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The Child Mind BlogBrainstorm

  • Living Up to the Potential of Dr. King's Dream
    Aug. 28, 2013 Harry Kimball

    Today is the 50th anniversary of the 1963 March on Washington and Martin Luther King's "I Have a Dream" speech. I was going to write that we are "commemorating" it today, but that word rings wrong. We commemorate what we feel we should remember. But when I hear that speech, it is fiercely present. In my mind the legacies of Dr. King and all the fellow travelers of the civil rights movement require a proactive re-engagement—because the story is not over. Not by a long shot.

    In one major way this is clear. Race relations in this country have come far since the dark days of...well, most of our history. Black and white children are free to hold hands, as Dr. King hoped. A black man holds the highest office in the land. However, we know that the journey is not over. A cursory look at the news will tell you as much. I don't know if there will ever be a "post-racial" America, but we certainly aren't there yet.

    But even as we continue to struggle with the lines of color that still divide us, let's not forget that the message of Dr. King and the civil rights movement was not only about racial equality. It was about equality, period. It was about respect for our fellow citizens and our fellow human beings. It was, as we all know so well, about a dream of a country where children "will not be judged by the color of their skin, but by the content of their character."

    I propose that that statement applies beyond differences of skin color. It applies to differences of opportunity, of gender and sexuality, of opinion. And it applies to the different inherent challenges our children may face because of illness, of the body and of the mind. That phrase means to me that the potential that lies within every child is the most important thing, and that impediments to the nurturing of that potential are the enemies of a just and vibrant society. And I think it is important to remember that even when Dr. King made that speech fifty years ago, there were laws on the books guaranteeing equality to black Americans, even as now there are laws on the books guaranteeing parity to those who struggle with mental illness. Law is not enough. The heart of this nation also needs to change.

    Listening to the radio this morning I was reminded of the link between Dr. King's speech and Langston Hughes famous 1951 poem "Harlem." "What happens to a dream deferred?" Hughes wonders. "Does it dry up like a raisin in the sun?" Or, he ends pointedly, "does it explode?" Hughes was hinting at the possibilities of stymied potential-withering, on the one hand, and rage, on the other. We see these same possibilities in our underserved, forgotten children. But, like all of us, they have a dream. They just need some help moving towards it. I am thankful today that Martin Luther King and all the marchers from 1963 are still showing us the path.

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  • Getting Kids to Put Down the Phone
    Aug. 20, 2013 Rachel Ehmke

    Dwight Garner, literary critic for the Times, took an unusually personal assignment lately—trying to figure out how to wrest his children away from the various technologies that they seem increasingly addicted to. This is a perennial issue for Garner and his wife, who apparently try to introduce ambitious new rules restricting the children's technology usage at the beginning of every school year, only to watch these rules routinely fizzle out by the second week of school.   

    Like many frustrated parents, Garner turned to books written on the subject, hoping they might have the answer he's been looking for. The subsequent review he produced was as amusing and depressing as you might expect it to be. He didn't get any answers, but he did get some laughs. One of the books discusses "tweeting mindfully," for example.

    The truth of the matter is that Garner is pretty aware of what he needs to do to limit his kids' technology usage, starting with not abruptly issuing mandates that he's unprepared to enforce. But his dilemma is a common one for many parents. We're in a new era of technology, and parents don't want their kids to get left behind. Garner writes, "I like that they are comfortable and alert in the wired world, able to fish in it like young bears in a salmon stream." (Really the last thing parents should be worried about is wired literacy, since kids do a pretty good job taking care of that themselves, even without unfettered access.)

    Like Garner, many parents also feel uncomfortable setting boundaries with children, even though he knows limits are important. This is true especially with kids, but it's also true for ourselves. In part Garner's essay is also about his own immoderate technology usage. "Without my iPhone in my palm, I feel bereft," he writes. "I'm fairly obsessive. I must change my life a bit." But it doesn't really sound like he wants to.

    One commenter noted that his essay was reminiscent of one that Adam Gopnik wrote for The New Yorker about his daughter's imaginary friend Charlie Ravioli, who was always too busy to play with her. She'd call and get Ravioli's machine, or he'd answer and say he's too busy working to play. He frequently canceled their imaginary lunch dates but sometimes they'd manage to grab coffee. Eventually Ravioli acquired an assistant, named Laurie, who screened his calls for him. It was obvious that his daughter was mirroring the glamorously ultra-busy lives of the adults around her, and having some fun while doing it, but it was disturbing to witness.

    That essay was written in 2002, but the point that it raised is only getting more applicable. Until we start modeling the values that we want to see in our own children, we shouldn't be surprised if, like so many Charlie Raviolis, they don't have any time for the things that happen outside their phones. 

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  • A Sweet, Sensitive Film About Kids in Foster Care
    Aug. 20, 2013 Dr. Harold S. Koplewicz

    I recently attended a screening of Short Term 12, a wonderful movie about a foster care facility for at-risk teenagers in Los Angeles, told through the eyes of a twentysomething mental health director, Grace. It was inspired by the real experience of the writer-director, Destin Daniel Cretton, who worked in the foster-care system, and it shows in its insight into the struggles of both the residents and the staff.

    It's an affectionate, thoughtful look at the challenges of being these wounded, complicated kids, as well as the challenges of helping them, of reading their behavior and responding effectively. It's an emotional film but not a sad one, because it's really about resilience, and the healing power of being open about painful experiences and the feelings they generate.

    The kids who come to live at Short Term 12 have been abused or neglected, but they're not sensationalized or stereotyped. Right in the opening sequence the tone is set when a young resident comes screaming out the front door, heading for the gate, beyond which the staff is legally not allowed to touch him. Grace and her coworker (and live-in boyfriend) Mason swiftly and gracefully intersect the boy, who's shouting obscenities but also clearly relieved to be caught, and ready to "de-escalate," as Mason puts it, inviting him to come back on the unit and take a nap. They react with insight born of seeing plenty of kids act out, and not being either impressed or frightened by the behavior.

    The plot of Short Term 12 is as much about Grace and Mason as it is about the kids. There's a marvelous scene in which we discover that Mason was raised by foster parents, and he has a chance to toast them, with the other children they took in. "You took in a punk kid and taught me how to love," Mason tells them, and we have seen the power of their teaching in Mason's way with both the kids and Grace.

    Grace struggles with her own past, and the powerful connection she makes with a new resident named Jayden, who has serious problems with her father, helps her begin to come to terms with very difficult feelings. A good deal of Short Term 12 is a sensitive depiction of the ways in which we acknowledge and express things that have hurt us—sometimes in very small increments—and how expressing them allows us to live more fully, and let other people into our lives.

    None of the residents of the home called Short Term 12 are "bad" kids or "good" kids—they're kids with vulnerabilities and weaknesses, who by acknowledging them are able to achieve some degree of transcendence. We don't know how many of them have psychiatric issues and how many are just damaged by abusive or neglectful environments—and of course we do know that kids with psychiatric issues often attract abuse in very troubled families.

    The backdrop to the film is the system, which sends kids to Short Term 12, highlighted when newbie staffer Nate asks on his first day,"How long do they stay here?" Grace unflinchingly responds, "Less than a year, but we have a few that have been here a little over three—we just keep them until the county figures out where they are going to go next."

    In my years as a child and adolescent psychiatrist I have seen many kids fall through the cracks in an overwhelmed mental health care system. But what kids get at Short Term 12 is really a substitute family; an ad hoc family that shows how much can be achieved, despite daunting odds, with mutual trust, open-mindedness, and patience.

    Short Term 12 arrives in theater August 23rd in New York and LA. For more on the film visit

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  • Autism Linked to Induced or Augmented Labor
    Aug. 19, 2013 Caroline Miller

    A new study made headlines last week with the claim that induced and/or augmented labor might increase a child's risk of developing autism. It was the latest in a steady stream of what I think of as studies linking autism to ... anything and everything.  Typically, these studies take batches of records—in this case North Carolina birth and education department records—and mine the data for correlations.

    In this sample of more than 600,000 kids, those who were born after induced and augmented (speeded up) labor were 23% more likely to be identified in special education records as having autism. The group with induced labor alone were 13% more likely, and those whose labor was augmented but not induced were 16% more likely.

    Of course there's no causation shown here and you don't have to be a doctor to wonder, if there is actually some kind of meaningful link here, it might instead be to one or more of the things that can cause labor to be induced or augmented, such as fetal distress or maternal diabetes, both of which have previously been linked to autism. Other things that have been linked to autism in this kind of study, with varying degrees of credibility, include mother's flu during pregnancy, obese mothers, mothers taking antidepressants, and, stepping away from the usual suspects, older fathers.

    I mention this study mostly to draw attention to an analysis by the terrific Forbes science blogger Emily Willingham, who shows you how little meaning there is to this correlation and others of its ilk. These studies usually attempt to exclude factors that might influence the findings, but the relevant data is often not available.

    What was apparently was available, if overlooked, in this data set was the mother's educational level. Willingham notes with some amusement that per this study mothers who have a college education are more than 30% more likely to have a child with a special education label. "That is two or three times the odds linked to induction or augmentation," she writes, "and greater than the odds of labor and induction together. But no headlines."

    I recommend the whole post, which gives you questions to ask next time you read one of these studies. It also might bring some comfort to parents agonizing over the ever-increasing laundry list of risks associated with autism, often including things that they can't avoid. At least some reports on the study noted that inducing labor can be a life-saving technique for an endangered child, and nothing in this research suggests that a change in procedures is warranted.

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  • Ninja Warriors Tackle Mental Health Obstacles
    Aug. 15, 2013 Jessica Kashiwabara

    My guilty pleasure this summer is American Ninja Warrior, a competition series airing on NBC and G4 that follows a diverse group of competitors as they attempt to get through a series of fairly brutal obstacle courses. The show is pretty physical: Competitors leap, hang, and suffer dramatic fails from obstacles like the Spider Climb (climbing 30 feet wedged between two walls) and the Salmon Ladder (hanging and moving a bar up a series of notches). So I was surprised when the profile of two competitors brought up mental health issues not often spoken about—Tourette's and selective mutism. These stories highlighted two individuals who have gained a lot from the show, one as a competitor and the other, a young fan.

    Two-time competitor Justin Walcker was diagnosed with Tourette's Syndrome at the age of 5. He describes the frustration and stress he experienced as a child having to deal with vocal and physical tics that at times were so bad they caused him pain. But when he found parkour, the popular, acrobatic extreme sport, the intense focus required to jump and move with ease and speed helped him to control his tics. Justin encourages others with Tourette's to persevere and his positive attitude is inspiring. It's great that he is equally proud of who he is and what he's accomplished as he states on his Facebook page: "I'm a traceur with tourettes and love competing in American Ninja Warrior."

    In the backstory of another  veteran competitor on the show, we learn about a fan named Lenny , who suffered from selective mutism. At 5, Lenny wouldn't speak to his teachers, his sisters or even his mom. When he met John "JB" Douglas, who was teaching gymnastics at his preschool summer camp, he felt so comfortable with JB he started to speak. Lenny's mother said it was his first step to his opening up and being able to speak to others. And the bond is important to JB, too. As he says: "When Lenny's mom tells me how much of an impact I've made in his life, it means so much more than winning American Ninja Warrior would."

    Both Justin Walcker and JB Douglas have made it to the final rounds, and I'll definitely be cheering these two on as they show us that inspiration can come from some pretty surprising places, even for a ninja warrior.

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  • Soaring Use of Antipsychotics in Young Children
    Aug. 12, 2013 Caroline Miller

    The Wall Street Journal broke a story today about a federal investigation into the use of antipsychotic medications to treat children with disruptive behavior. The particular concern is kids in the Medicaid system, and the statistics are fairly alarming. The number of kids under age 20 with Medicaid-funded prescriptions for antipsychotics is said to have tripled between 1999 and 2008. And in 2008 they included 19,000 children under the age of five—more than twice the number in 1999.

    These medications, which are called atypical antipsychotics, can be very helpful for children with extreme emotional dysregulation, especially those who are unable to remain with their families without them. But the worry here is that they're being given to lots of kids whose behavior problems are prompted by common underlying issues that deserve treatment—trauma, anxiety, depression, ADHD, learning disorders. These are problems that respond more effectively to behavioral therapy, school supports, and medication targeted to them. But those responses assume expert diagnosis, patience, and other resources that a lot of kids don't have the benefit of, especially kids in the foster care system.

    The Journal quotes Dr. Fernando Siles, a Dallas pediatric psychiatrist, who says that antipsychotics may be used to keep kids prone to aggression from being kicked out of their foster homes. "The antipsychotic is to stabilize the behavior of the child, to keep him from being moved and moved again." Dr. Siles notes that there's "no budget" for behavioral therapy.

    This is a very disturbing trend and one of the reasons we think it's urgent that more parents have enough information about children's mental health to know when the care they're getting is not good. It's why we wrote our Parents Guide to Getting Good Care—to help weed out clinicians who aren't giving your child the careful attention he needs and deserves before pulling out the prescription pad. We need to try to understand behavior in order to respond to it most effectively, especially when children are young and the right intervention can change the course of their lives.

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  • When Stomach Aches Indicate Anxiety
    Aug. 12, 2013 Rachel Ehmke

    A study published today in the journal Pediatrics links childhood stomach aches with future anxiety disorders in adulthood.

    The long-term study followed over 300 children who experienced recurring stomach aches without any apparent medical explanation (called functional abdominal pain) throughout adolescence and young adulthood. Researchers at Vanderbilt University found that the kids with functional abdominal pain were more likely to develop anxiety disorders and depression later in life than the almost 150 control children without stomach aches. In fact, in most cases an anxiety disorder was already present before the children were evaluated for functional abdominal pain. This despite the fact that the study's lead author, Lynn S. Walker, PhD, told the New York Times that the majority of kids "had not seen a mental health professional, ever." Which isn't much of a surprise. Anxiety is often overlooked in kids because it tends to have quieter consequences than some other childhood disorders. Anxious kids are often more introverted and, as Dr. Walker says, preoccupied with doing a good job.

    This new study is a helpful reminder that the mental health disorders that affect adults often begin in childhood, where they are typically overlooked. Not only does that mean that many kids who are suffering don't get support, it also means that families are missing out on the opportunity to help kids when they are younger and treatment can be most transformative.  

    Anxiety tends to grow with us—the more time we spend with overwhelming anxiety, the more we learn to contain our discomfort with maladaptive coping techniques that we devise ourselves. This means that anxious kids learn early to close themselves off from things that make them nervous, so they miss out on many of the academic, extracurricular, and social opportunities that their peers get to experience.

    Recurring stomach aches, something that kids might be more vocal about, can be a good warning sign for families. 

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  • #dearmentalhealthprofessionals Is Trending on Twitter
    Aug. 12, 2013 Caroline Miller

    Amanda O'Connell, a  woman who runs a mental health training business in Scotland, hit a nerve Saturday when she started the Twitter hashtag #dearmentalhealthprofessionals. Given the very negative effect isolation has on people with mood disorders and other mental health challenges (and, of course, everyone else), it seemed like a good idea. We were curious to see what people might have to say, and whether the posts reflected issues we hear about regularly from parents.

    Amanda, who her bio says has experienced some mental health issues herself, wrote, as several others did, about the importance of clinicians treating patients as peers, not condescending to them: "There is no 'them' and 'us.' We can become professionals, and just as easily you can become mentally unwell."

    Of course there were some who voiced criticisms: "When I'm struggling, in crisis and ask for help, don't call me an attention seeker and actually help." But also some thank yous: "... And now because of your persistence, humanity and compassion I am well enough to return to med school."

    Availability is obviously a sore subject, and rightly so. One wrote: "do not prescribe medication that increases suicidal thoughts & then not offer an appointment for 6 weeks." Another "I shouldn't have to beg to be allowed to see you" and finally "There aren't enough of you. Government has failed us all."

    The final word goes to Amanda herself, from a post which may have referred either to the hashtag or to mental health care in general, but applies equally well to both: "Appropriate humour can actually be really helpful. Everything doesn't need to be really serious."

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  • Asperger's: Out of DSM but Still in the Brain?
    Aug. 6, 2013 Harry Kimball

    The DSM-5 may have done away with the diagnosis of Asperger's syndrome—as distinct from autismbut the conversation (fracas is often a better word) over how to and whether we should differentiate low- and high-functioning autism continues. The latest item to address this thorny issue is a study out of Boston Children's Hospital that aimed to uncover physical brain differences between Asperger's children and children with the wider autism spectrum disorder diagnosis using electroencephalography, or EEG. The results are...mixed.

    Lead researcher Frank Duffy had already, in a previous study, determined that EEG could differentiate pretty well between kids with autism diagnoses and a typically developing control group. He did this by attaching those familiar EEG electrodes to their scalps and recording the electrical impulses the brain uses to communicate with itself. This paints a picture of connectivity between brain regionsand allows researchers to differentiate between stronger or weaker connections. Using some sophisticated data analysis tools, they were able to show that most kids with autism have similar differences in connectivity when compared to the control group. That is, properly interpreted EEG data agreed with clinical diagnosis.

    Now, to the current study: Let's say that Duffy's earlier work showed EEG could reliably differentiate between apples (kids with autism spectrum disorders) and oranges (typically developing kids). The new study reaches two conclusions that fall neatly on either side of the Asperger's debate. First, in the new study Duffy distinguished three groups of kids: those with Asperger's, those with autism, and those who were typically developing. Duffy found that, physiologically, Asperger's and other forms of autism are much more like each other than they are like the control group. Apples were still grouped with apples, oranges with oranges.

    But! Duffy's second discovery is that if you compare kids with Asperger's and other kids on the autism spectrum, EEG can reliably differentiate them based on brain connectivity. There are brain differences that support the (now passé) clinical separation between Asperger's and autism. So the study shows that Asperger's is on the autism spectrum, but also distinctthey're both still apples, but Asperger's is a Red Delicious and autism is Granny Smith.  

    I detect in Duffy's paper where his affections lie, and it isn't a far-fetched position for anyone who has experience with the incredibly wide range of the autism spectrum. "Although the findings above in many ways agree with the DSM-5 placement of [Asperger's disorder] within the broad autistic spectrum," the study authors write, "they also demonstrate that patients with Asperger's can be physiologically distinguished from those with ASD. Recognition of Asperger's as a separate entity is important from the patients' perspectives of obtaining appropriate medical and educational services as well as of establishing a personal identity." 

    In other words, though the diagnosis has changed, the kids are the same, and need the same personalized supports. This is true whether a child has limited communication and self-injurious behaviors or is highly verbal, intelligent, and socially awkward to the point of impairment. The results of this study could lead to new tools for diagnosis, prognosis, and monitoring of treatment efficacy. But in the meantime, it helps to remember what I've been told by every experienced autism clinician I have spoken with. "You've seen one child with autism," the saying goes, "and you've seen one child with autism."

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  • Kicking OCD's Butt at the International OCD Foundation Conference
    Aug. 6, 2013 Rachel Ehmke

    The International OCD Foundation's annual conference is different from other conferences. Instead of just convening professionals, the IOCDF conference includes people with OCD. A large portion of their programming is aimed at people personally impacted by the disorder—kids and adults with OCD as well as parents, spouses, and siblings. This is because the association includes nonprofessionals in its membership, which gives a unique immediacy to the work being done there. 

    A team from the Child Mind Institute attending this year's conference seized the opportunity to run a workshop for kids with OCD called A Weekend Adventure of Kicking OCD's Butt! Led by Dr. Jerry Bubrick and Dr. Rachel Busman, the team provided what's known as exposure and response prevention—a cognitive behavioral therapy used for treating OCD—to over 30 children over the course of two days. The conference was in Atlanta, but the kids participating came from all across the country—from Seattle to New Jersey, Florida to California. What's more, the kids came with a wide range of experiences with cognitive behavior therapy. Some kids had never received CBT, some received regular CBT back home, others were used to driving several hours for treatment because there aren't any providers near them—an all too familiar story. There was a range of ages in attendance, too—from 9 to 15 years old—but the kids were able to build a supportive community, which is important for the kind of therapy they were doing.

    Exposure therapy works by gradually exposing people to things they are afraid of, with the idea that our anxiety over something diminishes the more we become accustomed to it. With the help of CMI staff Marc Shuldiner, Jessica Meister, Erika Rooney, Naomi Reyfield, and Julia Brilliante, the kids performed what's known as "exposures." Some kids at the workshop were afraid of germs, so they'd practice handling money, sitting on the hotel conference room floor, and not washing their hands. Some kids with obsessions over symmetry or making things "just right" practiced not correcting mistakes, wearing twisted socks, or putting shirts on backwards. Kids who were afraid of heights took rides in the hotel's big glass elevator with Dr. Bubrick. One boy who was very troubled by aggressive thoughts that he couldn't control practiced holding a plastic knife to a clinician's arm.

    The idea of doing something you're afraid of in a room full of strangers sounds tough, but in this case it might have actually been an advantage. At the beginning of the workshop the team from the Child Mind Institute spent time explaining what OCD is and what symptoms might look like. "We saw a lot of head nodding," said Dr. Busman. "Kids would call out, 'Oh, I used to do that.'" Some kids remembered each other from attending past conferences, but others got to know each other quickly, bonding over shared experiences. The boy who was disturbed by his aggressive thoughts told the group that just admitting that he had these fears was an exposure on its own, but his peers were in a unique position to understand what he was going through, which helped destigmatize his confession.

    The kids also understood how to help each other during exposures. One of the hardest concepts for parents of children with OCD to grasp is how to provide comfort without giving reassurance, which can actually exacerbate a child's anxiety. During one difficult exposure, Dr. Busman remembered one boy who recognized the dilemma telling her, "I want to say something supportive, but I don't want to be reassuring."

    Parents didn't participate in the workshop directly. Some watched from the sidelines, but many attended parent-targeted talks happening elsewhere at the conference. Instead, the kids worked through their exposures together, and everyone made progress. "It was very challenging and very cool," said Dr. Busman.

    The workshop was a mini version of Fearless Friends, the Child Mind Institute's intensive weeklong treatment program for kids with OCD and specific phobias that starts again August 19th. The Child Mind Institute also hopes to do another workshop for next year's IOCDF conference in Los Angeles.  

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