SICHER, PAMELA M.D.; LEWIS, OWEN M.D.; SARGENT, JOHN M.D.; CHAFFIN, MARK Ph.D.; FRIEDRICH, WILLIAM N. Ph.D.; CUNNINGHAM, NICHOLAS M.D., Dr.P.H.; THOMAS, RANDALL Ph.D.; THOMAS, PATRICIA Ph.D.; VILLANI, V. SUSAN M.D.
Although the dissolution of the Soviet Union in 1989 brought a welcome end to the Cold War, the subsequent reestablishment of independent Eastern European countries revealed a host of problems. Among these was frequent child abuse and neglect, although lack of epidemiological data precluded any accurate estimate of prevalence. In an effort to address the problem of child abuse within this rapidly changing sociopolitical environment, the Children's Mental Health Alliance and the Soros Foundation organized the Eastern European Child Abuse and Child Mental Health Project in 1995. The authors describe the development of this multidisciplinary initiative involving collaboration with professionals from 17 countries in Eastern Europe. They highlight the goals, principles, and major phases of the project, as well as some of the challenges involved in its implementation.
Child maltreatment has occurred throughout human history in all cultures (Daro et al., 1996; Sicher, 1995). Thus it was not surprising that evidence of child abuse and neglect was observed in the former Soviet Union and allied Eastern European countries after the dissolution of the Communist bloc in 1989. Isolated reports provided some confirmation of abuse, but there had been no opportunity to collect epidemiological data and thus there was no way to accurately estimate actual prevalence. A rare study before the collapse of the Soviet Union found evidence of childhood sexual abuse in Czechoslovakia (Zverina et al., 1987). Of the 373 women interviewed, about one sixth (60) reported having been sexually abused by an adult male before menarche. A study of child abuse in Croatia in 1990 found that 3 of every 1,000 children under the age of 18 had been identified as being maltreated (Ajdukovic et al., 1993). Another study supported the view that actual cases significantly exceed reported cases (Pejcinovic, 1990, cited in Ajdukovic et al., 1993). But systematic research was lacking, in part because valid measures had not yet been developed (Pecnik and Ajdukovic, 1995). Other scattered reports provided evidence of physical abuse in Russia (Berrien et al., 1995), dissociative episodes in Hungary (Vanderlinden et al., 1995), abuse and neglect of children by alcoholic fathers in Bulgaria (Christozov and Toteva, 1989), child abuse in Poland (Kordacki, 1991), and domestic violence in Russia (Horne, 1999). Agathonos-Georgopoulou (1998) pointed out the many challenges involved in developing effective child protection policies in Eastern Europe.
Even without the legacy of a repressive political system, maltreated children often grow up to become abusing or neglecting parents, thus perpetuating a vicious cycle (Egeland et al., 1988; Sicher, 1995). The long history of Soviet state control involved a strong tendency to mistrust families (Agathonos-Georgopoulou, 1998), with consequent encouragement of children to inform on their own parents. Such practices severely undermined the family unit, which fostered pervasive mistrust and often incited parents to mistreat their own children. Alcoholism and spousal abuse further complicated the picture (Christozov and Toteva, 1989). In a few places, practices supporting family stability existed under communism. For example, in the Czech Republic, new mothers were given several months off work to spend time with their infant, and nurse home visitors were assigned to every new mother and child (Chaffin, 1998). But in general the repressive communist system created and reinforced a climate conducive to child abuse and neglect.
At the same time, clinical training in mental health care and psychotherapy services were severely restricted. During the long Soviet era, clinicians were typically pressured to adhere to strict communist ideology (Puras, 1994; Sourander and Piha, 1998). Thus families often viewed them as agents of the state rather than as providers of care. A meager income further discouraged aspiring and practicing clinicians. Indeed, the communist system viewed psychotherapy, with its focus on the individual, as a bourgeois, Western practice (Chaffin, 1998). And since the communist system did not admit any social ills, there was no need for clinical services (Lewis and Sicher, 1998). Child abuse and neglect were also portrayed as a Western problem that did not exist in the Soviet bloc, so of course there could be no agreed-on definitions of child abuse and neglect or of children's rights (Pecnik and Ajdukovic, 1995). In a few areas, psychotherapists managed to overcome these daunting ideological, political, and economic obstacles. For example, there was a hidden tradition of psychology in Czechoslovakia and Hungary (Friedrich, 1998). Psychoanalyses were secretly conducted in the Czech Republic and in Hungary, and psychodrama was taught in Macedonia (Lewis and Sicher, 1998). But for the overwhelming majority of the population, any treatment approximating psychotherapy was nonexistent.
It was within the context of this complex, extremely unsettled sociopolitical situation and the marked difficulties associated with economic transition-now further disrupted by a war within the former Yugoslavia (now Slovenia, Croatia, Bosnia and Hercegovina, Yugoslavia, and Macedonia)-that a project evolved seeking to address the problem of child abuse in Eastern Europe. The Eastern European Child Abuse and Child Mental Health Project was organized in 1995. This project involves 17 Eastern European countries: Albania, Bulgaria, Croatia, Czech Republic, Estonia, Kyrgyzstan (entered the project in 1997), Latvia, Lithuania, Macedonia, Moldova, Poland, Romania, Russia, Slovakia, Slovenia, Ukraine, and Yugoslavia. Hungary originally participated but subsequently withdrew. The government of Byelorussia terminated involvement after participation by delegates from that country between 1995 and 1997 (Sicher, 1998). In this article, we will describe the origin and development of this project.
The initial impetus for this project resulted from the efforts of financier and philanthropist George Soros. A native of Hungary, Soros emigrated to the United States in the 1950s. With the lifting of the Iron Curtain in the late 1980s, he became interested in the emerging nations of Eastern Europe and what had happened to the people, their cultures, and their countries under communism. He had visions of restoring Hungary to its former glory, with Budapest as its commercial, intellectual, and cultural center. To this end, he created the Central European University there, with a state-of-the-art conference center for students and visiting faculty from all over the world (Sicher, 1998).
Soros also established a foundation, which he named the Open Society Institute (OSI). He borrowed the term open society from English economist Karl Popper, who used it to describe a society governed by free markets and characterized by tolerance for divergent ideas (Popper, 1945). Soros believed that there was a remarkable opportunity-one that might not come again-to restore democracy to Eastern Europe. One of his most serious concerns was whether adults indoctrinated in communism and their children would be able to adapt to democratic process. He realized that it might well take one or two generations to bring about such a change and that educational and psychological resources would be essential in this transformation. During this time, he began to establish a regional network of OSI offices in the various Eastern European countries. Each office had its own local board of directors with the authority to establish goals and priorities for its region. These groups were founded as nongovernmental organizations (NGOs), which not only gave them greater local autonomy but also enhanced their acceptance in the eyes of community members. OSI independence also enhanced the opportunity for innovation and program development. That is, they were not identified with the traditionally oppressive state system (Sicher, 1998).
The first large project that OSI initiated on behalf of children was Step by Step, an educational program begun in preschools that now includes children up to age 14. Through this program, teachers sent from the United States to train local Step by Step staff became aware of the mental health of children and their families in Eastern Europe. These teachers soon reported a very high incidence of child trauma, domestic violence, and alcoholism, but virtually no treatment services (Sicher, 1998). In 1995 OSI contacted the first 2 authors, seeking assistance in addressing the problem of child trauma and abuse in these newly emerging nations. Sicher and Lewis assembled a coalition of respected child and adolescent psychiatrists, child psychologists, pediatricians, and educators, and they formed the Children's Mental Health Alliance (CMHA) in 1995. Later that year, OSI and CMHA organized the Eastern European Child Abuse and Child Mental Health Project.
Three guiding principles have informed this project: the priority of prevention, the importance of family preservation, and the understanding that child abuse is fundamentally a societal issue.
Because abuse is a multiply determined event, our definition of prevention includes the creation and/or strengthening of those elements in society that support the ability of children to grow as individuals, having the capacity to think freely and act morally. The foundations of child development are laid down in the home and at school, but they must be supported by the larger society. A home is the first society that any child sees. School is the second. When these first 2 societies reflect decency, fairness, morality, and democracy, children's innate capacity to identify with the adults they see will enable them to incorporate the same character traits.
Winnicott first presented these ideas in a 1950 essay, "Some Thoughts on the Meaning of the Word 'Democracy'": "The place of the home ... not only enables children to find themselves and to find each other, but also makes them begin to qualify for membership of society in a wider sense" (p. 248). According to Winnicott, the likelihood that any society will function democratically is directly related to the proportion of emotionally mature individuals in it. The "innate democratic factor" (p. 246) of mature adults is related primarily to the "ordinary good mother-infant relationship, and with the ordinary good home" (p. 250). Thus the cornerstone of democracy is set in the healthy functioning of each and every family. Research conducted since Winnicott made his observations has confirmed the validity of early intervention, as summarized in Starting Points, a 1994 Carnegie Foundation report which states: "How individuals function from the preschool years all the way through adolescence and even adulthood hinges to a significant degree on their experiences before age 3."
Prevention must therefore start broadly with focused programs to help young families get off to a good start. Family-focused prevention includes 2 elements: (1) education for all parents and would-be parents in child development (e.g., infant attachment, toddler separation, age-appropriate discipline, socialization); and (2) family support (e.g., postpartum home visitation, quality child care, social work services, a "medical home" for each child). To ensure that healthy development is maintained, preschools and schools should offer ongoing preventive programs that include parent and staff participation. This type of effort merges prevention and treatment. Although the costs can be substantial, they remain well below the societal costs associated with ignoring the need.
The second guiding principle is family preservation. Although the Eastern European project began in countries with virtually no established protocols, procedures, or laws for handling child abuse, this situation has proven advantageous in some ways. The one reliable "resource" in every country has been the family. Rather than embarking on a social policy course that advocates removal of members (abused or abusers) from the family, the goal-both by necessity and by design-has been family preservation whenever safe and possible.
Since the 1970s, studies of the American foster care system (e.g., Gilbert, 1997) and its many problems have led to increasing efforts to keep children in their homes. These studies show that a child has a much greater chance of developing soundly by remaining at home rather than by being placed in a series of foster homes. Allowing the child to remain at home also makes treatment of the entire family possible. Our aim in this project is to move from an "us versus them" model to one that recognizes that the circumstances in which child maltreatment occurs often reflects parental illness, parental history of abuse, and severe social stressors. These parents are often isolated, troubled, and unable to solve their problems independently, and so they are equally in need of treatment.
The third principle is that child abuse is a societal issue rather than strictly a mental health concern. Child abuse challenges society's values and its resolve to raise children safely. Abuse also occurs most commonly in situations of economic disadvantage. Therefore, although this project was initiated from the field of child mental health, a multidisciplinary approach is necessary to effectively prevent and treat child abuse. To this end, the project includes educators, police officers, legislators, other physicians, and lawyers and judges, as well as mental health professionals. Our intent is to train professionals in all the involved disciplines to recognize maltreatment, to implement effective evaluation techniques, and to be familiar with a variety of treatment modalities. In all these areas, the emphasis is on attempting to preserve and strengthen the family. In Eastern Europe, we believe that we have an opportunity, through work on the issue of child maltreatment, to assist these countries in establishing institutions that will support not only the strength of the individual (parent and child) but also his or her relationships and the strength of the roles that the individual plays in the wider community (e.g., as mother, father, professional, or worker) (Sicher, 1995; Sicher and Lewis, 1997).
As it has developed, the project has involved several major, sometimes concurrent, activities, including training conferences, dissemination of information and training materials, provision of small grants and supervision to innovative local projects, site visits, including both American and Eastern European faculty, and ongoing mentoring by professionals from the United States, Europe, and Central Eastern Europe for new country teams. In addition, OSI has provided funding to translate training materials into native languages.
Training conferences not only provide opportunities for teaching, training, and the distribution of materials (it has not been uncommon to transport 2,000 pounds of literature to a 1-week training conference), but they also give professionals from the region the opportunity to report on their technical assistance needs and priorities. Delegates are also provided supervision concerning their clinical work. Grants are usually awarded to support local multidisciplinary teams as well as to establish programs for addressing child abuse where little or no governmental or other foundation support is available. Site visits allow us to assess the functioning of the local multidisciplinary team and its relationship to other local services and programs. Such visits also enable us to provide teaching to a wider audience (Sicher and Lewis, 1998).
As we conceptualize it, the project involves 4 major phases: (1) assessment of the level of professional knowledge, public awareness, and social and legal policy in relation to child abuse in each country; (2) education and training of core multidisciplinary groups of mental health professionals in the diagnosis, treatment, and prevention of child abuse and neglect; (3) development of interdisciplinary teams and their achievement of NGO status; and (4) influence on social policy, with consequent legal reforms to address child abuse and neglect while supporting family preservation. In this phase the independence and fiscal solvency of these NGOs is solidified.
At our first conference in Budapest in November 1995, we surveyed delegates to ascertain how child abuse and neglect were being addressed in their home countries and to learn about the priorities of the participating countries. These delegates had been selected by OSI foundations in each of the 17 countries based on interest in child abuse. They were asked to identify the current status of institutional structures addressing child abuse in their countries. Information was categorized into 4 major areas: (1) voluntary agencies and their role; (2) child protection laws, their jurisdiction, and their effectiveness; (3) child abuse reporting; and (4) public awareness and services (Sicher, 1995). These surveys demonstrated the widespread prevalence of child trauma and domestic violence, the overwhelming absence of services, and the lack of any legal structure protecting children. Not surprisingly, the surveys also revealed pervasive distrust of the legal system as having any capacity to protect children or families. Also of significance, the surveys indicated that there was great fear of the consequences of exposing abuse (Sicher, 1998). Several other difficulties including the absence of foster care were also noted. Bribery of legal officials was common in cases of sexual abuse. These children were frequently runaways, and they were often placed in state-run orphanages.
On the last day of the 1995 conference, each delegation proposed specific, immediate steps necessary to address the issue of child abuse. In addition to unanimously emphasizing the need for training materials, the delegates identified the provision of professional education and development as a key "first step." In particular, delegates requested better training in the identification of abuse syndromes, a need for the dissemination of this information through interdisciplinary collaboration, and specific training in psychotherapeutic techniques. In light of this feedback, CMHA and OSI developed a program of technical assistance services to respond to these requests of each country team on an individual basis. In 1996 the program provided resource and training materials, as well as training in prevention of child abuse and neglect and in crisis intervention. The program also offered small grants to innovative national projects on a competitive basis. Teams provided with such support included the Nobody's Children Foundation in Warsaw, Poland, and a multidisciplinary team in Tartu, Estonia (the Children's Support Center). Other supported projects have included developing in-country training programs for professionals and training courses for parents of preschool children.
We agreed with the delegates that a key step was to educate and train professionals in the treatment of abused children and abusing families. Treatment services must be in place before large-scale attempts could be instituted to influence public awareness, identify cases of abuse needing treatment, and change social policy. If we began our work with lawyers, the police, or pediatricians before treaters were available, identifying potential abuse cases might overwhelm the system; it might also revive pessimism and even bring about renewed repression. Thus training a core group of therapists (child and adolescent psychiatrists, general psychiatrists, psychologists, and social workers) became a priority.
To this end, we designed a 4-week training course, divided into several conferences to be offered during 1997. Supervision between conferences would be provided by email or fax. Carefully selected teams of professionals from each participating country were chosen to attend the conferences. To be selected, delegates had to be actively involved in the treatment of children and families, and they also had to able to teach what they had learned to significant numbers of professionals in their home countries. Participants were required to develop a "back-home" teaching plan for their colleagues. Team members were all required to commit themselves to attending all conferences, so that there would be little or no turnover in the approximately 100 participants. Participants also needed to be able to understand and communicate in English.
The first week of this training sequence occurred in Budapest; the second and third weeks in Kazimierz Dolny, Poland; and the fourth week again in Budapest (Lewis and Sicher, 1998; Sicher, 1998; Sicher and Lewis, 1998). The first week of the course consisted of a series of presentations on the treatment of child abuse. Topics covered included principles of integrated dynamic treatment, the first meeting with the abuse victim, interventions with abusive families, and making meaning of the abuse experience. In addition to these presentations, we held several workshops on specific aspects of treatment and requested that participants present cases for group discussion and supervision.
The 2-week conference in Poland focused on hospital treatment, cognitive-behavioral therapy, treatment of couples experiencing domestic violence, treatment of offenders, additional family and group therapy techniques, and the treatment of alcoholism, substance abuse, and dissociation.
The final week initiated the transition into the third phase of the project and encouraged team development and highlighted special techniques, including parent-child interaction therapy.
At the final 1997 conference, each participating country was asked to assemble a carefully selected multidisciplinary team consisting not only of professionals already trained and working in the country's program, but also of members of other disciplines, particularly pediatrics, the police, and the law. These teams are to become the core of future indigenous NGOs or professional associations that will lead movements in their country to prevent and treat child abuse. In 1998 we focused on building these multidisciplinary teams, sponsoring 3 regional conferences on "multidisciplinary organizational skills" in Latvia, Croatia, and Budapest. We also conducted a meeting for pediatricians in Estonia. Two conferences in Prague (Czech Republic) and Vilnius (Lithuania) focused on creating public awareness campaigns and using the media effectively to highlight the problem of child abuse for the public in each country. One or 2 delegates from each participating country attended the meeting in Stockholm of the International Association of Child and Adolescent Psychiatrists and Allied Professions (IACAPAP), which reinforced the training they received in 1997 and allowed for a presentation of this project.
Site visits and mentoring have also supported the development of these multidisciplinary teams. In 1998, each participating country was able to invite U.S., European, and Central Eastern European project faculty to their country to conduct a site visit. These visits gave country teams the opportunity to introduce and include outside professionals in their strategy-planning sessions. The visiting faculty were also able to provide additional training for local professionals. During this time, 11 countries received site visits. Also in 1998, each country was paired with a mentor from the United States, Europe, or Central Europe. The mentor maintained monthly contact with the core multidisciplinary team, providing advice and feedback (Sicher and Lewis, 1998). See Table 1 for a listing of conferences.
Site visits and mentoring provide both tremendous opportunities and major challenges. We have all conducted site visits and have found them most profitable, if at times exhausting. Each country presents a unique situation and thus each site visit is different, although there are many common themes. During a site visit to Russia in January 1998, for example, one of us (J.S.) had the privilege not just of delivering lectures to local mental health professionals, but also of developing relationships with the local OSI staff and other local professionals. The visit also included consultation and case supervision and visiting local clinics, shelters, orphanages, and hotline centers. In addition to the challenge of communicating new ideas, the task was to communicate through a translator, which presents its own special difficulties. In addition, in Russia the legacy of embedded hierarchical relationships is so deep-seated that open communication and encouragement of autonomy both among professionals and within families is often still problematic. In spite of such difficulties, which vary from country to country, the intention is to build a collaborative network among the project team, the OSI office, and the country's professionals and to support the development of systems specific to each country that will effectively address the problem of child abuse and neglect. The site visitor may also interact with local media, enhance clinical and professional networks, and interact with government officials, highlighting the problem of child abuse and promoting the efforts of the local team (Sargent, 1998).
The ultimate goal of Phase III is that the multidisciplinary organizations will register as NGOs in their individual countries for fund-raising to ensure ongoing development and for other legal purposes. Activities of NGOs may include (1) development and ongoing supervision of training programs for all medical and nonmedical professionals involved in child care and protection; (2) creation of consistent and confidential systems for collecting data, to be used for augmenting public awareness, establishing appropriate treatment initiatives, and initiating legislative reform; (3) improvement of coordination of services between NGOs, schools, pediatricians, mental health professionals, hospitals, and the legal system; and (4) creation of a child protection ombudsman, an independent advocate on behalf of children and families. NGOs in different countries may have different emphases. Each one should retain its independence and focus on the pressing issues in its own country. Above all, NGOs must be seen as prestigious (including knowledgeable national resources), so that they attract the most capable individuals who can nurture the development of increasingly capable networks within each country (Sicher, 1995).
The project has supported these teams with technical assistance and small grants, but the goal is that by January 2001 these organizations will become stable, self-sufficient, legally recognized groups in their countries. As such, they will be able increasingly to provide resources and training for professionals in their local areas. Establishing such indigenous programs will enhance the NGOs' fund-raising efforts and academic reputation, enabling them to create links with other NGOs in Eastern Europe as well as with Western European academic centers and universities. Moreover, the establishment of such connections and attendance at future conferences-not only as participants but also as instructors-further validates the knowledge base of the NGO members themselves (Lewis, 1998; Sicher and Lewis, 1998).
Several programs have already emerged as a result of this project, including the Children's Support Center in Tartu, Estonia, and the Nobody's Children Foundation in Warsaw. Two professionals from these organizations are now members of our core faculty. Dr. Ruth Soonets, a pediatrician from Estonia, and Maria Keller-Hamela, a psychologist from Poland, teach at our conferences and make site visits in their own and other countries to help us evaluate the progress or solve problems within funded projects. These 2 organizations serve as model programs.
The Estonian Children's Support Center was organized in 1995, and it registered as an Estonian NGO in 1996. This center has counseled more than 600 families. Eight staff members provide services and treatment. The center's headquarters are located in a previously communist housing tract where 20,000 people live. The center rented 2 rooms in the tract, from which it directs numerous activities, including an educational program for social workers, psychologists, pediatricians, and educators; individual and family mental health evaluation and treatment; and a training program for police officers. When one of us (O.L.) conducted a site visit there, the center arranged meetings with prosecutors, lawyers, the dean of the university law school, and 3 representatives of the Estonian Supreme Court to develop further the Estonian response to child abuse (Lewis, 1998).
In addition to working with more than 550 abused children and their families, the Nobody's Children Foundation has applied to other foundations for funds and grants and already functions autonomously. Working out of 2 centers in Warsaw, 10 staff members provide training programs, disseminate professional literature (which the Eastern European project provided and the OSI had translated into Polish), and mentor 3 other Polish centers in Gdansk, Poznan, and Krakow. In addition, they are conducting research on the interface between the legal and the mental health system to determine how cases of child abuse actually move through the legal system (Lewis, 1998; Nobody's Children Foundation, 1998). Two program faculty (W.N.F. and M.C.) have made site visits to Poland to provide specific training and support to the Nobody's Children Foundation.
The fourth phase of the project centered upon raising public awareness about the problems and consequences of child abuse and neglect, influencing social policy, and catalyzing legal reform. The NGOs that have been created are beginning, in several countries, to be seen as valuable consultants to the developing health ministries and social welfare systems. This has already happened in Latvia, Estonia, Lithuania, Poland, and Macedonia. Other activities that NGOs might initiate to bring about social and legal change include public awareness campaigns, conferences with lawyers, training sessions with police, and lobbying efforts to change laws. Many of the trained experts are now on national panels and also are teaching courses on child abuse within medical and nursing schools, police academies, and universities. Brochures about abuse have also been written in each native language. The aim of such activities is to influence social policy in such a way that family preservation will guide prevention and intervention.
Evaluation of the overall effectiveness of this project will be carried out in site visits in 1999 and 2000. Effectiveness and impact will also be measured through annual surveys distributed to country teams/NGOs in 1999 and 2000. These assessments will form the basis of a subsequent report. Clinical outcomes of cases treated by the professional teams will be collected. Other changes such as the development of laws and protocols regarding reporting child abuse, family preservation and family therapy treatment programs, and the development and function of the NGO multidisciplinary team itself will also be assessed and reported.
The Eastern European Child Abuse and Child Mental Health Project is time-limited with a goal of producing autonomous, self-sustaining national child abuse prevention and intervention networks. The ultimate aim of this project is to support the development of multidisciplinary NGOs in each participating country, so that they can establish and pursue nationally appropriate strategic priorities, become the professional educators for all disciplines, coordinate services from different disciplines, and involve all professions in collaboration. These NGOs will also initiate special projects on the prevention and treatment of abuse and eventually influence the creation of legislation that will protect children, while they act to help ensure that both offending and nonoffending parents receive treatment and to enhance family and community strength. By providing information, building upon the strengths of these professionals and their emerging countries, and by creating an international support network, this project has encouraged the system change and system development necessary for these tasks.
Agathonos-Georgopoulou H (1998), Future outlook for child protection policies in Europe. Child Abuse Negl 22:239-247
Ajdukovic M, Petak O, Mrsic S (1993), Assessment of professionals' and non-professionals' attitudes toward child abuse in Croatia. Child Abuse Negl 17:549-556
Berrien FB, Aprelkov G, Ivanova T, Zhmurov V, Buzhicheeva V (1995), Child abuse prevalence in Russian urban population: a preliminary report. Child Abuse Negl 19:261-264
Carnegie Foundation (1994), Starting Points: Meeting the Needs of Our Youngest Children. New York: Carnegie Corporation
Chaffin M (1998), The Impact of Politics on Child Abuse and Children's Mental Health Services in Eastern Europe. Panel presentation on the Eastern European Child Abuse and Child Mental Health Project at the meeting of the American Academy of Child and Adolescent Psychiatry, Anaheim, CA
Christozov C, Toteva S (1989), Abuse and neglect of children brought up in families with an alcoholic father in Bulgaria. Child Abuse Negl 13:153-155
Daro D, Migely G, Wiese D, Salmon-Cox S (1996), World Perspectives on Child Abuse: The Second International Resource Book. Chicago: National Committee to Prevent Child Abuse
Egeland B, Jacobvitz D, Sroufe L (1988), Breaking the cycle of abuse. Child Dev 59:1080-1088
Friedrich W (1998), Training Professionals From Other Countries. Panel presentation on the Eastern European Child Abuse and Child Mental Health Project at the meeting of the American Academy of Child and Adolescent Psychiatry, Anaheim, CA
Gilbert N, ed (1997), Combating Child Abuse. New York: Oxford University Press
Horne S (1999), Domestic violence in Russia. Am Psychol 54:55-61
Kordacki J (1991), Blindness to child abuse in Poland (letter). Child Abuse Negl 15:616-617
Lewis O (1998), Emerging Child Abuse Programs in Eastern Europe. Panel presentation on the Eastern European Child Abuse and Child Mental Health Project at the meeting of the American Academy of Child and Adolescent Psychiatry, Anaheim, CA
Lewis O, Sicher P (1998), Psychotherapy in Eastern Europe (letter). J Am Acad Child Adolesc Psychiatry 37:904-905
Nobody's Children Foundation (1998), Annual Report. Warsaw: Nobody's Children Foundation
Pecnik N, Ajdukovic M (1995), The Child Abuse Potential Inventory: cross-validation in Croatia. Psychol Rep 76:979-985
Popper K (1945), Open Society and Its Enemies. Princeton, NJ: Princeton University Press
Puras D (1994), Treatment approaches in Lithuanian child psychiatry: changing attitudes. Nordic J Psychiatry 48:397-400
Sargent J (1998), A Site Visit to Russia. Panel presentation on the Eastern European Child Abuse and Child Mental Health Project at the meeting of the American Academy of Child and Adolescent Psychiatry, Anaheim, CA
Sicher P, ed (1995), Child Mental Health and Child Abuse: Report of Findings: Budapest Conference 1995. New York: Children's Mental Health Alliance
Sicher P (1998), Introduction of the Project. Panel presentation on the Eastern European Child Abuse and Child Mental Health Project at the meeting of the American Academy of Child and Adolescent Psychiatry, Anaheim, CA
Sicher P, Lewis O (1997), Child Abuse and Child Mental Health: Faculty Seminar on Treatment of Child Abuse: Status Report 1997. New York: Children's Mental Health Alliance
Sicher P, Lewis O (1998), Children's Mental Health Alliance Foundation/Soros Foundation Eastern European Child Abuse Prevention and Treatment and Children's Mental Health Program. New York: Children's Mental Health Alliance
Sourander A, Piha J (1998), Child psychiatry in Estonia (letter). J Am Acad Child Adolesc Psychiatry 37:250-251
Vanderlinden J, Varga K, Peuskens J, Pieters G (1995), Dissociative symptoms in a population sample of Hungary. Dissociation 8:205-208
Winnicott DW (1950), Some thoughts on the meaning of the word "democracy." In: Home Is Where We Start From: Essays by a Psychoanalyst, Winnicott C, Shepherd R, Davis M, compilers and eds. New York: Norton, 1986, pp 239-259
Zverina J, Lachman M, Pondelickova J, Vanek J (1987), The occurrence of atypical sexual experience among various female patient groups. Arch Sex Behav 16:321-326
Key Words: child abuse; Eastern Europe; mental health training; post-Soviet transition