The Child Mind BlogBrainstorm

  • JFK's Stirring Words on Mental Illness, 50 Years On
    Feb. 5, 2013 Harry Kimball

    We must fix mental health care in this country. And that is what President John F. Kennedy thought 50 years ago today when he passionately advocated for reform of the broken institutional mental health care system that, in his words, leads "in most cases to a lifetime of disablement for the patient and a lifetime of hardship for his family." He continues:

    This situation has been tolerated far too long. It has troubled our national conscience—but only as a problem unpleasant to mention, easy to postpone, and despairing of solution.

    President Kennedy was talking specifically about mentally impaired patients languishing in huge, inhumane hospitals. Those institutions have been closed, but the robust community care he envisioned to replace them hasn't materialized. The president hit many of the same points we make today: inadequately treated mental illness costs our economy billions of dollars. Most signs of psychiatric disorders appear in childhood. And yet we do not—not now, and not in 1963treat these diseases with the same urgency as what he calls "diseases of the body." These "are beginning to give ground in man's increasing struggle to find their cause and cure," he wrote half a century ago. "But the public understanding, treatment and prevention of mental disabilities have not made comparable progress since the earliest days of modern history," he laments.

    But I think we can take heart in JFK's words. His goaldeinstitutionalizationmay not have been the whole answer, but it was achieved. And it was achieved by a combination of will and means. Listen to him: "The time has come for a bold new approach. New medical, scientific, and social tools and insights are now available."

    Fifty years down the road we would do well to remember JFK's optimism and his resolve to change what needed to be changed. We are wiser now in many ways; let us borrow the strength from the past to put that wisdom into practice.

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  • Stimulants and Suicide: A Tragic Story With Misleading Implications
    Feb. 4, 2013 Caroline Miller

    The very sad piece in the New York Times yesterday about a young man who committed suicide after serious abuse of stimulant medications was upsetting for a number of reasons. It's a terribly tragic story about mishandled medication, about the ravages of addiction, and about the powerlessness of parents to help adult children who are self-destructively mentally ill.

    It is also verges on the kind of fear-mongering that is unhelpful to parents trying to provide the best support and care to struggling children. Families whose children have ADHD deserve, we think, a more even-handed assessment of the risks of the disorder and its treatments, as well as the circumstances leading to the suicide of Richard Fee.

    Fee was a young man who, according to his father, had no symptoms of ADHD, but was able to convince a series of mental heath practitioners that he had the disorder and persuade them to provide multiple prescriptions for stimulant medications he was abusing. The story paints a painful picture of lapses in the mental health care system. Most painful of all was the portrait of his father practically accosting a psychiatrist who had been fooled by his son's fabrications and begging him to stop providing the prescriptions. It's appalling that he couldn't get the message across that his son was an addict, and that a series of mental health practitioners didn't do due diligence about how many prescriptions he had already filled.

    But the story was also disturbing because the writer did painfully little to make it clear how far this kind of abuse of stimulants is from monitored use by children and adolescents who actually have ADHD. It suggests two misleading and frightening notions. First, that taking stimulant medication for ADHD puts kids at higher risk for addiction. Research shows that it doesn't. For kids with ADHD, medication is not a steppingstone to the kind of abuse Fee was engaged in.

    The second misleading suggestion: that it's easy to take a little too much Ritalin or Adderall and end up in the predicament that Fee was in, addicted and at risk for the kind of psychotic, suicidal crash that ended his life. The fact is that stimulant medications are metabolized rapidly in the body, and when one takes them according to a doctor's orders the medication does not accumulate in the body. You have to do a lot of sustained doubling up on medications to accumulate enough amphetamines in the body to enable the crippling withdrawal symptoms that Fee is said to have experienced.

    It's terrible that Richard Fee was able to manipulate a lax system to get enough medication to get into very serious trouble. It is terrible that Fee's caring and tireless parents knew their son was out of control and found themselves powerless to intervene on his behalf.

    But it's also unfortunate that this story slyly inflates the risks of stimulant medications used appropriately by not acknowledging that Fee's abrupt change in personality, extreme behavior, and suicide may well have had other contributing factors. For a doctor with no connection to Fee to say that stimulants "in all likelihood" were the "primary issue" contributing to his suicide is irresponsible, and to print this statement is reckless. Fee was at a prime age for the onset several other major psychiatric disorders, and was also apparently abusing marijuana, which has also been linked to higher risk of suicidal thoughts, psychotic symptoms and depression. Did he have depression or mania or schizophrenia? We have no idea. Are stimulants fairly safe for people with ADHD under the close care of a physician and with the support of the family? Yes.

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  • The Ravitz Report: The Radiant Child
    Feb. 1, 2013 Alan Ravitz, MD, MS

    Dr. Alan Ravitz, a child and adolescent psychiatrist at the Child Mind Institute, is an avid movie watcher who has a keen eye for the pleasures and insights to be found in all genres, from action flicks to intimate character studies. Each week Dr. Ravitz will recommend here a film for weekend viewing. Expect surprises, psychological twists, and a taste for emotional subtlety.

    The Radiant Child, a documentary about Jean Michel Basquiat, is available as an instant download on Netflix. There are 3 very good reasons to watch the movie. First, you can learn about art. I always thought Basquiat's reputation was overblown, despite the universal opinion of every one of my art-knowledgeable friends and acquaintances that he was a verifiable genius. After watching the film, I'm coming around to their point of view (although his work is still not my cup of tea). Second, the movie is a great cultural document of downtown life in the 80's. Third, and for this audience most important, The Radiant Child is very deeply about development—the impact of biology, family, culture, and personal experience on the way each of us turns out. I was very impressed with this film.


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  • Victoria Azarenka: Panic Attacks and Armchair Diagnoses
    Jan. 29, 2013 Harry Kimball

    Tennis player Victoria Azarenka made news this past week—she won the Australian Open, sure, but more ink was spilled over her defeat of Sloane Stephens in the semifinals. Azarenka took a medical break in the second set, and some commentators think she used the time to rebound in a game that was slipping away from her. One went so far as to diagnose her supposedly unsporting behavior: "That was not an injury," Greg Couch writes for Fox Sports. "It was a panic attack."

    Now, we don't know what really happened to Azarenka, whether her motives were pure, or even what Couch knows about panic disorder, which is in actuality a severely impairing psychiatric illness. I'm guessing he was using the term more generallyand incorrectly. "Azarenka was falling apart and didn't know what to do," he continues. "So she manipulated the injury timeout rules to freeze Stephens." 

    What we do know is that after the match, Azarenka said that before her medical timeout she "couldn't breathe" and she felt like she was "getting a heart attack or something out there." And we know that many people with undiagnosed panic disorder end up in the emergency room time and time again because their symptoms do feel like heart attacksand that they can't really begin to address the disorder until someone notices that it is severe anxiety, and not a pulmonary issue, that is causing them distress.

    It is normal for people to be anxious in a variety of situationsand particularly, I imagine, in the semifinals of a Grand Slam tournament. Couch accuses Azarenka of being a coward and a cheat. "She was so scared she couldn't get the ball onto the court," he concludes. But "panic breaks are not within the rules." I don't know-as many have pointed out, athletes are not above "diving" for an advantage. But I do know that if you feel like you are dying it's ok to get help, whether or not that feeling comes from a physiological injury or an anxiety disorder. Both of those things are real, and we should watch our language when we're saying something is "fake."

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  • Living With Schizophrenia: A Success Story
    Jan. 28, 2013 Caroline Miller

    It's been on the most popular list on the New York Times web site for days, and no wonder. It's a great feel-good story. A woman in her 20s diagnosed with schizophrenia is told that she's not likely to be able to live independently, marry or have children, hold anything more than a menial job, or enjoy more than intermittent periods without debilitating symptoms. Thirty years later she's a law professor at USC who also teaches in the psychiatry department at UCLA, is married, and is the recipient of a MacArthur genius grant. 

    Part of the draw is just the headline,"Successful and Schizophrenic"—a conjunction of two words not seen together all that often. But it's a good deal more than a beating-the-odds story. Elyn Saks is one of a growing number of people with mental illness talking candidly about how they are able, with the help of excellent therapy and medication, to manage their recurring symptoms—the way someone with diabetes or arthritis manages their symptoms.

    Saks cites participants in a study of high-functioning schizophrenics who report that they have trained themselves to recognize triggers to their symptoms and do things that help avoid them, like minimizing stimulation, or eating comfort food. One man, an educator, says he has learned to face his hallucinations and ask, "What's the evidence for that? Or is it just a perception problem?" Another, a nurse's assistant, says, "I'll listen to loud music if I don't want to hear things."

    They're marvelously matter-of-fact about how they manage. One of the main things most of them cite for keeping them sane is work. As Saks puts it rather charmingly, "In other words, by engaging in work, the crazy stuff often recedes to the sidelines."

    And—perhaps the most important thing—none of these people manage their illness alone. "Personally," Saks writes, "I reach out to my doctors, friends and family whenever I start slipping, and I get great support from them."

    It's a very inspiring argument for not underestimating what kids with developmental and psychiatric disorders can accomplish—with the right treatment and support, and a focus on their strengths and talents.

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  • Haunted by High School
    Jan. 25, 2013 Caroline Miller

    Whether you remember your high school years as happy or hellish, Jennifer Senior bets that the experience is still surprisingly vivid to you, lo these many years later, and the teenage identity you forged in those halls still has an inordinate (perhaps even ridiculous) amount to do with your adult identity. In her piece in this week's New York magazine Senior writes about the brain changes in adolescence, and why they make emotions more intense, and the business of finding your place so fraught.

    It's a pretty irresistible look at the cauldron in which identity is formed in those arduous years. Senior argues that by quarantining teenagers in an environment filled overwhelmingly with their peers, we set the stage for aggressive, even desperate, competition for acceptance, status and power. "Most American high schools are almost sadistically unhealthy places to send adolescents."

    But beyond that she argues that those experiences tag us long after we graduate and go on to bigger and (in most cases) better things. "During times when your identity is in transition," a developmental psychologist tells Senior, "it's possible you store memories better than you do in times of stability."

    There is research that shows that being popular and attractive in high school, at least for boys, is predictive of greater earning power as adults. But an interesting thing happens when you look at girls—and this, I think, is an important takeaway from the piece.

    A group of 10th graders were asked which of the five characters from The Breakfast Club they most considered themselves to be—Jocks, Princesses, Brains, Basket-Cases, and Criminals. (I know you're thinking, "This is science??" But bear with me.)

    Girls who categorized themselves as Princesses when they were 16 were on the top of the pecking order at that point, but by the time they were 24 they had lower self-esteem than the girls who considered themselves Brains.

    The researcher attributes that finding to the notion that Princesses had come to define themselves by their social success in the world of high school, while the brainy girls, for whom popularity was elusive, had to rely on said brains and the skills they could use them to develop as a basis for self-esteem. "Out of high school, they suddenly had agency," Senior writes, "whereas the princesses were still relying on luck and looks and public opinion to carry them through, just as they had at 16. They'd learned passivity, and it'd stuck."

    To me, this reinforces the point that the most important thing to do to help our daughters build healthy self-esteem is to urge them to do things—acquire skills, explore interests, experience mastery—not to rely for their sense of self on how they look or how much other people like them.

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  • The Ravitz Report: Catfish
    Jan. 25, 2013 Alan Ravitz, MD, MS

    Dr. Alan Ravitz, a child and adolescent psychiatrist at the Child Mind Institute, is an avid movie watcher who has a keen eye for the pleasures and insights to be found in all genres, from action flicks to intimate character studies. Each week Dr. Ravitz will recommend here a film for weekend viewing. Expect surprises, psychological twists, and a taste for emotional subtlety.

    Catfish is a 2010 American documentary, directed by Henry Joost and Ariel Schulman, as the two of them film Ariel's brother, Nev, in his pursuit of a romantic relationship with a woman, Megan, he met on Facebook. As they get to know each other, she sends him videos of some of "her songs," but they turn out to be nothing more than YouTube rip-offs. Undeterred, Nev moves forward into the unknown—well, actually a small town in Michigan, with his directors, to solve the mystery, and possibly find true love. I don't want to give anything away, but the denouement is interesting, complicated, kind of creepy, kind of funny, and very human in a thought provoking way. No one could have made any of this up—which is often what I think when I do my clinical work. Humanity is both horrifying and beautiful.


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  • School Bus Strike Hits Our Most Vulnerable Children
    Jan. 21, 2013 Beth Arky

    As the New York City school bus strike enters Week 2, it's clear that the 54,000 special-needs children and their already overtaxed parents are bearing the brunt of the walkout. It's important to understand that for many of these families, the school bus is not just a ride to school. It's a crucial piece of a support system for kids who can't just jump on the subway—in fact, they may not be able to walk—and parents who can't hold down jobs unless their children are in reliable, competent, and caring hands.

    It's not unusual that the only appropriate school for a child with complex developmental delays and resulting behavior problems might be an hour from home, so thousands of parents are missing work to endure long, arduous commutes, or keeping their kids home. But the personal cost doesn't end there. As Marie Myung-Ok Lee writes in a candid and thoughtful piece in The Nation ("A Good Matron Is Hard to Find"), children and parents alike are also missing the continuity and calm provided by experienced drivers and matrons now walking the picket line. 

    Lee, whose 13-year-old son, J, has serious medical challenges and developmental disabilities, including autism, has come to depend on J's excellent driver and matron: "Our son indeed relies on them to be consistent, calm, patient and firm."

    And that's not easy. "On bad days, our son can bite, head-butt, scream or pinch—fairly typical behaviors for autism, but they can be shocking when one first encounters them," Lee writes. And because of J's gastrointestinal problems, he can have toileting issues. "It can be difficult not to take such assaults personally or want to retaliate," she notes, "which is why experience and maturity needs to be taken into account."

    While experience doesn't guarantee expertise and sensitivity, Lee says it improves the odds; J's driver and matron each have worked with special-needs children for 18 years. Like many parents, Lee considers them valued players on J's team: "We all work together to keep our son calm, but when he's not, they know what do to. No amount of training and video-watching can prepare a driver for what it's actually like navigating New York City traffic with the bedlam of one (or more) children throwing a tantrum behind her." She also applauds her driver's "great communication skills with parents; she calls when she needs our input on our son's behaviors or medical issues. She and the matron make our son feel safe, which in turn helps us to feel safe."

    As the city and the unions continue their stalemate and questions arise about the cost of bussing special-needs students, Lee brings it down to the most human level: It's the children, "who have little voice and are often ignored or scorned in society," who are losing the most. Those who continue to attend school may be missing hours because of long commutes, while parents who are keeping their children home worry that they may regress as they miss out on the routine, socialization and therapies school provides.

    Lisa Quinones-Fontanez, another autism mom, explains in an open letter to Mayor Bloomberg and Local 1181 why 7-year-old Norrin, whose school is 22 miles from the family's Bronx apartment, spent the third day of the strike with her at her job as an administrative assistant, rather than at school. She writes that she has already used up two vacation days staying home with him, her husband, a court officer, can't take time off; and she needs the rest of her days for doctor's appointments and IEP meetings. She also needs to keep her job, and she's worried about that. "This is beyond a stressful situation," she writes. We hope both the union and the mayor understand that.

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  • The Ravitz Report: Tarnation
    Jan. 18, 2013 Alan Ravitz, MD, MS

    Dr. Alan Ravitz, a child and adolescent psychiatrist at the Child Mind Institute, is an avid movie watcher who has a keen eye for the pleasures and insights to be found in all genres, from action flicks to intimate character studies. Each week Dr. Ravitz will recommend here a film for weekend viewing. Expect surprises, psychological twists, and a taste for emotional subtlety.

    Now that I've recommended 56 Up, I thought I'd recommend another documentary about a child growing up. This time the child is an occasionally cross-dressing performer/film-maker, and his mother is a schizophrenic. Jonathan Caouette put together home movies, interviews, even answering machine messages to create a film about what it was like to be him growing up. Tarnation (2003) is an incredible testament to what makes all of us just human.

    This one's really hard to describe, so I'm including a link to its trailer.

    Cauette released a follow-up in 2011, Walk Away Renee, about a cross country trip he took with his mother. I liked it, but not as much as Tarnation.


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  • Mood Disorders and Violent Video Games
    Jan. 17, 2013 Caroline Miller

    If you want to read a provocative, insightful piece on violent video games, mental illness, and mass shootings, you'll find it on Kotaku, a gaming site that's part of Gawker Media. The headline tells the story and sets the tone: I'm Mentally Ill, I Love Violent Video Games, and They've Never Made Me Feel Like Killing Anyone. 

    The writer, Dennis Scimeca, is an articulate and startlingly frank gaming writer in his thirties who has bipolar disorder. And it's much more than a defense of the video games he has been a devotee of since childhood (though it is that). It's a close look at how games have interacted with his emotional life, both in the volatile years before he was diagnosed, in his 20s, and after.

    Scimeca figures he suffered from bipolar disorder for more than a decade before he sought, and got, treatment, and he describes video games as one of the most important sources of pleasure and solace for a kid who was bullied and frustrated as a teenager. It's the skills challenge that made them satisfying, he says, noting that it's pretty hard for those of us who doesn't play to understand the appeal of what he calls first person shooters. "I was rubbish at playing sports as a kid, but I'm a pretty good FPS player and I feel a healthy sense of satisfaction when I beat a Halo 4 level at the Legendary (highest) difficulty level."

    Of course he had revenge fantasies—everybody has revenge fantasies, he notes—but he says it wasn't just the fact that he didn't have semi-automatic weapons at his disposal that kept him from becoming Adam Lanza.

    Even if I had been able to get my hands on guns in high school I doubt I'd have used them. I had a family who loved me, and friends who listened to my suicidal rants and slides into depression. These people comforted me.

    Scimeca makes it very clear that it isn't just medication that helped him get control of his illness, but also his family and friends. And he's also clear that the real problem wasn't anger but emotional pain so extreme that he didn't want to "move or talk or even breathe."  Without that support system and attention to his pain, and with access to guns, he imagines that the outcome could have been very different.

    What might have made me a school shooter in some other reality would have been whether I was lonely, or whether anyone was paying any attention to the fact that I was in constant pain, or whether I could have easily laid my hands on a lot of guns, and I'm very glad that in my case none of those things were true.

    In another post last fall Scimeca writes about why it's important to be open about psychiatric problems, and how long it's taken him to be able to be public about his own diagnosis. We appreciate his candor about living with a disorder that is so easliy and frighteningly misunderstood.

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