking the child and caregivers to complete screening tools or diagnostic assessments specific to traumatic exposures as well as those related to other psychiatric diagnoses.

When a child in foster care is scheduled for a psychiatric assessment, clinical staff should inquire about the legal status of the child, the names and contact information for the person legally empowered to consent for treatment, and who will be bringing the child to the appointment. Unless the child and parent are prohibited from contact, arranging for parents to be present is optimal so that they can provide history, sign consents for release of information, and engage in consent for treatment. If a parent cannot be present, they can be contacted before the appointment for needed information.

The long-term priorities of the welfare systems are reunifying children and parents when possible and supporting family functioning. Engaging parents throughout their children’s time in foster care supports these goals; engaged parents are better equipped to address their children’s physical and mental health needs.

Unfortunately, involving parents is complicated by many factors. Maternal characteristics such as poverty, substance use, co-occurring disorders, and domestic violence as well as perception of the effects of sharing information may discourage involvement.

 Addressing parental needs (eg, substance use disorder treatment) is important for successful reunification, but may present a barrier to simultaneous engagement in a child’s health care.

 Given that reunification is the most common goal, educating all team members about the importance of parental engagement is important throughout foster care placement.

“James” is a 16-year-old admitted to a residential treatment facility after running away from 2 foster homes. His entrance into the foster care system was predicated by ongoing but undisclosed sexual abuse perpetrated by his stepfather that occurred for at least 5 years before discovery. At that time, he was diagnosed with bipolar disorder and anxiety. He was treated with ari- piprazole, titrated to 15 mg daily and 0.5-mg alprazolam up to 3 times daily for acute anxiety. During residential assessment, James reported periodic temper outbursts and moodiness without clear episodes of depression or mania. Also during this time, he reported significant anxiety and occasional panic attacks.

During residential treatment, he participated in individual and group therapy. The aripiprazole was gradually tapered and discontinued, alprazolam was also tapered. He made plans to transition from the residential facility to an independent living program.

There are a wide variety of psychiatric diagnoses among children in foster care (

 looked at Medicaid claims data (2002 to 2007) from a national sample of youths aged 3 to 18 years who were enrolled in foster care. The findings indicated that rates of mental health diagnoses generally increased over this time with 2 exceptions: depression was stable from 2002 to 2005 but decreased from 2006-2007, and schizophrenia remained stable throughout. Generally, the rates of diagnoses in this sample of children are higher compared with cumulative diagnosis by age 7 from a single state 2007 birth cohort sample.

Because of maltreatment, children in foster care often have trauma-related diagnoses, with posttraumatic stress disorder as the most specific trauma-related diagnosis. DSM-5 includes guidance about how PTSD may manifest in childhood. More general responses to trauma exposure may be captured by “trauma and stressor related disorder unspecified” if PTSD cannot be diagnosed with confidence.

To diagnose disorders common in childhood (eg, ADHD, anxiety disorders, and depressive disorders), psychiatrists should determine whether symptoms are present, the timing and duration of symptoms in relation to trauma exposures, and persistence after substantial reduction in trauma-related symptoms. Emotional dysregulation is a common response to traumatic exposures; if considering 

 or disruptive mood dysregulation disorder, clinicians must determine if full symptom, duration, and pattern criteria are met or if symptoms may be better explained by trauma.

Perception and thought disturbances are also relatively common in children with maltreatment exposure. Explanations may include intrusion of traumatic experiences (eg, nightmares, flashbacks, involuntary memories) and negative thoughts and feelings (eg, distorted beliefs about the self or others) rather than emerging psychosis.

Finally, the potential for other co-existing factors that affect diagnosis-such as exposure to substances and maternal stress in utero, perinatal stress related to neonatal abstinence syndrome, and the effect of any abuse-related physical or neurological injury-must be included in differential diagnosis, treatment planning, and assessment of longer-term services, supports, and prognosis. (See Keeshin et al

 for an in-depth discussion of manifestations of maltreatment and impact on psychiatric diagnosis.)

Psychotherapy is generally considered first line when addressing trauma- and stressor-related emotional and behavioral conditions in children. Strategies with empirical support include trauma-focused cognitive behavioral therapy (TF-CBT); parent-child interaction therapy (PCIT), which is suggested for children aged 2 to 7 years to improve parenting skills and reduce children’s disruptive behavior; and attachment and bio-behavioral catchup (ABC), which has been tested in toddlers in foster care.

 The National Child Traumatic Stress Network (

) provides information on a variety of evidence-based and promising psychotherapeutic approaches for children exposed to maltreatment.

Studies have shown an increase in the use of psychotropic medication, including antipsychotics, in children and adolescents through mid-2000.

 Use of psychotropics is even higher in foster care (

 Although this trend has raised over-medication concerns, other factors must be considered, eg, a higher risk of emotional and behavioral concerns related to family/genetic history and maltreatment exposure. Since its peak in the mid-2000s, psychotropic medication use has plateaued, possibly a consequence of oversight efforts.

Treatment with psychotropic medications should not be considered first line when targeting emotional and behavioral difficulties related to trauma. However, evidence-based use for co-existing disorders, and judicious use to target symptoms that cannot be managed by psychosocial treatments alone, may be considered.

Psychopharmacological treatment for psychiatric diagnosis such as ADHD, major depressive disorder, and bipolar disorder in the context of maltreatment should follow existing recommendations and guidelines. However, closer monitoring and re-evaluation should occur if the child’s response is not as expected, as children exposed to maltreatment may be more likely to experience side effects such as suicidal ideation on antidepressants.

 As generally recognized, clinicians should start with lower doses, advance slowly, maintain monotherapy versus multiple medications in combination and monitor for adverse reactions per clinical guidelines.14

When the child has symptoms that do not clearly meet diagnostic criteria for a specific disorder, the clinician should proceed more cautiously. Children, families, the psychiatrist, and other team members should discuss the full range of psychosocial interventions. If evidence-based interventions have not yet been implemented, the team should develop a plan to do so. The team should consider whether additional supports are needed, including the implementation of a parenting curriculum for children exposed to trauma or other support (eg, respite services).

Sleep disturbances are common in children but more frequent in the setting of trauma; the evidence for medications is limited. Melatonin is one option; other options such as benzodiazepines or second-generation antipsychotics should be avoided.

When children’s aggressive behaviors put them or others at significant risk, medications can be considered as one part of a comprehensive treatment plan. Medications should be used at the lowest possible dose and monitored carefully. The team should develop a plan to monitor response to medication (ie, improvement in target symptoms) and a target timeline for tapering and/or discontinuing medication. A plan to switch medications should also be in place; such a plan should include tapering of the first medication before starting the second. Additional support for the child and/or family may be needed during medication transitions.

Children in foster care who demonstrate symptoms such as severe aggression are also more likely to experience placement transitions in community and residential settings. Under these circumstances, there is risk of polypharmacy, and it is more difficult to assess individual medications. After any transition that involves a new treatment team, both written and verbal communication is critically important-some medications may need to be discontinued (

Young adults transitioning out of foster care may be less inclined to accept recommendations from treatment providers, if only because they perceive lack of control over their lives. They may also have fewer natural supports to help them navigate adult responsibilities. It is, therefore, important to inquire about support systems as well as to acknowledge their lived experience and engage them in shared treatment decision-making.

Children in foster care present with extra challenges and unique situations, but with thoughtful assessments and coordination, they can have positive outcomes. Psychiatrists are in the unique position to provide comprehensive clinical care and policy leadership supporting all children’s health and well-being.

is Associate Professor, Department of Psychiatry, Michigan State University, East Lansing, MI and Medical Consultant to the Michigan Department of Health and Human Services, Children’s Services Agency.

1. Szilagyi MA, Rosen DS, Rubin D, et al. Health care issues for children and adolescents in foster care and kinship care. 

2. Lee T, Fouras G, Brown R, AACAP Committee on Quality Issues. Practice parameter for the assessment and management of youth involved with the child welfare system. 

3. Keeshin B, Forkey HC, Fouras G, et al. Children exposed to maltreatment: assessment and the role of psychotropic medication. 

4. Marcenko MO, Lyons SJ, Courtney M. Mothers’ experiences, resources and needs: the context for reunification: 

5. Cao Y, Bunger AC, Hoffman J. Caregiver engagement in the behavioral health screening and assessment for child welfare-involved children: child welfare and behavioral health workers’ perspectives. 

6. Doab A, Fowler C, Dawson A. Factors that influence mother-child reunification for mothers with a history of substance use: a systematic review of the evidence to inform policy and practice in Australia. 

7. Rubin D, Matone M, Huang Y-S, et al. Interstate variation in trends of psychotropic medication use among Medicaid-enrolled children in foster care. 

8. Pennap D, Zito JM, Santosh PJ, et al. Patterns of early mental health diagnosis and medication treatment in a Medicaid-insured birth cohort. 

9. Sege RD, Amaya-Jackson L, et al. Clinical considerations related to the behavioral manifestations of child maltreatment. 

10. Olfson M, Blanco C, Liu L, et al. National trends in the outpatient treatment of children and adolescents with antipsychotic drugs. 

11. GAO. HHS Guidance Could Help States Improve Oversight of Psychotropic Prescriptions. 2011. GAO-12-270T.

12. Perry, B. Harris Walsh K, et al. Change in psychotropic prescribing patterns among youths in foster care associated with a peer-to-peer physician consultation program. 

13. Singh AB, Bousman CA, Ng CH, Berk M. High impact child abuse may predict risk of elevated suicidality during antidepressant initiation. 

14. Walkup, J for the American Academy of Child and Adolescent Psychiatry Workgroup on Quality Issues. Practice parameter on the use of psychotropic medication in children and adolescents. 

15. Owens JA, Mindell JA. Pediatric insomnia. 

In honor of National Foster Care Month, this article sheds light on these issues and provides information for psychiatrists caring for this vulnerable population.

Challenges and Strategies in Foster Care

Neither Deaths From Denial Nor Deaths From Despair

Weaving Beauty Into the Tapestry of the Pandemic

We want to be sure that just as when we treat psychiatric illness with medications or psychotherapy, there are no unintended consequences. The cure should not be worse than the disease; so must we be cautious about an exaggerated response to COVID-19.  To my mind, that is iatrogenesis.

More in this video with Harold J. Bursztajn, MD, Co-founder of the Program in Psychiatry and the Law at 

 and President of the American Unit of the 

Medical Choices, Medical Chances: How Patients, Families, and Physicians Can Cope with Uncertainty

 (1981/1990). He practices clinical and forensic psychiatry and risk management in Cambridge, MA.

The cure should not be worse than the disease; so must we be cautious about our response to COVID-19. More in this video with Harold J. Bursztajn, MD.

I met Talia almost 20 years ago. It wasn’t the usual doctor-patient relationship formed in the setting of an outpatient clinic or general inpatient hospital. Talia was locked on a forensic unit. Having been there for more than 10 years, it appeared that she was destined to live her life there . . . yet she had not committed a crime and it was unclear whether she had any 

During residency, we rotated through the forensic hospital twice weekly for 6 months and were assigned patients who were deemed to be less violent. I was the first resident to work with Talia.

On the unit, I felt an underlying sense of fear. During my rotation, an experienced attending was attacked and beaten. The hallways often buzzed with an unsettling frenetic and unpredictable energy. I couldn’t imagine what it was like to live there.

Talia was in her 30s and had a physical condition that made her look unusual. Because of this, she spent her childhood locked away in a basement room, with a bucket as a toilet. She stayed there alone and was never allowed out. It’s unclear if anyone knew she existed until she was almost an adult and authorities found her.

Initially, Talia only walked sideways, didn’t speak, and when brought to the bathroom she stood on top of the toilet with no idea what to do. She was described as bizarre and had been labeled as psychotic.

On this unit, no one remembered much about her history; as if she had been forgotten soon after she arrived. Her diagnosis, medications, and even the appropriateness of her long-term care bed being placed in a forensic unit didn’t appear to be questioned. All she did was lie quietly on her bed and stare at a blank wall. She never caused trouble, didn’t speak, and would silently drift to meals.

One of my beloved supervisors accompanied me to my first meeting with Talia. He suggested making a checklist so Talia could indicate the answers to a couple of simple questions. We had no idea what her cognitive abilities were, if she could read, or if she would engage at all.

After explaining to her who I was and that I would be meeting with her regularly I brought out the first list. “Do you want me to call you _____Talia or _____Ms. X (her last name)?”
	I read this to her while pointing to the boxes for each option. I had crayons and markers on the table and demonstrated what I wanted her to do. She grabbed a red crayon and marked off Talia.
	“Do you like ____Pizza ____ Cookies ____Ice cream?” She circled cookies.

This is how we began the slow and gentle process of getting to know each other. After a couple of months, I arranged for permission to bring her off the locked ward and down to the cafeteria to buy her a cookie. Eventually, we were able to walk outside around the building grounds. On these outings, she was scared but curious and stayed in my shadow, peering around at the sites. Because of her looks, people stared at us wherever we went.

Her physical condition had not been re-evaluated since admission to this facility, so I arranged an appointment. I apprehensively took her by myself in a taxi after being told the transportation van wasn’t available. She hadn’t left the hospital grounds since arrival.

Overwhelmed and scared by the taxi ride, she threw up all over herself and then at the hospital, she didn't want to come out from the safety of the bathroom stall. After a lot of reassurance, pleading, and wet paper towels we finally exited.

Reeking of vomit, we went to see the specialists who concluded there wasn’t much to do for her. Her physical condition wasn’t progressing, it wasn’t life-threatening, and because she couldn’t communicate it wasn’t clear what her preferences were.

Our time together was spent drawing in the recreation room and reading children’s books. She made pictures and gave them to me and I did the same for her. Her pictures were often hung in the nursing station, an otherwise cold and clinical space, now adorned with childlike pictures of rainbows and flowers.

Over the months, I gradually reduced her medications until she was off them all. I wondered if the medication had been presumed effective given her absence of outbursts and if it had ever really been necessary. No evidence of psychosis emerged.

Slowly she began to speak. At first, it sounded like a croak, a voice that hadn’t been used forever. She would softly whisper her words and I saw her occasionally smile.

I loved Talia, but in the end, I let her down because of my inexperience. I don’t fault myself for it as I know I was learning, and I did my best. Books don’t prepare you for this.

Because it was so painful, I avoided dealing with our upcoming termination. Properly preparing her for the fact that I would be leaving was extremely important, but I did not do it well.

I remember the day I told her. I stopped walking, turned to face her, and finally got up the courage to let her know my time with her was ending soon. It was clear she didn’t understand I was there temporarily. She whispered a response that I can’t remember, we both teared up, and I told her how sorry I was.

When I left, I wanted to give Talia a box of new crayons to continue drawing and bringing life to her world. I didn’t do it though, because I was too afraid it was inappropriate, weak, and that caring so much about her was a sign that I wasn’t a good psychiatrist. Not giving her the crayons became the regret that I replayed for years-it was easier to think about the crayons than the mistakes I made in the termination process.

Boundaries aren’t always as rigid as I initially imagined. Though they are essential, and emphasized for good reason, the individual needs to be considered. Over time I've learned that I could have given her those crayons and I've grown to know that caring deeply about my patients isn’t a flaw. I still have excellent boundaries, but now I listen to my intuition and reach out to colleagues if I am in doubt.

Talia’s spirit, body, and mind were never nurtured. Yet, despite 30+ years of neglect (and that is putting it nicely), she responded to attention and love. Talia didn’t need a psychiatry resident to take care of her for 6 months, she needed a parent to love and accept her, and a family to care for her. She needed a home, not a long-term bed located in a forensic unit.

I have her pictures saved in a box of special memorabilia. I hope Talia has found more people to love her.

is a psychiatrist in private practice in Milford and Fairfield, CT. She can be found at 

https://www.linkedin.com/in/drmelissawelby/

. She reports no conflicts of interest concerning the subject matter of this article.

“I met Talia almost 20 years ago. It wasn’t the usual doctor-patient relationship formed in the setting of an outpatient clinic or general inpatient hospital.”

The Boundary I Wish I Hadn't Kept

The scientific race to develop a vaccine is in full swing, but when will we begin to develop a more rational, healthy 

response to pandemics? Camus understood that “pestilences” recurred over time, yet always seemed to take us by surprise. In his classic, The Plague (

1947), he writes about a virus that destroys half the population of an ordinary town.

 It is considered one of the greatest novels of the postwar period. Camus lays out our stages of psychological response to a plague, writing: “At the beginning of a pestilence and when it ends, there's always a propensity for rhetoric. In the first case, habits have not yet been lost; in the second, they're returning.” Here, the master of the existential and absurd would have us recognize that inescapable death transforms a habit-constrained life into an exercise in absurdity.

Camus’ Plague may also be viewed as our vulnerability to random extermination by any means. Or as philosopher Alain De Botton

 writes: “Plague or no plague, there is always, as it were, the plague, if what we mean by that is a susceptibility to sudden death, an event that can render our lives instantaneously meaningless.” Camus and similar philosophers believed the Absurd arises out of the conflict between our search for meaning and the apparent random nature and meaninglessness of the universe. What is produced by the conflict will depend on the individual, but may include various forms of denial, dissociation, and sublimation.

And so, it is the Absurd to which we now turn. Indeed, we cannot turn away as we are in the midst of a storm of absurdity. Grocery stores with empty shelves. Hoarding of food and supplies. A 

 Historians of real-life pandemics understand that they unfold as social dramas.

 If this is the case, might this most recent pandemic supply us with some truths about human nature? A relatively clear response pattern has been described by epidemiologists throughout history. The recurring pattern is as follows: 1) deny and ignore, 2) recognize and attempt to explain as the drama unfolds, and 3) the resolution. Epidemiologists are perpetually aghast at our ability to forget this pattern and be caught off guard. Camus understood this conundrum exceptionally well, writing: “So all a man could win in the conflict between plague and life was knowledge and memories.”

Beyond the basic stages of denial, recognition, and recovery, are we able to discern any other psychological themes based on a social and psychological analysis of our behavior? Let us approach this in the manner of a psycho-dynamic anthropologist sent from another planet to observe our species at this moment in time. This investigator would first note our extreme “contamination” fears that go well beyond social distancing, handwashing, and so on.

Our observer would note our curious scramble to obtain and hoard toilet paper. Next, our hoarding of provisions and sudden rush to purchase more weapons would be of interest. The observer could easily discern that the stress humans are currently experiencing has created visible fault lines in our socio-cultural structures. All of these findings would be viewed as our reflexive response to sudden and acute death fears-or what is called “mortality salience” in the terror management literature.

 Our alien observer may well conclude that our species has not yet achieved a rational response to our own mortality-impending or otherwise. Finally, it might be recorded for posterity that humans appear to “forget” the social drama pattern, preferring to bury it back into the unconscious not long after the resolution of a pandemic.

Even a brief review of our past concerning responses to intense reminders of death is both enlightening and disturbing. They include such startling responses as scapegoating, “othering,” and a variety of risky death denying behaviors. Anti-Semitism and blaming of Jewish people were rampant when the Bubonic Plague swept across Europe in the 14th century. The Great Flu Pandemic (1918) is more commonly known as the “Spanish Flu,” despite the fact that the virus did not originate in Spain. Other countries were fearful of reporting their own afflicted status, while Spain transparently reported the problem to the press. It would appear that in the recognition stage of an epidemic, the need to explain is so powerful that if uncertainty remains, identification of a scapegoat becomes the default position. And have we seen such responses recently? Indeed, we have. Early anti-Chinese sentiment spread much more rapidly across the globe than actual virus itself. 

 As the pandemic has progressed over the past few weeks, we have seen all manner of panic-inducing reports in the media.

Morbid statistics that rise daily. Breaking news about the latest celebrity to have contracted the virus. One cannot but have sympathy and understanding for the general public who are relentlessly bombarded with confusing, and often divergent, messages. A scientist, who underscores the impact of his op-ed article by noting he is “an MIT-trained physicist and complexity scientist who studies pandemics,” urgently recommends a five-week “national lockdown.”

 Almost simultaneously, a Nobel laureate and Stanford biophysicist, who has analyzed 

 cases worldwide, writes that the data don’t support such a dire scenario, and that “

Without a consistent, calm, level-headed message, how can we expect the public 

to resort to well-worn habits that result from confusion and reminders of death? Certainly, they will-and absurdity will, temporarily, ensue. We will divide and “other” just as surely as viruses will mutate and infect us again in the future. Besides reports of hate crimes against Asians rising, the absurd can be seen in recent generational tensions. Millennials have been 

to the virus as the “#BoomerRemover,” while the older generation responds by shaming the younger for their “#CoronaParty” during spring break.

Virtually every culture engages in rituals to both forestall and ease death anxiety. It was not until the late 80s that researchers began formally studying death anxiety and how it is a “driving force behind the human motives for self-esteem and meaning in life, and thus plays an important role in diverse aspects of human behavior.”

 (TMT), our innate biological instinct for survival, combined with our capacity for self-consciousness, sets the stage for painful awareness of our mortality and its attendant terror.

 TMT research, derived from the Pulitzer Prize winning work of cultural anthropologist Ernest Becker, suggests that increased death terror motivates us towards the familiar (e.g., tradition, in-group worldviews, and cultural orientations.

 TMT research has progressed over the past several decades, finding that “death primes,” or reminders of mortality, are associated with:

• Hardening of traditions and fundamentalist beliefs

• Enhanced efforts to achieve attachment security

• Aggression against others who threaten one’s culture or traditions

Given the continuous media reports of death primes (the pandemic, the precarious nature of our environment, economic and political instability, etc.), one may wonder if the resultant death terror will be more intense than usual.

 Even if this turns out to be accurate, is there any reason for optimism? There is reason to believe so. For example, resilience-a proven strength of humans, is often seen in the midst of crisis and disaster.

What we learn in times of pestilence: that there are more things to admire in men than to despise.

At the heart of every tragedy is the finality of “the end” (e.g., loss) -the ultimate expression of which is death. To reckon with the end and death is to struggle with finding meaning in the face of the absurd. This can be seen in Samuel Beckett’s modernist works dealing with loss, suffering and death.

 Facing the absurd and death terror need not always result in morbid outcomes. TMT research has begun to suggest that resilience, when under the strain of death terror, may lead to positive progress, flexibility and new meanings. Of course, resilience in general is capable of producing personal growth and improved functioning in the face of stress and adversity.

My colleague, Dr Lloyd Sederer, who has led mental health disaster responses in New York, notes that there are always lessons to be learned and optimistic actions we can take.

 In addition to providing calming guidance in the form of organizational mandates and coordinated responses, we can begin with ourselves. In line with TMT research, Dr Sederer suggests turning to our sustaining, meaningful relationships; adequate self-care; exercise and various mindfulness exercises. TMT research from a positive psychology standpoint has found that death anxiety may also result in the following positive opportunities and growth-oriented goals:

• Valuing creativity and creative achievement

• Prioritizing growth-oriented goals and positive standards

Within times of chaos may lie the seeds of opportunity leading to new strategies, novel solutions and expanded meaning. Yet this will depend largely on our ability to sit with uncertainty and avoid the pressure to regress to unhelpful habits. In this way, death fear may serve as a cognitive reorganizer to develop a stronger “existential self-consciousness that sustains a process of self-overcoming.”

 A balance must be achieved, however, between healthy death terror buffers and outright panic driven denial. The influence of death awareness is truly profound, and may generate negative outcomes, as well as impel us along “more positive trajectories and contribute to the good life.”

Around 1637, the classical French painter Nicolas Poussin completed a masterpiece titled 

, also referred to as The Arcadian Shepherds. The beautiful painting shows an idyllic pastoral scene in which shepherds are gathered around a tomb. The title can be translated roughly to “Even in Arcadia, there I am,” or “Even in Arcadia, death is there.” Since the time of ancient Greece, Arcadia has been a metaphor for a Utopia, as it was far from the complexities and troubles associated with urban city life. As with all great art, it contains multiple meanings. One message is for us to never forget the fragility and brevity of life. Another message, more subtle but equally important, is that we have a duty to do our best to calm and sublimate our death fears. Recognizing this duty now seems to be an important task-one that we cannot allow ourselves to continue repressing.

Camus would likely have endorsed this approach, as his solution to the Absurd was to fully accept it – while continuing to live on – thereby achieving a transcendent form of freedom and personal meaning. Perhaps we might let this pandemic serve as our creative stimulus to begin to develop and test a set of go-to responses to mitigate panic in the face of a pandemic? We will surely have more opportunities to implement them. This would be a human triumph – to better understand and respond to those in the throes of overwhelming death terror, and develop “robust international responses to affected patients and communities.”

 and adopt a Camus-type philosophy which leads us away from fear and despair, and towards “a softening of the heart, a turning away from judgment and moralizing to joy and gratitude.”

is Director of Forensic Psychiatry and Professor of Psychiatry at SUNY Upstate Medical University in Syracuse, NY. He is Editor in Chief Emeritus of 

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We often push thoughts of death far out of our awareness, but at the present time they unavoidably re-emerge. Can we learn something helpful from this?

Panic and Pandemics: The Return of the Absurd

by Kenneth J. Weiss for the Group for the Advancement of Psychiatry Committee on Art & Humanities

Across the centuries, March has been an eventful month for the 

 on both sides of the Atlantic, and the McNaughten rule remains the prevalent standard to this day.

On March 2, 1843, Daniel McNaughten went on trial for murder, leading to a ruling of not guilty by reason of insanity. The McNaughten Rule has influenced insanity defenses ever since.

In the 1840s, Britain was the scene of protests over the Corn Laws, which stressed lower socioeconomic classes by taxing grain. Prime Minister Robert Peel of the Tory Party was vilified as an oppressor. A Scottish woodworker, McNaughten, became obsessed with Peel, believing he and the Tories were persecuting him, directly and severely enough to threaten his life. Under that fixed idea in 1843, he came to London to study and assassinate Peel in order to save his own life.

On January 20, 1843, McNaughten lay in wait near Peel’s home. A man left the home, and McNaughten shot him from behind. The victim, however, was not Peel; rather, it was his secretary, Edward Drummond. Though it remains 

whether McNaughten knew he was shooting the wrong man,

 sources say the shooter believed he had shot Peel.

 Regardless, the shooting was intentional. The victim died less than a week later, making it a murder case.

On March 2, 1843, McNaughten’s trial began at the Central Criminal Court of London. He had a talented lawyer, Alexander Cockburn. Expert testimony said that as a result of his delusions, McNaughten did not know what he was doing was wrong. Cockburn, who had read 

A Treatise on the Medical Jurisprudence of Insanity

 published in 1838 by American physician Isaac Ray, relied on Ray’s idea that there should not be a single test for insanity. The defense so persuaded Lord Chief Justice Tindal that he directed a verdict of not guilty on the ground of insanity. McNaughten, considered dangerous, was civilly committed, the custom that began in 1800.

On January 20, 1843, McNaughten lay in wait near Peel’s home. A man left the home, and McNaughten shot him from behind. He shot the wrong man.

The verdict did not sit well with Queen Victoria, who had been the object of threats and attempts to harm her. She was incredulous that a man who opposed the conservative government would be considered insane and not responsible. The House of Lords promptly held an inquiry asking legal experts a series of questions. For example: What is the proper test for criminal responsibility?

The consensus was that the correct test is whether the defendant, at the time of the act, labored under such a defect of reason from disease of the mind as not to know the nature and quality of the act he was doing, or as not to know what he was doing was wrong.

 This was a cognitive test (knowing right from wrong), in contrast to the volitional test (not having the will to resist an impulse). The new standard became known as the McNaughten Rule, even though McNaughten was not tried under it. It quickly caught on in America, where it remains the predominant standard for insanity.

In the mid-20th century, Dr Ray’s advice was evident. First, federal jurisdiction in 1954 permitted juries to consider a standard Ray supported in 19th century: “an accused is not criminally responsible if his unlawful act was the product of mental disease or mental defect.”

 Then, in 1972, the federal jurisdiction adopted the American Law Institute’s standard (a volitional test in addition to a cognitive test).

On March 30, 1981, John Hinckley Jr shot and wounded President Reagan and his press secretary, James Brady. He was tried and acquitted by reason of insanity under the federal standard. This troubled Congress, just as it did the Crown after the Drummond assassination. The result was the removal of the volitional standard in new legislation-the Insanity Defense 

 of 1984-and a return to the McNaughten Rule.

Group for the Advancement of Psychiatry Committee on Art & Humanities: David Sasso, MD, MPH 

Across the centuries, March has been an eventful month for the insanity defense on both sides of the Atlantic, and the McNaughten rule remains the prevalent standard to this day.

Forensic Psychiatry

Challenges and Strategies in Foster Care

Weaving Beauty Into the Tapestry of the Pandemic

The Boundary I Wish I Hadn't Kept

Panic and Pandemics: The Return of the Absurd

Assassins in London and Washington Force Changes in the Insanity Defense

News Headline: “Psychiatrist, Three Accusers Settle Out of Court”

Treatment and Prevention of Parental Alienation

Psychiatric Malpractice Grand Rounds: Addiction Psychiatry

A Rock and a Hard Place

Cruel, Immoral Behavior Is Not Mental Illness