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Wednesday 31 August 2011


Biomarkers in psychiatry

Ilina Singh & Nikolas Rose(Nature,460,July 2009)


The use of biomarkers to predict human behaviour and psychiatric disorders raises social and ethical issues, which must be resolved by collaborative efforts.

Psychiatry has long been a second-class citizen in science and medicine. Despite much effort, the causes of many psychiatric disorders remain unclear, and it has been difficult even to categorize such disorders precisely


Beyond polemics: science and ethics of ADHD

Ilina Singh


What is attention-deficit hyperactivity disorder (ADHD)? Why are so many children being diagnosed with ADHD and prescribed medication? Are stimulant drugs an effective and safe treatment strategy? This article explores the current state of scientific research into ADHD and the key social and ethical concerns that are emerging from the sharp rise in the number of diagnoses and the use of stimulant drug treatments in children. Collaborations among scientists, social scientists and ethicists are likely to be the most promising route to understanding what ADHD is and what stimulant drugs do.

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• Personal subscribers to Nature Reviews Neuroscience can view the full article.

ADHD diagnosis rates vary hugely between countries - proving a socially constructed factor.

Diagnosis And Treatment Of ADHD Varies Significantly Across Countries

Main Category: ADHD

Article Date: 03 May 2011 - 2:00 PDT

Social attitudes about Attention Deficit Disorder Hyperactivity Disorder (ADHD) and treatments vary by country, according to a new study of the diagnosis and treatment of ADHD in nine countries. The study appears in the May issue of the American Psychiatric Association's journal Psychiatric Services.

ADHD is widely recognized internationally as a chronic neurodevelopmental disorder leading to impairment and requiring treatment. Until recently, epidemiological research supported the conclusion that the prevalence of ADHD varies significantly from country to country. However, a recent meta-analysis indicated that differences in prevalence are largely attributable to methodological differences in the studies themselves (e.g., differing definitions) rather than to cultural or national-level factors. The new survey shows that treatment procedures do vary a great deal between countries, even though ADHD prevalence may not.

Researchers for the new study recruited 18 researchers participating in an international conference on ADHD to review literature, history and current practices in their country and respond to questions about the diagnosis, treatment, payment systems, and beliefs in the educational system about ADHD in different locations.

The nine nations surveyed were Australia, Brazil, Canada, China, Germany, Israel, the Netherlands, Norway, and the United Kingdom. (U.S. data were also gathered, but they are not reported in the article because of space considerations.) All ten nations saw an increase in use of medications; use of longer acting, more expensive medications is becoming more common. In some countries, medications are viewed as a first-line treatment, whereas in others psychosocial treatments are the recommended first-line approach. For example, in the United Kingdom treatment guidelines advocate use of psychosocial treatments first in many cases, and in Canada the use of medication and psychological interventions is determined by doctor and patient preferences.

The report looks at social and economic factors and cultural values influencing ADHD treatment as well as divergent professional training that affects the choice of treatment models. An interesting example of variation is in the way that school settings perceive and react to ADHD symptoms. Respondents from Israel commented on the tolerance for high activity levels in classrooms, whereas respondents from China noted that children are expected to remain still and on task for long hours in quiet classrooms. Brazil retains a highly psychoanalytic perspective on ADHD, which results in low rates of referral from schools. In addition, Brazil's education system is largely under the influence of "constructivisim," meaning that behavioral problems are not viewed as related to clinical manifestations of disorders.

The authors, led by Stephen P. Hinshaw, Ph.D., Department of Psychology, University of California, Berkeley, conclude there is a particular need for evidence-based treatments for long-term impairments related to ADHD and call for "culturally sensitive research to enhance understanding of both across-nation and within-nation variability in intervention procedures and access to treatment." They also noted a lack of research on ADHD in adults and lack of resources for treatment of adults.


American Psychiatric Association


Diagnosing the DSM

Diagnostic Classification Needs Fundamental Reform

By Steven E. Hyman (HARVARD PROVOST)

April 26, 2011

Editor’s Note: If all goes as planned, the American Psychiatric Association will release a new Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in May 2013. Since 1980, the DSM has provided a shared diagnostic language to clinicians, patients, scientists, school systems, courts, and pharmaceutical and insurance companies; any changes to the influential manual will have serious ramifications. But, argues Dr. Steven Hyman, the DSM is a poor mirror of clinical and biological realities; a fundamentally new approach to diagnostic classification is needed as researchers uncover novel ways to study and understand mental illness.

Author’s disclaimer: I have written this piece to argue my individual views. These do not represent official views of the DSM-5 Task Force, of which I am a member, or of the International Advisory Group working on the International Classification of Diseases (ICD-11) chapter on Mental and Behavioral Disorders, which I chair.

Writing in Cerebrum (October 2009), distinguished psychiatrist Paul McHugh noted that the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) “aims only to enhance diagnostic consistency. It does not speak to the nature of mental disorders or distinguish them by anything more essential than their clinical appearance. Not a gesture does it make toward the etiopathic principles of cause and mechanism that organize medical classifications. …”1

McHugh’s diagnosis of the core limitation of the DSM-IV (first published by the American Psychiatric Association in 1994) is absolutely correct. No sensible person could disagree. The challenge, however, is not so much the diagnosis as the cure. Many of the scientific advances that will be needed to understand the neurobiological underpinnings of mental disorders remain in the future. The DSM-IV is so deeply ingrained in the practice of psychiatry, psychology, and general medicine that it codifies mental disorders not only for patients, families, and clinicians, but also for insurance companies, regulatory agencies (such as the U.S. Food and Drug Administration), the justice system, school systems, and others. Any substantial change to the DSM system must be carefully managed to avoid many serious disruptions.

Since the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), released by the American Psychiatric Association in 1980, the diagnosis of mental disorders has been based entirely on clinical descriptions: lists of symptoms, their duration, timing of onset, and the like. Motivated as much by the desire to elide the deep theoretical divisions (e.g., between psychoanalysts and psychopharmacologists) that had existed among clinicians for much of the 20th century as by the recognition that the underlying science was fragmentary at best, the DSM-III, DSM-IIIR (“R” for “revised”), and DSM-IV have eschewed explicit references to possible causes of illness or to pathologic processes, whether at the psychological or neurobiological levels.

Although there has been enormous progress in neurobiology during the past decade, the problem for those hard at work on the DSM-5 remains the stubborn difficulties of the science. The attempt to understand the workings of the human brain and to learn exactly what goes wrong to produce mental illnesses must number among the most challenging problems scientists have ever faced. Although, for example, the DSM-5’s writing is well under way, even today its authors do not have the benefit of objective medical tests for any common mental disorder. Despite the steep challenges facing modern neurobiology, psychology, and genetics in their attempts to decode the mysteries of the brain and its ills, I argue that much can be done in constructing the DSM-5 (and also the World Health Organization’s International Classification of Diseases, 11th edition, or ICD-11) that could facilitate the transition from the shallows of descriptive psychiatry to diagnoses based on cause and mechanism.

The Benefits of Shared Diagnostic Criteria

Despite the limitations we see so clearly in hindsight, the publication of the DSM-III in 1980 represented a major advance. Earlier editions of the DSM had provided lists of mental disorders but no guidance as to how a clinician was to make these putative diagnoses. Even where objective diagnostic tests exist in general medicine, as for hypertension or iron-deficiency anemia, explicit guidance is needed, such as for translating a specific set of blood-pressure readings into a diagnosis and treatment recommendations. Lacking objective tests, clinicians varied widely in their diagnosis of mental disorders before the DSM-III, and diagnoses also differed among countries where different diagnostic practices predominated. For example, it appeared in the 1950s that schizophrenia might be twice as common in the U.S. as in Great Britain, but the true difference was that in Great Britain, schizophrenia was understood only as a chronic condition; in the U.S., “acute schizophrenia” also was diagnosed. As new drug treatments began to emerge in the second half of the 20th century, however, it became critical to be able to match patients with the most appropriate treatment—to separate schizophrenia from bipolar disorder, for example, because the latter responds to lithium, whereas schizophrenia typically does not.

A pressing need thus emerged to address the lack of inter-rater reliability (often shortened to “reliability”). Inter-rater reliability means that two different trained raters, whether clinicians or researchers, using the diagnostic system are highly likely to reach the same diagnosis for a given patient. The solution that scientists embraced in the DSM-III was to develop and promulgate diagnostic criteria (rules) that were explicit and straightforward to apply based on observations of patients or questions that patients or family members should readily be able to answer. Thus, for example, the DSM-III defined schizophrenia as a chronic disease by explicitly basing the diagnosis on a requisite six months of active illness. As a result, the prevalence of schizophrenia was recognized to be equivalent on both sides of the Atlantic. Similarly, beginning with the DSM-III, major depression was diagnosed only if at least five out of a list of nine symptoms were present for at least two weeks.

The Downside to Standardizing Diagnoses Early in Scientific History

The DSM-III did yield significant progress toward inter-rater reliability, although the lack of objective tests keeps reliability far from perfect. Under the surface, however, lurked a different problem: validity. Lacking the necessary scientific information, DSM-III diagnoses were, perforce, the products of expert consensus, not the result of deep scientific understanding. In fairness, neither the DSM-III nor any of its successor manuals claimed that the diagnoses contained therein represented replicable abnormalities of anatomy, physiology, or biochemistry within the brain or provided information about the causes of the patient’s symptoms. The most careful thinkers have always understood that DSM-III diagnoses should be understood as useful placeholders pending advances in research. However, this “validity problem” is often pushed into the background as a pragmatic matter. Paradoxically, the very success of the DSM system in improving diagnostic agreement among clinicians and across countries required widespread acceptance, a development that might not have occurred if users saw the DSM-III as merely heuristic.

As I have argued elsewhere, however, worldwide acceptance of a scientifically immature system has come at a price.2 Clearly, it is important that a schizophrenia treatment study performed at one center is applicable to patients diagnosed with schizophrenia at another. However, the entrenchment of the DSM system has had the unintended consequence of suppressing important avenues of scientific investigation. What has happened? Clinicians rely on DSM-IV diagnoses to get reimbursed by insurance companies. Scientists must generally use DSM-IV criteria to obtain research grants or to have papers accepted by journals. The pharmaceutical industry must use DSM-IV criteria in selecting patients for clinical trials in order to obtain regulatory approval for a new treatment. Psychiatrists and psychologists must memorize DSM-IV criteria for licensure exams. As a result, the DSM-IV is often treated more like the periodic table of elements than as a highly useful but limited product of expert committees working in the United States in the late 1970s—before the advent of modern molecular genetics, almost two decades before the first functional magnetic resonance imaging study, and only a few years after neurobiology began to coalesce as an academic field.

Limitations of the DSM-IV

As a result of its widespread acceptance, and the de facto reification of its diagnostic silos, the DSM-IV exerts far too much influence on the questions that scientists can ask and, in practice, do ask.2 For example, most neuroimaging studies, clinical trials, and other investigations published in mainstream journals have, almost by necessity, taken as their starting point individual DSM-IV diagnoses, such as panic disorder, generalized anxiety disorder, or anorexia nervosa. Too rarely, however, have scientists asked (or been encouraged by funders or journal editors to ask) questions about anxiety symptoms, eating-related symptoms, or other constellations of symptoms that transgress DSM constructs. Of course the replicability of research on mental disorders benefits from a shared diagnostic language. The problem with the DSM-IV, our current shared diagnostic language, is that a large and growing body of evidence demonstrates that it does a poor job of capturing either clinical and biological realities. In the clinic, the limitations of the current DSM-IV approach can be illustrated in three salient areas: (1) the problem of comorbidity, (2) the widespread need for “not otherwise specific (NOS)” diagnoses, and (3) the arbitrariness of diagnostic thresholds.

Multiple Diagnoses, Shared Genetic Risks

Both in clinical practice and in large epidemiological studies, it is highly likely that any patient who receives a single DSM-IV diagnosis will, in addition, qualify for others, and the patient’s diagnostic mixture may shift over time. There is a high frequency of comorbidity—for example, many patients are diagnosed with multiple DSM-IV anxiety disorders and with DSM-IV dysthymia (chronic mild depression), major depression, or both. Many patients with an autism–related diagnosis are also diagnosed with, obsessive-compulsive disorder and attention-deficit/hyperactivity disorder. The frequency with which patients receive multiple diagnoses far outstrips what would be predicted if co-occurrence were happening simply by chance. Researchers who have made careful studies of comorbidity, such as Robert Krueger at the University of Minnesota, have found that co-occurring diagnoses tend to form stable clusters across patient populations, suggesting to some that the DSM system has drawn many unnatural boundaries within broader psychopathological states.3 Kenneth Kendler of Virginia Commonwealth University, who has performed twin studies designed to discover genetic influences on disease risk, has found that the DSM-IV disorders that frequently co-occur with each other may do so as a result of shared genetic risk factors.4 In addition, emerging technologies in genomics and molecular genetics have begun to identify shared “disease risk genes”—better described as variations in DNA sequences that correlate with illness—across multiple DSM diagnoses. For example, DSM-IV schizophrenia and bipolar disorder appear to share a large number, although not all, of their genetic risk factors. One significant divergence is that the genomes of many people with schizophrenia, but not bipolar disorder, may harbor disease-associated duplications and deletions of large DNA segments.

Shared genetic risk factors do not refute the existence of patients with “classical” schizophrenia or bipolar disorder who would have differing treatment responses and different outcomes. What the genetic findings do suggest, however, is that the DSM-IV handling of each disorder as a discrete natural category, discontinuous from other categories of disorder and from health, is palpably wrong. The sharing of genetic risk factors is reflected in clinical populations; more patients have mixed symptoms of schizophrenia and of mood disorders than have pure DSM-IV disorders. Some of these intermediate patients meet DSM-IV criteria for “schizoaffective disorder,” a rather strange chimeric diagnostic construct, but many do not; many such patients exhibit changing symptom patterns during their lifetimes. For these and other disorders, it appears that a purely categorical approach to mental disorders fails to capture the realities of either clinical practice or laboratory science. Much psychopathology would be better represented in terms of quantifiable dimensions analogous to those in hypertension (in which the dimensions are systolic and diastolic blood pressure) or diabetes mellitus (in which quantitative measures include serum glucose and hemoglobin A1c). In a system with underlying dimensions, schizophrenia might be diagnosed in patients with elevated scores on symptoms scales that measure psychosis, cognitive disorganization, and deficit symptoms. Those patients with mixed symptoms would also have abnormalities on scales of negative or positive mood states. These patients would no longer be diagnostic orphans (who fall outside DSM-IV’s narrow categories); they would be more amenable to study, and ideally they would benefit from the development of new treatments.

“Not Otherwise Specified” and Arbitrary Diagnostic Thresholds

The overriding focus on reliability led the authors of the DSM-III to produce highly specific criteria. Unfortunately, in many domains of psychopathology, these criteria pick out small islands in a sea of patients who do not quite fulfill the diagnostic criteria—such as many patients with symptoms of both psychosis and mood disorder. These patients may receive a diagnosis of “psychosis NOS,” or psychosis not otherwise specified. In some areas of practice, such as eating disorders and autism spectrum disorders, a majority of patients may receive NOS diagnoses. This observation, like the problem of comorbidity, points to categories being far too narrowly drawn, unable to capture the full range of symptoms and severities in diagnostic spectra (as in autism) or of complex or shifting symptom patterns (as is typical of eating disorders).

Finally, the categorical system means that a disorder is either absent or present. One needs five of nine symptoms for two weeks to qualify for major depression, but someone with only four of the symptoms, of high severity, may be more impaired than someone else with five, six, or seven. Despite much research, scientists have failed to identify any natural “cut point” for the diagnosis of depression—any specific point of discontinuity with ordinary sadness. This suggests that it, too, might be better seen in dimensional terms, with treatment recommendations based on levels of impairment or distress just as treatment recommendations for hypertension are based on long-term outcomes, such as avoiding heart attack and stroke.

Rethinking Diagnostic Classification

The question facing the DSM-5 Task Force is how it can encourage new approaches for science—at present we are not in a position to successfully portray disorders in dimensional terms, for example. At the same time, the task force must respect the influence of the DSM-IV and not create a premature revolution that might return us to a pre-DSM-III state that lacks a shared diagnostic language. How can we give the research community not only permission but also encouragement to rethink the classification of psychopathology? How can we encourage scientific innovation while ensuring that clinicians can still communicate with patients and families—and also with insurance companies, schools, and courts?

The approach for which I have argued is to focus the major efforts of the DSM revision not on individual diagnoses but on the assembly of larger clusters that could facilitate the application of modern neuroscience, psychology, and genetics to the understanding of mental disorders.2,5 Lest that seem far too abstract: Simple phobia, social phobia, panic disorders, and generalized anxiety disorder would continue to be found in the DSM-5. However, they would be placed in an anxiety disorders cluster. This cluster would, moreover, be situated within a larger meta-cluster termed the “emotional” or “internalizing” cluster. This meta-cluster would comprise several additional clusters: depressive mood disorders (perhaps to include major depression, dysthymia, and a proposed mixed anxiety-depression diagnosis); disorders resulting from trauma or severe experiences of adversity; and a newly recognized cluster of obsessive-compulsive disorder and related disorders (such a compulsive hair pulling or skin picking).

Scientists would be free to continue to work on individual disorders, but they would be encouraged to be agnostic about the narrow boundaries within clusters or even some of the divisions within the meta-cluster when designing new genetic, cognitive, imaging, or treatment-development studies. We also would hope that new ways of representing symptoms within and across clusters would be tested, such as the identification of symptom dimensions, neurobiological endophenotypes (neural abnormalities that might underlie symptom productions), and the like. Some candidate clusters, such as the emotional or internalizing clusters described above, have come directly from the work on comorbidity3 and twin studies,4 which find that certain disorders are highly likely to co-occur. Another proposed cluster might derive from our emerging understanding of brain development. Within the DSM-5, these clusters might be represented as chapters or other major divisions. What is important, however, is not a new table of contents for the DSM-5 but a system that facilitates a fundamental and thorough reanalysis of diagnostic classification.

An important goal, without which such an effort will have little utility, is to persuade scientists, funding agencies, and journal editors to treat clusters and meta-clusters, instead of individual DSM categories alone, as valid bases for research. I would imagine that if such an effort were successful, the DSM-6 (more than a decade from now) will have far fewer individual diagnoses than the DSM-5 and will represent many disorders as intersections among symptom dimensions. It is also possible—indeed, much to be wished for—that DSM-6 diagnoses will be constrained by objective tests, such as neuroimaging and genetics.

With respect to the DSM-5, I am agnostic about the diagnostic criteria for individual conditions, such as panic disorder or generalized anxiety disorder; in the end, I am not certain that either of these categories capture nature or will even appear in the DSM-6. When it comes to individual diagnostic categories, I would recommend that the DSM-5 take a conservative approach, leaving criteria unchanged unless compelling new evidence suggests that a change would be beneficial. Whatever the ultimate approach to the DSM-5, it is critical that the scientific community escape the artificial diagnostic silos that control so much research, ultimately to our detriment.

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1. McHugh, P. R. (2009). Psychiatry at stalemate. Cerebrum. Retrieved from http://dana.org/news/cerebrum/detail.aspx?id=23560#McHugh_jump.

2. Hyman, S. E. (2010). The diagnosis of mental disorders: The problem of reification. Annual Review of Clinical Psychology, 6, 155-179.

3. Krueger, R. F., & Markon, K. E. (2006). Reinterpreting comorbidity: A model-based approach to understanding and classifying psychopathology. Annual Review of Clinical Psychology, 2, 111-133.

4. Kendler, K. S., Aggen, S. H., Knudsen, G. P., Røysamb, E., Neale, M. C., & Reichborn-Kjennerud, T. (2010). The structure of genetic and environmental risk factors for syndromal and subsyndromal common DSM-IV axis I and all axis II disorders. American Journal of Psychiatry, 168(1), 29-39.

5. Hyman S. E. (2007). Can neuroscience be integrated into the DSM-V? Nature Reviews Neuroscience, 8, 725-732.


Features | Published in TES Magazine on 26 August, 2011 | By: Liz Lightfoot

   Of the thousands of children excluded for violence and disruption every year, some are as young as four. Liz Lightfoot reports on the ‘nurture’ groups whose efforts to keep these infants in mainstream education can be astonishingly successful

There would be an outcry if the health service told the mother of a very sick child to take him home because it did not have the money or staff to cope with his condition. And if that child were allowed to deteriorate at home until he was so ill that he needed a £1,700-a-day critical-care bed, questions would almost certainly be raised about why he had not been treated in the first place.

Strange it is, then, that something similar happens without protest every day in the world of education. Children as young as four are excluded - often from more than one school - and are stuck at home until a place can be found for them at a special unit - and later in their lives, all too often at a young offenders’ institution.

Figures published in July revealed that 6,320 pupils aged seven and under were given fixed-term exclusions in 2009/10, many of them more than once as the total number of exclusions was 13,060. There were also 220 permanent exclusions of children aged seven or under after schools said they could not cope with their behaviour.

The vast majority of these cases involved violent, aggressive and anti- social behaviour not normally associated with children at an age when most still believe in fairies and Father Christmas. Of the 620 permanent exclusions of children aged 11 and under, 90 were for assaulting another child and 180 for assaulting an adult, according to Department for Education figures. Verbal abuse and threatening behaviour against another child led to 30 permanent exclusions, and against an adult a further 70; sexual misconduct led to 10; damage 10 and persistent disruptive behaviour 190.

It is hard not to feel sympathy for the schools that have to take such drastic action. Teachers with a class of 30 pupils, or even 20, can hardly be expected to cope with children, however tiny, who throw chairs and tables at them, pull their hair or scratch them on the face. While the disruptive children take the lion’s share of attention, other pupils miss out.

But what of the children? Is their own home really the place where they will recover? Across the country a growing number of schools are convinced that it is not and have set up “nurture” groups in which children most in need of attention are taught by specially trained staff in groups of eight to 12 in more relaxed, family-style surroundings for part of the day. Usually they join their classes for the start and end of the day, and for activities they can cope with.

While inappropriate behaviour and the inability to mix socially are sometimes found to be linked to a medical condition, nurture groups are set up primarily to help children who have suffered a trauma or faced neglect or violence in the home. Sometimes the cause can be traced back to family bereavement, marriage breakdown or a mother’s postnatal depression. In other cases, children come from homes where there is alcoholism, drug abuse or domestic violence.


There are now around 1,500 nurture groups at schools in the UK and they claim some stunning successes. In one instance, a violent boy who had attacked teachers and other children traumatised the staff looking after him even further when he tried to hang himself in front of them. He was moved to another primary that adopts the nurture-group approach and within a year his behaviour and self-confidence had improved so much that he was able to rejoin mainstream classes.

Teachers have cited the case of the six-year-old who stripped off his clothes to check he was still there after his mother had told him he was such a bad little boy that he did not exist, and of the girl who thought she was ugly and would not believe that photographs of what she called “that pretty girl” were really of her. Both children made huge strides in their nurture groups and were later reintegrated into mainstream classes.


Nurture groups were first introduced in Hackney, east London, in 1970 by educational psychologist Marjorie Boxall. She was a proponent of attachment theory, which stresses the importance of children forming secure and happy relationships in their early years. A typical nurture group will eat breakfast together in homely surroundings that usually include soft chairs and toys. Children are accepted for what they are, not punished or criticised. They are taught the behaviour that is expected of them and are rewarded at every stage to encourage them. It is an approach much like the one a parent might take with a toddler who has limited skills to express himself and has not yet learnt to distinguish right from wrong or how to behave socially with others.

The expectation is that when the children have learnt to behave socially within the small group, they will be able to re-join their mainstream classes.

Last month, the nurture-group approach received a huge accolade from Ofsted, which reported that this form of intervention was having a “highly significant and far-reaching” effect on the behaviour of children who might otherwise be at risk of exclusion. Ofsted’s report, based on visits to 29 schools and 379 pupils in nurture groups, said the approach was giving children the skills they needed to remain in education and saving them from permanent exclusion.

But while new groups are being set up, others are closing or running reduced hours as the Government’s spending cuts hit school budgets. A survey by the umbrella organisation the Nurture Group Network (NGN) found that 87 of the groups have closed and others are under threat.

When schools return from the summer break, new Government guidelines on tackling poor behaviour will be in place and the Education Bill going through Parliament will extend schools’ powers of search and prevent exclusion appeals panels from sending children back to those that excluded them.

Teachers generally welcome the extra powers, but Anne Marie Carrie, chief executive of children’s charity Barnardo’s, wants to see far more emphasis on helping and supporting pupils. “Clearly, managing challenging and disruptive behaviour in schools is essential. But very vulnerable children who are persistently disruptive often have problems at home which means they need extra help to manage their behaviour,” she says.

“Repeatedly excluding a child is ineffectual and does little to improve their behaviour. For this reason, the ‘tough discipline’ approach currently being recommended by the Government is misguided.”

Clare Clarke, the head of Tottenhall Infant School in Enfield, north London, says her school does not exclude pupils. Sometimes the child needs to stay in the nurture group - called Rainbow - for four or five terms and other support is sought for them through social services or the educational psychology service, she says. Most of these children, however, re-join their mainstream classes within one to three terms. Rainbow has 10 places, with two of them usually left free for emergencies, such as the arrival of refugees from war-torn parts of the world. “One day a little boy’s mother died overnight. He was eating mud, ripping up and defacing things. Rainbow gave him space and time to help him work through the trauma,” Ms Clarke explains.

Rainbow runs to between £60,000 and £70,000 a year to cover the cost of an experienced teacher and a classroom assistant. “It is incredibly cost- effective when you think about what would otherwise happen to the children. Without a shadow of doubt, these are children who would be excluded if they had to be taught in mainstream classes. They head-butt, bite, kick, swear, throw things. They are angry, but not at us. It is their way of saying, ‘Please help me.’ We teach them to articulate their feelings,” says Ms Clare.

“You need to be inclusive and believe that every child has a right to be in school. If you exclude a child, they will be shunted to another school. They are only four or five - they are not out to deliberately hurt people.

“Marjorie Boxall said we must nurture these children because they have missed out on nurture in the family. If there has been no key person to value the child, the child has a hostile view of the world out there. We help them to build up relationships and trust people again.”

But are parents offended by the idea that their children need nurturing that they have not had at home? Ms Clare says only one parent has voiced strong objections. “We always invite the parent in, and when we sit down and have a discussion about the child’s early experiences, they begin to trust you and tell you things that have happened in their lives,” she says. “Very often we see not only the child begin to flourish - with clean shoes and shiny hair - but the parents begin to take more pride in themselves as they grow in self-esteem and confidence with their children.”

Ms Clare’s school was praised for its emphasis on reintegrating the children back into class. The Rainbow children join their classes for activities that they enjoy, such as PE or singing, and are gradually eased back into other lessons. Here, Ofsted also cited the liaison between classroom teachers and the Rainbow staff to ensure the children did not fall behind with the curriculum.

Inspectors said the highlight of their visit was when former members of the Rainbow group returned from their new educational settings to speak to them. “I feel like a president coming back on a state visit,” said one former pupil. “I feel honoured to have had a time in Rainbow. I used to be angry and unhappy and it saved me.”

The positive Ofsted report has given nurture groups a boost, but there are tough times ahead as local authorities and headteachers struggle with reduced budgets. Irene Grant, the national director of the NGN, says successive studies and reports have identified early intervention as the key to success in this area. Cutting the modest funding needed to run the groups will cost the country far more in the long run when troubled children turn into aggressive teenagers, anti-social adults and parents who cannot give their own children the security they lack, she warns.

New discipline measures in the Education Bill 2011

- Staff powers of search extended to items banned by the school and articles that they reasonably suspect have been, or are likely to be, used to commit an offence or cause personal injury or damage to property.

- Appeal panels abolished and replaced by review panels that will not have the power to force a school to reinstate an excluded pupil.

- Repeal of the requirement to give 24 hours’ notice of detention to a parent, allowing schools to issue same-day detentions.

- Repeal of duty to enter into behaviour and attendance partnerships with other schools.

- Anonymity for teachers accused of misconduct against a pupil until the teacher is charged or the Secretary of State publishes information about an investigation or decision in a disciplinary case.

Revised behaviour guidelines

- Schools should not have a “no touch” policy. It is often necessary or desirable for a teacher to touch a child (dealing with accidents or teaching musical instruments).

- Teachers have a legal power to use reasonable force - for example, to remove a pupil who is disrupting a lesson or to prevent a child leaving a classroom.

- Heads can search for an extended list of items, including alcohol, illegal drugs and stolen property.

- Heads have the power to discipline pupils who misbehave outside the school premises and outside school hours.

See: www.nurturegroups.org

www.ofsted.gov.uk/resources/supporting-children-challenging-behaviour- through-nurture-group-approach

Case study: from aggression to nativity’s ‘absolute joy’

Cheryl first started being aggressive and hitting out at other children in the nursery. Both her parents were addicted to drugs and she was living with her grandmother.

When she moved into the infant classes, aged five, her behaviour deteriorated. She was biting, scratching, nipping and pushing for no reason. She would attack adults and other pupils every day. As a result, she was suspended from school.

Her grandmother was desperate for help and it was agreed that Cheryl would go into the nurture group and that home and school would keep daily diaries to keep in touch.

Her behaviour changed in the small group. She was extremely quiet and scarcely spoke. She would come into the room, sit down and clasp her hands on the table in front of her, only nodding and shaking her head in response to questions.

The teachers insisted she said the minimum of “yes” or “no” and built up her responses slowly. When she became violent with others, she was taken to a quiet corner to talk through what had happened. Very often she did not know why she had done it. The child she attacked was brought in so that Cheryl could apologise.

“The one positive thing in her first term in the group was that she did not bite anyone,” her teacher said. “She still nipped other children or pushed them, but these incidents were fewer in number. She stopped attacking adults in the playground when they spoke to her. She still screamed ‘No!’ at them when she was asked to do things and could be heard swearing at playtime.

“Then she started to say she did not want to come to the nurture group and wanted to stay in the class - probably because she did not want to follow the rules of the group and face the consequence of her behaviour. We started a treasure box for each child so that the children gained treasures for a variety of things. This proved to be a big success. She loved counting her treasures with us and working out how many more she needed to win a prize.”

After three terms in the group, her behaviour had improved so much that she was able to join a mainstream class for part of the day and performed in the nativity play.

“She showed absolute joy at taking part. She now had an environment where she knew what to expect each day and she felt safe,” the teacher said.

Tuesday 30 August 2011

Time is ticking out until DSM5 arrives in 2013!


Time is ticking out
There is no doubt
The resulting "diagnosed" levels of  "madness"
Should be greeted by all with much sadness,
For a society that drugs the child
Is only one step from the wild.

What of the West being civilised?
"It would be a good idea,"
As Ghandi once summised.

Sunday 28 August 2011

What was the harm? - for I am only a child - Majorcan Ditty day 5

Please forgive me
For I am only a child
And my innocence
Has been medicated away.

What was the harm
In chattering
As talking gets you on in life?

What was the harm
In being energetic
As drive gets you places?

What was the harm in being impulsive
As risk taking 
Is often highly valued in adults?

What was the harm?

Saturday 27 August 2011

End of the Stone Age

The Stone Age didn't end
Due to lack of stones.

The drugging kids for control age
Will only end because more caring ideas
Take the fore. 

There are better ways
To support our children

And to brighten their future.

Join me on the parapet the view is improving especially with the BPS critique of DSM5

Why I chose to put my head
Above the parapet now.
In 2013 the subjectively biased new DSM5
Will change the mental health scene
Permanently for the worse
Opening the door insanely.

We collectively must act
As responsible professionals
And  world citizens
To oppose it.

See DSM5 posts.(on 10 Popular Posts above or
 August 2011 posts)

Friday 26 August 2011

Warnings Writ Large - Majorcan Ditty re Black Boxes


They might have a 'Black Box Warning'
But what the hell do they care!
Read the labels mister and the small print
I am just a child
A minor inconvenience
Who can't be quiet when it suits you!

They might work on lab rats
But they've never been tested on me!
Read the protocols Doc,all of them,
I am just a child
A minor inconvenience
Who can't sit still when you want me to!

I am just a child
A minor inconvenience!?

Thursday 25 August 2011

False Profits - A Majorcan Perspective on Business Models

What will they make of our shared story
  A few generations down the line,

A society -

That gives potential poisons
To young children,
To calm them down
And make them supposedly happier.

That makes continuous war
On other countries
To protect jobs and keep
The arms production lines moving.

That values those who short sell what they don"t yet own
Far more than the makers of goods
Even arms,drugs or selling war diamonds.

What will they make of our shared story 
A few generations down the line.

Will they laugh at us historically

Tuesday 23 August 2011

1984 to Now - Orwell Commonalities with Today Poem

When deceit is so common
Telling the truth
Is revolutionary.     -is Orwell quote

When common sense isn't so common
Then using it
Is enlightening.

When being reasonable is so rare
Acting on evidence
Is compelling.

When abusing children isn't so rare
Then exposing it
Should be more common.


Sunday 21 August 2011

THE NURTURED HEART APPROACH - INTRODUCTION FROM- 'Transforming the Difficult Child ' Website


Transforming the Difficult Child - Howard Glasser and Jennifer Easeley.

The Nurtured Heart Approach is an amazing set of strategies developed specifically for children with ADHD and other challenging behaviors to facilitate parenting and classroom success. These methods have helped thousands of families to transform their child from using their intensity in primarily negative ways to using their intensity in beautifully creative and constructive ways. This approach has also helped teachers and other school personnel to have a dramatically positive effect on all children.

Most ordinary methods of parenting and teaching inadvertently backfire when applied to ADHD and other challenging children, despite the best of intentions. Most methods accidentally reward children by giving them far greater evidence of richer relationship and more alive energy when things are going wrong in contrast to our typically low key responses when they are living their life successfully. The Nurtured Heart Approach is a powerful and quick way to create a new scenario of success. This approach is fully described in the book, Transforming the Difficult Child, The Nurtured Heart Approach.

The Children's Success Foundation has achieved national acclaim for work with children who have been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiance Disorder (ODD) and other behaviorally challenging conditions. The approach has also had excellent results with Obsessive Compulsive Disorder, Reactive Attachment Disorder, Post-Traumatic Stress Syndrome (PTSD) and other abuse, neglect and chaos related syndromes, as well as with Fetal Alcohol Syndrome (FAS) and Autism.

We have had extraordinary results in helping parents and teachers to quickly succeed in becoming extraordinarily skillful and effective in helping children to achieve wonderful new levels of competency... almost always without the need for medications or long-term treatment.

Medications moderate the child's intensity or, in effect, make it go away. The normal view is that the child's intensity is the problem. The medical community generally reports that ADHD is a genetic and bio-chemical condition and that the best one can hope for, through a combination of medications and behavior management, is a modest amount of improvement. The truth is that with the right approach you can turn these children around to an amazing level of success, despite the propensities of a pre-existing condition. With the Nurtured Heart Approach these very same children can use their intensity in wonderful ways and instead of acting-out problems can act-out greatness!

The following article was published in a Best Practices journal in the spring of 2000 and it has been updated with a more recent Nurtured Heart Approach research findings.

The Nurtured Heart Approach

Howard N. Glasser, Executive

Director, The Children's Success Foundation

The Nurtured Heart Approach has been practiced at Tucson's Center for the Difficult Child (CDC) between 1994 and 2001. It is a strategic family systems approach designed to turn the challenging child around to a new pattern of success. The approach has also been found to produce substantial success in helping the average child flourish at higher-than-expected levels of functioning.

The approach is now used in hundreds of classrooms nationally, and its strategies have been adopted with substantial success as the school-wide discipline plan in several Tucson schools.

The Nurtured Heart Approach teaches significant adults how to strongly energize the child's experiences of success while not accidentally energizing his or her experiences of failure. Most approaches, because they were designed for the average child, get stretched beyond their capacity when applied to challenging children. Traditional approaches for parenting and teaching can easily backfire with challenging children: they inadvertently reward children by providing more energy, involvement and animation when things are going wrong. Challenging children wind up being very confused because they perceive a high level of incentive for pushing the limits and for negative behaviors and little incentive to make successful choices. Often, the harder adults try applying these normal methods, the worse the situation becomes, despite the best of intentions.

Since The Nurtured Heart Approach was first introduced at CDC in 1994, a number of studies have been undertaken and several positive outcomes have emerged.

School Outcomes:

Tolson Elementary School in Tucson Arizona, a Title I school of over 500 children (80% free or reduced lunch) has shown remarkable progress since beginning a school-wide Nurtured heart Approach intervention in 1999. Prior to that many children were referred for ADHD assessments and were put on medications. They had eight times the normal number of school suspensions per year as other schools in the district and teacher attrition was well over 50% per year. Since that time there has only been one child suspended, no children at all diagnosed as ADHD and no new children on medications. Special education utilization has dropped from 15% to 1%. In counter-balance the Gifted and Talented Program has grown from less than 5% to over 15%. Best of all, the school has gone from the worst in district as measured by standardized test scores to Excelling - having dramatic and continuing positive progress. Another huge area of gain is that teacher attrition (teachers quitting the field or requesting transfers) has fallen from over 50% to nearly 0% and there is no longer the high rate of teachers calling in sick on Friday's and Monday's. Student attendance is also now dramatically higher. This data is in keeping with a multitude of other informal observations noted when this approach has been applied in other school-wide applications. "When children are led to feel great about who they are they act-out greatness." Howard Glasser.

Many HeadStart programs around the county use The Nurtured Heart Approach. The city of Tucson adopted the approach in the year 1999 and has used it successfully every since. The data they have collected for the 3,000 underprivileged children they serve each year confirms that in this time period they too have not needed to send a child for a diagnostic assessment or medication services at all. They use the approach class-wide and in addition to feeling that the approach helps all the children to flourish it has helped them to help the at-risk children to do well within the classroom setting without needing outside services.

Both Tolson Elementary and Tucson HeadStart report a strong increase in their ability to positively impact the parent communities they serve.

Foster Care and Treatment:

As of 2009 the Drenk Center in New jersey reported that they currently have a 0 (zero) rate of broken placements and this goes back to all of 2007. In years prior to 2007, before teaching workers and foster parents The Nurtured Heart Approach, their annual rate of broken placements was in the range of 20-25%. Broken placements involve a great deal of costs and a continuation of problems for the children involved. In contrast, when placements go well and foster parents experience the beauty of positively influencing a child, they then actually welcome more foster children into their home. When it does not go well, well-intentioned parents often call an end to the dream of helping children in this way.

Focus on Youth, a large fostercare agency in Ohio has reported in the period of 2007 to 2009 that not only are their broken placements low as a result of using The Nurtured Heart Approach in all modes of their treatment and care but their utilization of medications for these child have dropped to around 18% with a program average population of 70 children. This is in stark contrast to the very high percentage of foster children on medication management in the United Staes as a whole. They also report that in relation to using the Nurtured Heart Approach in all aspects of their organization that the average length of time that parents continue fostering has increased from 2 years prior to NHA to 5 + years at present.


The most recently published findings are from the 1999 "Year in Review" study conducted by Pima County Juvenile Court in relation to the Pre-Adolescent Diversion Project (PADP) of Tucson's Child and Family Resources. The project's parenting component and several other aspects of the program are based on The Nurtured Heart Approach. The project is a 16-hour workshop series over 4 weeks for first offending youth and their families.

According to Pima County Juvenile Court researchers, first offenders referred to other Juvenile Court programs have shown a 32% rate of recidivism, whereas the rate of re-offense for those youth who have completed PADP with their families is only 18%. This represents a 45% rate of improvement over other diversionary programs. Typically, youth who re-offend do so at escalating rates of intensity, committing bigger crimes and more often. The graduates of PADP who did re-offend committed lesser offenses. The statistical significance of the 18% rate of recidivism is .00001. This occurrence could not have happened by chance alone. Therefore, the strategies and approach of the Pre-Adolescent Diversion Project have been shown to produce noticeable improvement.


Another indicator of The Nurtured Heart Approach's effectiveness may be related to informal research regarding the use of medications among CDC clients.

Although many children referred to CDC are already on medication, CDC has scrutinized the records of children who are referred to the agency with no prior evaluation and therefore are not taking medications at the time of intake.

Upon close examination of the initial assessments of those already on medications and those not on medications, no difference is discernible. Those who are referred who are not on medications typically have very much the same symptoms and levels of severity as those who are already on medications at the time of intake. Most frequently those symptoms match the profiles of Attention Deficit/Hyperactivity Disorder (ADHD) and Oppositional-Defiant Disorder, with problems of aggression, compliance, impulsivity, distractibility, and a preponderance of school related issues.

National statistics show that of all children going to a primary care physician or a child psychiatrist for an initial assessment with these kinds of symptoms, 75% are prescribed medications at the time of that evaluation. It can therefore be assumed, given the kinds of symptoms and the level of severity of the children referred to CDC, that approximately 75% of these children would be put on medications if CDC's very first step were referral to a physician for an evaluation.

During a 10-month period in 1998, CDC worked with 211 children. Of these, 51 were already on medications prior to referral to CDC. Of the 160 children who were not already on medications, only eight were subsequently referred for psychiatric evaluations and only four were actually prescribed medications subsequent to the evaluation. This represents less than a 3% rate of utilization of medications. Perhaps just as interesting is that nine of the 51 on medications were successfully transitioned off medications during this time frame.

Overall improvements:

A separate on-going study conducted collaboratively by the Community Partnership for Southern Arizona (CPSA) research department since late 1996 involves pre- and post-treatment administration of the Connor's Parent Rating Scale with all CDC clients. Preliminary assessment of the data indicates excellent results in terms of efficacy of treatment. All scales of the Connors show improvement at the .01 level of significance and five of the six scales show improvements beyond four standard deviations. The study further confirms that, in general, the presenting symptoms of CDC clients at intake show a high degree of severity while the outcomes show children well within the mid-range of normative behaviors. Further analysis will be forthcoming.

Utilization of high-level services:

Considering the consistently high severity of CDC clients at intake, a fairly remarkable outcome has emerged over the years in relation to the number of CDC children who eventually needed high level and costly interventions such as out-of-home placements. Since 1994, only 8 children have required higher levels of intervention. This is despite the fact that many of the children referred to CDC over the years had one or more mental health related hospitalizations prior to referral to CDC.

The Nurtured Heart Approach also has been called upon numerous times to help transition children from high-level interventions to normal family life and regular levels of treatment. The related preventive request--to take on a child headed for a high-level intervention as a way of re-stabilizing the child--is also a routine facet of the capacities of this approach.


In a study of 808 of CDC cases from November 1994 through October 1998, only 28 children needed to have their cases re-opened and, in most of these instances, subsequent treatment was very brief and successful. Most of these families needed only a little inspiration or clarification on how to get back on track with the approach. The rate of re-utilization is less than 3.5%.


Many consumers do not qualify for the public mental health system and find the cost of on-going private treatment prohibitive. The Nurtured Heart Approach, typically taught for 8-12 total hours over a four-week period, is very well-suited to multi-family group scenarios, thus allowing families without insurance benefits to have an alternative form of affordable treatment.

In 1996, Dr. Shirli Ward researched The Nurtured Heart Approach for her doctoral dissertation. Comparison of a Nurtured Heart Approach large group format (over 30 parents in one group training) showed levels of success similar to that produced by therapeutic work with individual families. Dr. Ward pointed out that other prominent parent training programs were limited in size to a maximum of eight families, making The Nurtured Heart Approach considerably more time and cost effective.

The study also found that it was not necessary for both parents to participate in the training to achieve beneficial results. In one component of the study, only mothers were involved in the training and their children were not directly involved in the treatment. The mothers were able to become, in effect, the "therapists." The results reflected a high degree of satisfaction with the program in terms of improvements in family life and the progress their children made.

Dr. Ward further assessed the effect of the approach on child and parent functioning using the Devereaux Scale of Mental Disorders along with the Parent Stress Index, the Parenting Sense of Competence Scale, the Beck Depression Inventory, and the Forehand Satisfaction Survey.

Dr. Ward found that, relative to subjects in the comparison group, those involved in The Nurtured Heart Approach parent-training model demonstrated significant changes in functioning following treatment. Mothers reported improvements at the .01 level of significance in their child's behavior related to the following: conduct, anxiety, communication, acute problems, and overall severity. In addition, in terms of their own well-being, mothers reported fewer depressive symptoms, decreased stress levels and increased parenting effectiveness and satisfaction following treatment.

These results were found to be consistent across the researched diagnostic categories of Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, Conduct Disorder and Depressive Disorder as well as for children for whom treatment was sought for general noncompliance and Adjustment Disorder.

In 1994, Dr. Lorence Miller, also using the Devereaux Scale of Mental Disorders, found that a sample population of children in treatment at CDC had higher levels of severity at entry into treatment than the comparison groups of selected specific diagnoses used in the Devereaux groups own studies of criterion-related validity. The CDC sample population had more severe problems in all areas but attention. Dr. Miller's post-test results for both The Nurtured Heart Approach family treatment and large multi-family group treatment modalities were shown to have extremely significant effects toward normalized behaviors.

Perhaps one last measure of The Nurtured Heart Approach could be viewed in relation to the training of professionals. The approach is so readily transferred to other professional that they become fully competent in a relatively short period of time.

CDC accepted its first two interns, both Masters Degree students in the University of Phoenix Marriage and Family Program, in 1999. Within two months, both were so effective with families in treatment that they were comparable to senior therapists in both the results they produced and their own perceived level of competency. This year, five more interns have applied to CDC training program and are following suit in their level of confidence. CDC attributes a great deal of the success of the training to the inherent power of the model:

The Nurtured Heart Approach.

40th Anniversary of Stanford Prison Experiment - Phillip Zimbardo

Prof Phillip Zimbardo
Zimbardo Stanford Prison Experiment

by Saul Mcleod, published 2008

Aim: To investigate how readily people would conform to the roles of guard and prisoner in a role-playing exercise that simulated prison life.

Zimbardo (1973) was interested in finding out whether the brutality reported among guards in American prisons was due to the sadistic personalities of the guards or had more to do with the prison environment.

Procedure: Zimbardo used a lab experiment to study conformity.

zimbardo prison experiment picture of a guard

To study the roles people play in prison situations, Zimbardo converted a basement of the Stanford University psychology building into a mock prison. He advertised for students to play the roles of prisoners and guards for a fortnight. 21 male college students (chosen from 75 volunteers) were screened for psychological normality and paid $15 per day to take part in the experiment.

Participants were randomly assigned to either the role of prisoner or guard in a simulated prison environment. The prison simulation was kept as “real life” as possible. Prisoners were arrested at their own homes, without warning, and taken to the local police station.

stanford prison experiment picture of a prisoner being arrested

Guards were also issued a khaki uniform, together with whistles, handcuffs and dark glasses, to make eye contact with prisoners impossible. No physical violence was permitted. Zimbardo observed the behaviour of the prisoners and guards.


Here they were treated like every other criminal.  They were fingerprinted, photographed and ‘booked’.  Then they were blindfolded and driven to the psychology department of Stanford University, where Zimbardo had had the basement set out as a prison, with barred doors and windows, bare walls and small cells.  Here the deindividuation process began.

When the prisoners arrived at the prison they were stripped naked, deloused, had all their personal possessions removed and locked away, and were given prison clothes and bedding. They were issued a uniform, and referred to by their number only. Their clothes comprised a smock with their number written on it, but no underclothes. They also had a tight nylon cap, and a chain around one ankle.

There were 3 guards to the 9 prisoners, taking shifts of eight hours each (the other guards remained on call)

Findings: Within a very short time both guards and prisoners were settling into their new roles, the guards adopting theirs quickly and easily.

Within hours of beginning the experiment some guards began to harass prisoners. They behaved in a brutal and sadistic manner, apparently enjoying it. Other guards joined in, and other prisoners were also tormented.

 The prisoners were taunted with insults and petty orders, they were given pointless and boring tasks to accomplish, and they were generally dehumanised.

The prisoners soon adopted prisoner-like behaviour too.  They talked about prison issues a great deal of the time. They ‘told tales’ on each other to the guards. They started taking the prison rules very seriously, as though they were there for the prisoners’ benefit and infringement would spell disaster for all of them. Some even began siding with the guards against prisoners who did not conform to the rules.

Over the next few days the relationships between the guards and the prisoners changed, with a change in one leading to a change in the other.  Remember that the guards were firmly in control and the prisoners were totally dependent on them.

As the prisoners became more dependent, the guards became more derisive towards them. They held the prisoners in contempt and let the prisoners know it. As the guards’ contempt for them grew, the prisoners became more submissive.

As the prisoners became more submissive, the guards became more aggressive and assertive. They demanded ever greater obedience from the prisoners. The prisoners were dependent on the guards for everything so tried to find ways to please the guards, such as telling tales on fellow prisoners.

One prisoner had to be released after 36 hours because of uncontrollable bursts of screaming, crying and anger. His thinking became disorganised and he appeared to be entering the early stages of a deep depression. Within the next few days three others also had to leave after showing signs of emotional disorder that could have had lasting consequences. (These were people who had been pronounced stable and normal a short while before.)

Zimbardo (1973) had intended that the experiment should run for a fortnight, but on the sixth day he closed it down. There was real danger that someone might be physically or mentally damaged if it was allowed to run on. After some time for the researchers to gather their data the subjects were called back for a follow-up, debriefing session.

Conclusion: People will readily conform to the social roles they are expected to play, especially if the roles are as strongly stereotyped as those of the prison guards. The “prison” environment was an important factor in creating the guards’ brutal behaviour (none of the participants who acted as guards showed sadistic tendencies before the study). Therefore, the roles that people play can shape their behaviour and attitudes.

After the prison experiment was terminated Zimbardo interviewed the participants. Here’s an excerpt:

‘Most of the participants said they had felt involved and committed. The research had felt "real" to them. One guard said, "I was surprised at myself. I made them call each other names and clean the toilets out with their bare hands. I practically considered the prisoners cattle and I kept thinking I had to watch out for them in case they tried something." Another guard said "Acting authoritatively can be fun. Power can be a great pleasure." And another: "... during the inspection I went to Cell Two to mess up a bed which a prisoner had just made and he grabbed me, screaming that he had just made it and that he was not going to let me mess it up. He grabbed me by the throat and although he was laughing I was pretty scared. I lashed out with my stick and hit him on the chin although not very hard, and when I freed myself I became angry."’

Most of the guards found it difficult to believe that they had behaved in the brutalising ways that they had. Many said they hadn’t known this side of them existed or that they were capable of such things. The prisoners, too, couldn’t believe that they had responded in the submissive, cowering, dependent way they had. Several claimed to be assertive types normally. When asked about the guards, they described the usual three stereotypes that can be found in any prison: some guards were good, some were tough but fair, and some were cruel.

Ethics: The study has received many ethical criticisms, including lack of fully informed consent by participants and the level of humiliation and distress experienced by those who acted as prisoners.

The consent could not be fully informed as Zimbardo himself did not know what would happen in the experiment (it was unpredictable). Also, participants playing the role of prisoners were not protected from psychological and physical harm. For example, one prisoner had to be released after 36 hours because of uncontrollable bursts of screaming, crying and anger.