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The Child Mind BlogBrainstorm

  • Two Psychiatrists Discuss the Changes (and Controversies) of DSM-5
    May 28, 2013 Caroline Miller

    At we've had our heads bent over the DSM-5 this week, chasing down the changes we've been expecting in diagnoses that affect children. We should have the details reflected in the updated disorder guide in the next week or so. But in the meantime, an excellent piece on considers both the reasoning behind the changes, and some of the important objections that have been raised about the DSM-5 recently.

    The new piece is a very incisive conversation between Drs. Bennett Leventhal and David Shaffer, two eminent child and adolescent psychiatrists, that took place Friday for Speak Up for Kids. The doctors discussed the updates on diagnostic thinking included in the DSM-5, and the widely publicized charge that the DSM itself is invalid because it is based on clinical observation and studies, rather than on brain research. You know, the quip about how the brain didn't read the DSM.

    Dr. Shaffer sums up the history of the DSM, from its prewar origins in an effort by the Department of Defense to categorize the mental disorders suffered by veterans of the Armed Forces, to an effort to standardize what had been rough classifications into more and more precise descriptions. The gradual iteration of DSM criteria (this many symptoms, over this period of time, with this effect on functioning) was done, he notes, not to pathologize more behavior but to make it possible for researchers to be able to effectively identify subjects for their studies and, not incidentally, to make diagnosis something that many different professionals could do.

    Changes in the DSM are made, he says, when new information calls into question the validity of criteria and their effectiveness in clinical setting. One example is the important new diagnosis disruptive mood disregulation disorder. It's a response to what Dr. Shaffer describes as a real crisis in child psychiatry—an escalating number of kids being given the diagnosis of bipolar disorder when they don't meet the criteria applied to older-onset bipolar disorder: episodes of mania. These kids are chronically irritable and prone to meltdowns, and their need for help is urgent. But they don't follow the typical course of bipolar disorder into adulthood, and the medications used to fight bipolar disorder don't work well for these children. Bipolar disorder is a very serious, lifelong diagnosis to give to parents, especially, he notes, "when the evidence was so weak."

    Creating a new diagnosis, he says, is the first step to studying and rethinking approaches to helping these children. Rather than developing adult bipolar disorder, many of them develop anxiety disorders as they get older. It may be more fruitful, he hypothesizes, to think of them as very anxious children. Children with early-onset anxiety fight very hard to control their environments in order to manage anxiety and feel safe; the smallest change in plans or deviation from their expectations can make them melt down. Instead of treating them with antipsychotics, it makes sense to treat them with antidepressants and other medications that are effective for anxiety. And it could change the therapeutic approach, as well—to exploring and treating the anxiety, if that's what's making them very upset and very aggressive, with behavioral therapy.

    Drs. Shaffer and Leventhal go through the other big changes in DSM-5 as well, and if you're wondering about the rationale, I recommend listening to the whole talk here. But they also offer some interesting thoughts about the controversies that have surrounded the changes.

    Specific changes, Dr. Shaffer notes, are always debated fiercely within the mental health community, with some advocating against the updates. He argues that some of the many professionals who lobby against changes in the DSM have a vested interest in seeing the criteria remain the same—books, rating scales, research projects all face updating or rethinking when the DSM changes. Some worry about schools and the insurance companies—whether they will accept the changes, rather than whether they will allow professionals to do a better job understanding and helping kids. Just something to keep in mind.

    To the charge that psychiatrists are bent on medicalizing more and more of human behavior, he notes that half of the members of the committees who worked on the updates for DSM-5 are professionals other than psychiatrists. He also notes that no one is allowed on the working committees who has pharmaceutical ties or is receiving pharma research funding.

    Both doctors noted that the prevalence of mental illness isn't likely to change, but the updates may bring some different symptoms into the discussion of a disorder, and hence "make people who use it more sensitive to certain symptoms." If your child's diagnosis has changed, do you need to get a new diagnosis? That depends, Dr. Shaffer said, on two things: "Has the diagnosis been useful?  Has it led to effective treatment?" If the answer to those questions is yes, he said, don't worry about DSM-5. Your current diagnosis will be grandfathered in. If treatment is not working, you might want to see your clinician about how the changes affect your child.

    And to the charge that the DSM is a "philistine endeavor" because it isn't based on brain science, I think it's safe to say that both doctors look forward to advances in brain science that will yield treatment applications, but at this point those applications are few, and the DSM is an enormously valuable tool for identifying, investigating, and treating mental illness.

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  • Sesame Workshop's Advice for Families Going Through Divorce
    May 28, 2013 Rachel Ehmke

    Divorces are hard on kids. And because 50 percent of all first marriages end in divorce, and two-thirds of those marriages involve children, Sesame Workshop—the people behind Sesame Street—have pledged to help families going through divorce stay as resilient and strong as possible. As part of their effort, JoAnne Pedro-Carroll, PhD, a clinical psychologist who specializes in divorce, joined Sesame Workshop and Speak Up for Kids last week to share some of her expertise.

    Dr. Pedro-Carrol focused on some of the risk factors that can prevent kids and parents from moving forward healthily, and some resilience factors that can help. She said one of the biggest risk factors is conflict, which unfortunately is also something very natural at the end of a relationship. Dr. Pedro-Carrol notes that ongoing conflict is "like a toxin" for children, especially when they're stuck in the middle. To help children stay healthy, she advises that parents present a united front as best they can and shield children from any bickering that might be going on behind the scenes. For couples struggling with this, she recommends, "renegotiating the relationship with a former spouse to that of business partner" in the business of raising your children.

    The second biggest risk factor she mentioned is poor quality parenting. Even when parents are trying their best, the added stress and pressure of a divorce does take its toll, and parents often "don't have the patience or ability to set limits" says Dr. Pedro-Carrol. Setting limits might not even feel right to sensitive parents who are trying to make kids feel better during a tough time. But limits actually give kids a sense of security, she said, particularly during a time when everything else in their life seems to be changing. Dr. Pedro-Carrol notes that staying emotionally responsive to kids is important, too. Divorce brings up a variety of feelings for kids, and it's important for kids to know that all feelings are okay-but not all behaviors are. Finally, Dr Pedro-Carrol also told parents going through a divorce not to overlook their own limits, either. "Parents are able to give their best to their children only when they take care of themselves," she said.

    To listen to the entire Sesame Workshop talk, and to learn about some of the materials they have put together to help families going through divorce, click here. 

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  • 30 Years Later: Following Kids With ADHD Into Adulthood
    May 20, 2013 Caroline Miller

    Dr. Rachel Klein has been following a group of some 200 boys with ADHD for more than 30 years. I should say boys with the symptoms of what we now call ADHD, because the diagnosis didn't exist in 1970 when she and her colleagues began the study. The boys were around 8 at the start, of average or higher intelligence, and hyperactive and inattentive both at home and at school. Those who exhibited aggressive or anti-social behavior, which we'd now call conduct disorder, were not chosen for the study, to keep it focused on the outcomes of ADHD alone. They were compared to a control group of kids who were described by teachers and parents as behaving typically.

    It's a remarkable study because of the detailed interviews and data collected from these children well into adulthood. The boys were interviewed again when they were 18, 25 and 41. Dr. Klein, who is director of the Anita Saltz Institute for Anxiety and Mood Disorders at the NYU Child Study Center, reviewed the findings during a visit to the Child Mind Institute Friday.

    The kids with ADHD overall fared worse in school, in jobs, in family stability, and with the law, than the control group. But one of the one of the key findings is that 60 percent no longer qualified for an ADHD diagnosis at 18—and those kids who outgrew their symptoms fared differently over the long term than kids whose ADHD symptoms persisted. 

    Of the kids in the original ADHD group, the 40 percent who still qualified for the diagnosis at 18 were much more likely to have developed two new problems during adolescence—anti-social personality disorder and substance abuse disorders—than those who had outgrown their ADHD, or the control group. And they were most likely to develop them in the same order, in what Dr. Klein called a "developmental cascade": ADHD heightens risk for anti-social personality disorder, which in turn heightens risk for substance-abuse disorder.

    But the good news is that the interviews at 25 and then 41 showed no heightened risk for new anti-social or substance abuse disorders after the checkup at 18. There are still clear disadvantages that continue into adulthood for the group in which the ADHD persists-but they all started in adolescence. As Dr. Klein put it, "If you've made it through adolescence, you've made it, relatively speaking."

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  • 'I Wish I Was Dead': How to Respond to Suicidal Talk
    May 16, 2013 Caroline Miller

    USA Today ran a story yesterday about a 16-year-old New Jersey girl who posted a suicidal message on her Tumblr blog and, thanks to an alert reader in California and some enterprising police officers, was tracked down within hours and hospitalized.

    I read the story after listening to Dr. Nadine Kaslow, a clinical psychologist who is the president-elect of the American Psychological Association, talk about suicidal behavior in teenagers.  Dr. Koslow stressed the importance of taking all suicidal talk seriously—two of the worst myths about suicide are that talking about killing yourself is just a teenager being typically overdramatic, and that if parents respond to talk about suicide, the child is more likely to act on it.

    The idea that talking with a child about suicidal feelings will make them more lethal is exactly wrong, she said. A child who says "I wish I was dead," or, "If I had a gun I'd shoot myself," is likely to be in serious pain, overwhelmed by feeling hopeless, worthless, or ashamed. That child needs you to talk in a "calm, non-accusatory way" about how she's feeling, to hear "over and over and over" from you how much you love her and care about her and how important her well-being is to you. That connection to you, the active engagement in her life of caring adults, is one of the most important factors in lowering a child's risk of death by suicide.

    In her talk for Speak Up for Kids, Dr. Kaslow outlines the factors that put kids at higher risk for suicide (low self esteem, isolation, stigma against asking for help, access to lethal means, among others), as well as factors that protect them from suicide (good problem-solving skills, strong community ties, access to mental health care, among others).  She discusses events in a child's life that might trigger suicidal thoughts, and warning signs that a child might be in danger.

    I recommend the whole talk, even if you aren't worried about a child. It's a potent reminder of how easy it can be to get out of touch with teenage children, even when you're living under the same roof.

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  • Christine Quinn and Angelina Jolie Get Personal
    May 14, 2013 Caroline Miller

    We've been talking a lot this month about speaking up, and two very prominent women did that in a huge way today: Christine Quinn and Angelina Jolie.

    Christine Quinn, speaker of the New York City Council and mayoral candidate, went public about her battle, as a teenager and young adult, with bulimia and alcoholism. She described her struggles as a 16-year-old caring for her mother, who was dying of breast cancer, and secretly bingeing and purging to relieve her oppressive feelings.  She continued doing it, and getting into serious drinking, in college, as she wrestled with sadness and the challenge of acknowledging that she was gay. It wasn't until she had moved to New York and admitted her problem to Tom Duane, the gay city councilman whose campaign she ran, that she went into treatment.

    "I just want people to know you can get through stuff," Quinn told a New York Times reporter in her typically direct way.

    Angelina Jolie made the more startling announcement today, also in the Times, writing that she has recently had a prophylactic double mastectomy. She writes that she carries the BRCA1 gene, which indicates a very high risk of ovarian and breast cancer; her own mother died of breast cancer at 56. The decision is stunning, but so are the numbers Jolie said she was faced with: an 87 percent risk of developing breast cancer, and a 50 percent chance of getting ovarian cancer.

    "Once I knew that this was my reality, I decided to be proactive and minimize the risk as much as I could," Jolie writes with awesome concision. "On a personal note, I do not feel any less of a woman. I feel empowered that I made a strong choice that in no way diminishes my femininity."

    Both Quinn and Jolie took big risks to make these public statements:  They're both very tough women with very public lives, and both obviously wanted to turn painful experiences into something positive, something that could benefit others.  But I wonder if they both also saw value, at this moment in their lives, in being known as who they are, not who they were or who others want or imagine them to be.

    In the heat of a mayoral race, Quinn has been characterized as demanding and volatile. She's not, apparently, always nice when she's frustrated—a trait she shares, I would note, with both of our last two mayors. Perhaps, as critics will charge, she's offering this story to "humanize" herself; whatever the motive, it affords a less fairy-tale version of a life of considerable accomplishment.

    And what can I say about Jolie here that isn't understatement? Our reigning Hollywood sex goddess action hero wants the world to understand that she is a mom intent on living to see her children grow up. That's speaking up for the kids.

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  • Patrick Kennedy: Mental Health Care as a Civil Rights Issue
    May 14, 2013 Caroline Miller

    Congressman Patrick Kennedy gave a rousing talk this morning for Speak Up for Kids about equal treatment for people with mental illness as nothing short of a civil rights issue.

    He draws his passion and his insight, in part, from his own experience battling mental illness. He knows first hand how hard it is for families to get good diagnosis and treatment, and how damaging it is when psychiatric illness is not taken as seriously as physical illnesses. Brain illness deserves parity, he argues, not only under the law, in insurance coverage, but in research dollars devoted to unlocking new treatments.

    Asked about how and when he was diagnosed as bipolar, he said this: "The honest truth is that it's taken me a lifetime to get adequate diagnosis."

    Rep. Kennedy described being "bounced around the system"—a phrase we hear a lot from parents. In his case it was not because he lacked resources or insurance coverage, or family members fighting for him—he was very fortunate in those things, he acknowledged—but because when the diagnosis isn't correct, the treatment won't work. "When you're still trying to put your finger on the diagnosis, people are treated for various illnesses that may not be the specific illness they suffer from." There's a lot of ineffective treatment of brain illness, he added, because of misdiagnosis.

    "The crucial thing we need to do is improve the diagnosis," he said. "And that only happens when we improve the science." Rep. Kennedy advocates a national brain research initiative that will allow scientists to uncover the mechanisms that underlie mental illness instead of focusing on specific disorders like autism or ADHD.  

    Not making brain research a national priority, he argues, is tantamount to telling people with mental illness they have to wait for equality.

    He reminds us of President Kennedy's 1963 speech challenging all Americans to understand the urgency of those denied their civil rights on the basis of race: "Who among us would be content to have the color of his skin changed and stand in his place? Who among us would be content with the counsels of patience and delay?"

    Similarly, Rep. Kennedy says, "If you have a loved one with autism, a mood disorder, with Alzheimer, how long would you tolerate us taking the slow road to better cures and better treatments?"

    You can see the whole talk here.

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  • Chris Hadfield Inspired Kids From Outer Space
    May 13, 2013 Rachel Ehmke

    When Commander Chris Hadfield leaves the International Space Station and returns to earth tonight he'll be coming "with 800,000 Twitter followers in tow," as one website put it. The Canadian astronaut has been on board the ISS for five months now, and in that span of time he has uploaded hundreds of photographs and videos to Twitter, Facebook, and YouTube. With his microphone floating weightlessly in space in front of him, Hadfield let us see the day-to-day life of an astronaut—demonstrating how he brushes his teeth, trims his nails, drinks coffee, and settles into bed. He made a particular effort to reach schoolchildren—answering their questions, performing an experiment they designed, and participating in a live sing-along from space with hundreds of kids gathered at the Ontario Science Center. He even made a music video while he was there, a captivating cover of David Bowie's "Space Oddity."

    Chris HadfieldBeyond being the savviest astronaut on social media, Hadfield is a born communicator with a genius for teaching and inspiring kids and adults alike. His dispatches from space are as unassuming as they are compelling. I'm sure he's making many young people consider a career in science. I know I'm second-guessing the many science labs I blew off in college.  

    He also makes the world seem very small. On one of his Ask Me Anything sessions on Reddit someone asked if he ever tries to find his house from space. "At first, yes, but after a few days, you start to see the whole world as one place." Hadfield responded. His photos from space are awe-inspiring but also very human. Last month he shared a photo of Galveson, Texas, with the caption, "where my wife and I like to walk our dogs on the beach on Sunday mornings." Today he tweeted a photo of Hamburg, Germany, and noted that it would have been a good day to walk along the Elbe. There's a clear sense of camaraderie on board the Space Station, with people from three different countries sharing supplies, giving each other haircuts, and speaking in English and Russian interchangeably. Maybe the best illustration of their uniquely cosmopolitan attitude is that Hadfield and the American and Russian coming back with him tonight all consider landing in Kazakhstan coming home.  

    When he was speaking live to a school in Nova Scotia, Hadfield told the students, "I was about your age when I decided I wanted to become an astronaut. I hope that you remember today and continue to be curious about science and space. You are the space explorers of the future and the sky is no longer the limit." Coming from anyone else it would sound like a platitude, but Hadfield makes it real. And that's something special.

    Watch his videos on YouTube with your kids. Here's one to get you started

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  • Making Schools Safer Places to Learn and Grow
    May 13, 2013 Caroline Miller

    Any parent who's been around the block a few times knows that kids behave differently at school than they do at home. It's an environment where they spend a huge amount of time, and where they interact with far more people—both adults and other children—than they typically do at home. 

    So of course the school environment has a big role in shaping how kids act and how they feel. I thought about this while listening to three articulate school psychologists talk, as part of Speak Up for Kids, about how we can make schools safer places—not just physically safe, but safer for learning and healthy development.

    The presentation, by the National Association of School Psychologists, focused on what schools can do to support the mental health of their students. Some kids need help from a trusted adult to weather a short-term crisis; some need help to strengthen social skills and manage behavior; some need long-term support to deal with psychiatric or learning disorders.

    One important goal is to make school a safe place for all kids to ask for help when they need it, or they think a friend needs help.

    Melissa Reeves, PhD, a school psychologist and special education teacher in South Carolina, made a very interesting suggestion, I thought, to help make progress on this front. She proposed that learning about mental illness should be part of a school's health curriculum. "One of the most powerful things schools can do is to educate students about emotional health," she said. "What is depression? What is anxiety? Let them know that there are biological factors."

    Reeves said she uses a diabetes analogy: "You can't control whether you have diabetes or not, but we can learn different interventions to address the severity of the diabetes. For some that might mean a change in diet. Some might need insulin. With mental illness, it might mean counseling. Some may need medication to address the neurological component."

    She notes that educating children about mental health, encouraging them to talk openly about it and ask questions, tends to reduce stigma directed at kids who have a psychiatric, learning, or behavior issue.

    The more kids understand, the better chance they have to accept—not just tolerate—children who are different, and that is the single best way to make schools safe places for all children to learn and grow.

    You can listen to the whole talk here.

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  • Depression: The Webcomic
    May 10, 2013 Rachel Ehmke

    Allie Brosh, the woman who writes the popular webcomic Hyperbole and a Half, stopped updating her blog in 2011. This would be bad news for any person hoping to make a living out of her blog, as I think she is, but it was particularly ominous to her readers because we knew that Brosh was depressed.

    So I was glad to see that she resurfaced yesterday, with a new comic called Depression Part II (the more jauntily named Adventures in Depression was the last blog she wrote before the hiatus). Her latest post should be required reading for anyone who wants to understand what clinical depression feels like. In her characteristic combination of text and crude but expressive Paintbrush drawings, Brosch illustrates being unable to feel genuine emotion, needing to simulate the right reactions when talking to friends, and how dark it feels when life starts losing purpose.

    Hyperbole and a Half depression image

    At points the comic is funny, but it's also quite disturbing—Brosh describes thinking about suicide but never acting on those impulses. She talks about getting treatment, too, and is honest about how difficult that process can be.

    Brosh says she's been working on the post "for the better part of a year (partly because I wanted to get it exactly right, and partly because I was still experiencing it while attempting to explain it, which made things weird." The result is great, I think, and I encourage everyone interested in depression to check it out.

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  • A Bipolar Child, a Parent's Dilemma
    May 10, 2013 Caroline Miller

    Dorothy O'Donnell fought for years the idea that her precocious, ebullient, wildly imaginative daughter might have a mental illness. She admired Sadie's lack of inhibition—her ability to march up to kids on the playground and, pied-piper-like, lead them on an adventure to Princess Land, her impromptu dance recitals that charmed strangers at the fountain in the mall. She fended off warnings from preschool teachers that Sadie careened from giddiness to rage, that she chattered constantly during rest time, and that her antics were out of control.  

    But Sadie became increasingly anxious and explosive, increasingly unable to function in school and connect with other kids, until, at a low point, she told her mother, in tears, "I don't want to be on this planet anymore, Mama. I think I'd be happier in heaven."

    Like all of us, O'Donnell had read about overdiagnosis of young children with ADHD, about the spiraling rates of kids being diagnosed with early onset bipolar disorder and, worse, being medicated. She didn't want to fall into that trap. And she has written a very compelling account of her struggle to do the right thing for Sadie. It's called Dancing in the Rain: The Story of a Bipolar Child, and while the headline gives away the diagnosis, there's a good deal more to the story.

    If you've ever struggled with the question of whether to medicate a child, I think you'll find O'Donnell's piece very familiar, and quite moving.

    I'm happy to report that I got an update from O'Donnell, who tells me that Sadie, though she still has rough spots, is now a happy and stable tween. "She loves art, fashion, hiking and singing and writing her own songs," says her mother. "And she has the self-confidence to try things I once thought she'd never be capable of—taking dance lessons, performing in a school talent show and training for her first 5-K race. Most importantly, she has a busy social calendar and plenty of friends."

    For Sadie's own report on how she's doing, here's her video.

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