1.
Professor Vincenzo Di Nicola
MPhil, MD, PhD, FRCPC, FCAHS, DLFAPA, DFCPA
February 2, 2023
Child, Family, and Social Psychiatric Perspectives
on Forensic Psychiatry

2.
Professor of Psychiatry, University of Montreal
President, World Association of Social Psychiatry (WASP)
Vincenzo Di Nicola
MPhil, MD, PhD, FRCPC, FCAHS, DLFAPA, DFCPA
Email: vincenzodinicola@gmail.com

3.
• The presenter has no financial conflicts of interest to declare
Conflicts of Interest

4.
After this presentation, participants will be able to:
1. Appreciate how children’s developmental pathways interact with
forensic issues in their lives and those of their families and
caregivers.
2. Place forensic issues in a family context with a view to
multigenerational attachment issues.
3. Employ an understanding of the Social Determinants of Health and
Mental Health (SDH/MH) and the pioneering studies on Adverse
Childhood Experiences (ACE) in forensic cases.
Learning Objectives

5.
• I am not a forensic psychiatrist
• I am a child and adolescent psychiatrist, a family therapist, and a
social psychiatrist
• However, I trained and worked in places where Canadian forensic
psychiatry is especially strong:
• I trained at McGill with Bruno Cormier and Renée Fugère
• University of Ottawa where I was a junior colleague of John Bradford
• Queen’s University where I was a colleague of Steven Hucker
• Both Ottawa and Queen’s had Family Court Clinics that practiced
forensic child and adolescent psychiatry
Introduction

6.
• I see forensic child and adolescent psychiatry situated at the
crossroads of medicine and the law
• I also see these discourses or domains as sometimes in partnership,
sometimes adversarial, potentially compatible, hopefully
complementary
• Child and adolescent psychiatry is situated at the crossroads of
children’s health, the family, and the multiple social systems that
impinge on children and families, from education to sports, and
certainly the structures of authority represented by the rule of law
and implicit rules of culture
Introduction

7.
• In 1872, the English author Samuel Butler published a
famous novel in the utopian genre, Erewhon, which is
“nowhere” scrambled
• It was a satire of Victorian society
• In his depiction of an antipodean society, Butler imagined a
place where things are upside down in terms of the typical
European discourses of his time on health and the law
Erewhon

8.
• Simply put, in Erewhon, crime is an illness and illness a crime
• In a memorable passage, Erewhonians visit a banker who
embezzled money in sympathy for his “medical” misfortune,
while someone with pneumonia is sent to jail for his “crime”
• Philosopher Gilles Deleuze said that “Erewhon is not only a
disguised no-where but a rearranged now-here”
Reference: Deleuze, G. (1994). Difference and Repetition, p. 333, n. 7.
Erewhon

9.
Literature Review:
Forensic Child & Adolescent Psychiatry

10.
• Child psychiatry is becoming increasingly involved with the law.
• Other professionals have expertise in interpreting children's needs and
behaviours to the courts, but child psychiatrists have unique skills and
lawyers should be helped to understand what they have to offer.
• Difficulties in the dialogue between child psychiatry and the law are
discussed. Training child psychiatrists to function efficiently in the legal
system must be given priority by the newly established Faculty of
Child Psychiatry (Brisbane, Queensland, Australia)
Reference: Connell HM (1989). Grasping the nettle: Forensic child psychiatry. Australian &
New Zealand Journal of Psychiatry, 23(4):512-516.
Forensic Child & Adolescent Psychiatry

11.
• This article addresses the unique ethical conflicts that are
encountered in forensic psychiatry.
• Special issues for the forensic child and adolescent psychiatrist
in the areas of custody, sexual abuse, termination of parental
rights and adoption, evaluation of juvenile offenders, and
maternal-fetal conflicts are addressed.
• The need for neutrality, objectivity, and integrity in performing
forensic evaluations is stressed.
Reference: Schetky DH (1992). Ethical issues in forensic child and adolescent
psychiatry. J Am Acad Child Adol Psychiatry, 31(3): 403-407.
Forensic Child & Adolescent Psychiatry

12.
• Reviews developments in forensic CAP 1987-1996
• Found a large increase in research based on quantifiable descriptive data of
forensic populations; studies using comparison or control groups remain
relatively rare.
• While managed care has heavily influenced treatment practice, legal liability
remains largely with the clinician.
• Issues regarding techniques of evaluation for sexual abuse have been
scrutinized by the courts and by researchers.
• Legislative responses to rising rates of juvenile violence have been in the
direction of treating violent adolescent offenders as criminally responsible
adults.
• There has been a major move toward setting standards for forensic evaluations,
training, and credentials.
Reference: Ash P, Derdeyn AP. (1997). Forensic child and adolescent psychiatry: A
review of the past 10 years. J Am Acad Child Adol Psychiatry, 36(11): 1493-1502.
Forensic Child & Adolescent Psychiatry

13.
• The subspecialty of child forensic psychiatry has come into existence
relatively recently.
• The first text on the subject was not published until 1980.
• This field emerged slowly as a recognized subspecialty separate from
general child psychiatry and adult forensic psychiatry because child
forensic psychiatry could not exist until children gained legal rights,
and courts needed to know the impact of a child's mental state on
those rights.
Reference: Haller LH (2002). Overview of child forensic psychiatry. Child & Adol
Psych Clinics of North America, 11(4): 685-688.
Forensic Child & Adolescent Psychiatry

14.
• Child psychiatrists play important roles in the legal system.
• They have unique insight into the emotional life of the child, the dynamics of the
family system, and the relationship between child & parent.
• They help provide objective information to the judge and jury for making difficult legal
decisions in child abuse and neglect-related cases.
• Functioning in various roles, child psychiatrists must reach a clear understanding with
the hiring party as to the reason for the consultation, what materials and interviews
are necessary for a comprehensive evaluation, the charges involved, and ethical
principles to be followed.
• They must recognize and negotiate the challenges for objectivity in these forensic
evaluations.
• Finally, they should understand that the role of the child psychiatrist in forensic issues
is a dynamic one that is shaped by the ever-evolving response of society, law, and the
medical profession to the phenomena of child abuse and neglect.
Reference: Leavitt WT, Armitage DT (2002). The forensic role of the child psychiatrist in
child abuse and neglect cases. Child & Adol Psych Clinics of North America,11(4): 767-
779.
Forensic Child & Adolescent Psychiatry

15.
• Two Canadian forensic psychiatrists testify to the pioneering
contributions of John Bradford who founded CAPL and influenced
AAPL of which he became president (1993-94)
Reference: Glancy G, Chaimowitz GA. (2022). John Bradford: Father of the Canadian Forensic
Psychiatry. Journal of the American Academy of Psychiatry and the Law Bulletin of the American
Academy of Psychiatry and the Law., 50:177-181. 2022
Forensic Child & Adolescent Psychiatry

16.
Schetky’s list:
• Custody, sexual abuse, termination of parental rights and adoption, evaluation of
juvenile offenders, and maternal-fetal conflicts
My list:
• Parental alienation
• Neglect and abuse
• Coercion – medication, hospitalization, placement
• What is the meaning today of “in loco parentis”
• Continuity between child and adult psychiatry
– long-term prognosis of ODD, CD, and their attendant risks
• Special problems: Factitious disorders, Munchausen by Proxy
Child and Family Forensic Issues

17.
• It’s complicated!
• Who is authorized? (legally)
• Who can speak for children? (morally)
• What does it mean to speak for yourself? (developmentally)
Children and Coercion

18.
• Child rights principle
• Derives from Article 3 of the UN Convention on the Rights of
the Child
• “in all actions concerning children … the best interests of the
child shall be a primary consideration”
Reference: United Nations (2013). Convention of the Rights of the Child.
https://www2.ohchr.org/English/bodies/crc/docs/GC/CRC_C_GC_14_ENG.pdf
Best Interests of the Child

19.
• Trilogy by leading child experts at the Yale
Study Center and Anna Freud
• Continuity of care between the child and her
adult caregivers is a universal essential to
the child’s well-being
• Minimize intrusions by the law (“the least
detrimental alternative”)
Reference: Goldstein J, Solnit AJ, Goldstein S, Freud A.
(1996). The Best Interests of the Child: The Least
Detrimental Alternative. New York: Free Press.
Best Interests of the Child

20.
John Bowlby
(1907-1990)

21.
• John Bowlby – psychiatrist and psychoanalyst – Tavistock Clinic
• Synthesized all the relevant literature of paediatrics, child psychology,
psychiatry & psychoanalysis to create attachment theory
• Bowlby’s trilogy
• Attachment, Separation, Loss (1969, 1973, 1980)
• A Secure Base: Parent-Child Attachment and Healthy Human
Development (1988)
Attachment

22.
Attachment
Dominant model for the study of early social development
Key Features
• Toddlers form emotional attachments to familiar caregivers
• Establishing a lifelong “secure base”
• Foundation of later behaviour, emotions and personality

23.
Attachment
Events that interrupt or interfere with attachment have consequences
• Separation of a toddler from attachment figures
• Caregivers’ lack of sensitivity, responsiveness or consistency when
interacting with toddlers

24.
Adverse Childhood Experiences (ACEs)
Adverse Childhood Experiences (ACEs – Felitti, et al, 1998) are strongly
associated with negative health outcomes
• Physical, emotional and sexual abuse, neglect and household dysfunction
• Linear gradient between the number of ACEs and worsening health outcomes
Reference: Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, et al.
(1998). Relationship of childhood abuse and household dysfunction to many of the leading
causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American
Journal of Preventive Medicine, 14 (4): 245–258.

25.
Social Determinants of Health (SDH)
• Sir Michael Marmot – WHO Study (2008)
• Social Determinants of Health and Mental Health (SDH/MH)
• The most robust and relevant research done in medicine
• Key concept: Mental health gaps
• Children and women are the most vulnerable populations
• “There is no health without mental health” has become the mantra of the Global
Mental Health Movement
Reference: CSDH (2008). Closing the gap in a generation: Health equity through action on the social
determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva,
Switzerland: World Health Organization.

26.
• As an outside observer, ethical issues are front and centre in
forensic psychiatry as I believe they should be in every branch
of medicine and psychiatry
• Eminent French Philosopher Emmanuel Levinas held that
“philosophy is first ethics” deeply informed by the “face-to-
face encounter” even in the face of violence
Ethics

27.
• Medicine cannot be healing if it is not ethical
• Any form of healing is instrumental and limited
if it is not in a context of ethical conduct
Ethics

28.
Dr. Gary Chaimowitz
Professor of Psychiatry and Behavioural Neurosciences
Head of the Forensic Psychiatry Program
International Forensic Psychiatry Lecture Series
McMaster University
Acknowledgements

29.
Ash P, Derdeyn AP. (1997). Forensic child and adolescent psychiatry: A review of the past 10
years. J Am Acad Child Adol Psychiatry, 36(11): 1493-1502. doi.org/10.1016/S0890-
8567(09)66557-6
Bowlby J (1969, 1973, 1980). Attachment, Separation, Loss. New York: Basic Books.
Bowlby J (1988). A Secure Base: Parent-Child Attachment and Healthy Human Development.
New York: Basic Books.
Butler S (1872). Erewhon: Or, Over the Range. London: Trübner & Ballantyne.
Butler S (1901). Erewhon Revisited. London: Grant Richards.
References

30.
Connell HM (1989). Grasping the Nettle: Forensic child psychiatry. Australian & New Zealand Journal of
Psychiatry, 23(4):512-516. doi:10.3109/00048678909062619
CSDH (2008). Closing the gap in a generation: Health equity through action on the social determinants of
health. Final Report of the Commission on Social Determinants of Health. Geneva, Switzerland: World
Health Organization.
Deleuze G (1994). Difference and Repetition. New York: Columbia University Press.
Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, et al. (1998). Relationship of
childhood abuse and household dysfunction to many of the leading causes of death in adults. The
Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14 (4): 245–258.
Glancy G, Chaimowitz GA (2022). John Bradford: Father of the Canadian Forensic Psychiatry. Journal of
the American Academy of Psychiatry and the Law Bulletin of the American Academy of Psychiatry and the
Law. 50:177-181.
References

31.
Goldstein J, Solnit AJ, Goldstein S, Freud A. (1996). The Best Interests of the Child: The Least Detrimental
Alternative. New York: Free Press.
Haller LH (2002). Overview of child forensic psychiatry. Child & Adol Psych Clinics of North America,
11(4): 685-688. doi.org/10.1016/S1056-4993(02)00031-7
Leavitt WT, Armitage DT (2002). The forensic role of the child psychiatrist in child abuse and neglect
cases. Child & Adol Psych Clinics of North America,11(4): 767-779. doi.org/10.1016/S1056-
4993(02)00029-9
Schetky DH (1992). Ethical issues in forensic child and adolescent psychiatry. J Am Acad Child Adol
Psychiatry, 31(3): 403-407. doi.org/10.1097/00004583-199205000-00004
United Nations (2013). Convention of the Rights of the Child.
https://www2.ohchr.org/English/bodies/crc/docs/GC/CRC_C_GC_14_ENG.pdf
References