Talkin’ To A School District!

A school district “community health and safety advisory committee” wants me to talk about childhood anxiety disorders? Oh yes, sign me up. Why does this excite me? I feel that I have a public health mission to educate school professionals about childhood suffering, helping them to understand when they should intervene. I want to talk about the warning signs and then, most importantly, I want to talk about the referral process so that the administrators understand that depending on who they refer to, the child will get vastly different interventions. I also want them to understand the issues surrounding medicating or not medicating school-age children. In particular, I want to emphasize the role of the school personnel in aiding the assessment and treatment of children with anxiety disorders. This will no doubt bring up the issue of the school refusal kids. How does the school help if the child does not make it to school? Does providing online support help or hinder these kids? Hinder, will be my response, in that the school needs to provide a safe place for that child at school so that if the anxiety erupts, the child can stay at school, but go to a counselor who can give this child some comfort and support. Anxiety disorders are internalizing disorders meaning that unlike ADHD where the student typically disrupts learning, with anxiety, children tend to suffer quietly. As such, it is helpful if school personnel can try to attend to the child who is NOT demanding attention, but yet is lonely or lost on the playground. I have dreamed that both public and private schools could target these quietly  suffering children for intervention, as this gives so much  hope for helping these children live more fulfilling lives. Helping a lonely child, a lost child, develop connections such that they enjoy and look forward to school is a game-changer. As we all know, the future is in our children. These  children growing up will take charge of our world, and we hope, they will bring it to new and exciting places. We owe it to them to help them enjoy their childhoods, as part of  enlightened self-interest, since we want them to take care of us one day. I am on a very important mission. Wish me luck.

Head-Meds For Kids…Or..Medicine for the Child’s Mind?

 

May 6, 2016,  I am booked. Geez, that is advanced planning. Three hours, I have, to discuss medicating kids to mental health professionals dedicated to working with children. As usual, I expect to gain far more than I give, as this audience are folks who have spent years fine-tuning their skills to work with disadvantaged youth who struggle with coping with their circumstances. Nature and nurture will be discussed heavily, as the decision to medicate a child is never easy, simple, or straight-forward. The decision is made after a thorough history, but whose history? The parents, the child, another clinician, or all of the above? Yet, my first order of business is generating a title. I have a series of lectures which begin with Medicines for the…fill in the blank. Originally, I kept a similar title for all of my talks as a way of picturing my book on psychopharmacology for the lay public. Each talk was a chapter in my book, such that “Medicines for the Mind” was the large title and then there was “Medicines for the Female Mind”, “Medicines for the Old Mind,” and “Medicines for the Child’s Mind.” Yet, as the book has receded in my task list, and, as a patient once said to me, “you want to know about my head meds,” I began to think about changing my title. My next lecture on adult psychopharmacology will be entitled “Head Meds” but for my “kiddy talk” I will stick with “Medicines for the Child’s Mind.” I want to emphasize that the complexity of working with children is that their minds evolve as time goes on, such that all practitioners are made humble in that we never know whether we had an impact or maturation finally kicked in. I suppose the same is true of parenting. Parents take credit for “how well their children turned out,” when, in fact, it could very well be that their brain was developing in a non-linear fashion such that the child surprisingly became a responsible adult. Oh, so we return to nature vs. nurture, in which I will say that if the child does well it is nurture, and if he does not, it is nature. I hope I will get a laugh.

Growing Up Alone

Continuing on the topic of needing a “mother,” a person who is passionate and hopeful for your existence, I am thinking about those children out there, who for a variety of reasons lack that passionate advocate. It is my feeling that for some children, that passionate advocate is the key person who takes a hedonistic child and turns him into a productive and giving human being. Without that advocate, the child becoming an adult could be lost in a drifting world, where there is little future planning, and life is very self-centered, mostly as a means to survival. In other words, some children lack the imagination to see themselves as a powerful force who can bring change into the world, and with a passionate push, that child gets the confidence to grow, both personally and professionally. This is the tale as old as time. A supportive mother, friend, and/or wife, gives the child, friend, and/or husband the push to apply for a new job, move to a new city, or take on more responsibility, and in so doing confidence grows. Without the push, stagnation sets in.

Vince, fifty-four, comes to mind. He grew up with a mom who was always “busy” doing “charity things” and a father who was never home, and who years later confessed to having a girlfriend and another family. Vince was not good at school, but he managed to go through college, but dropped out when school got too hard for him. At thirty-five, Vince marries Cory, a thirty-year old female, who openly says  she is “desperate to have a family.” Cory encourages Vince to start a business in commercial real estate. Vince is scared, but Cory is a strong advocate that Vince can handle it, so with Cory’s encouragement, Vince starts and eventually grows a very successful business. What if Vince never met Cory? I would wonder if Vince would have remained a drifter. Vince is grateful to Cory, but he has a difficult time admitting it, because it makes him feel “small”. With time, though, Vince develops the courage to tell Cory how much he appreciates her push, and how now he is living a life he never dreamed he could. Vince opened himself to Cory’s ideas because he loved her, and he wanted to make her happy. Cory was able to push Vince because she saw potential in him that he did not see in himself. This is an example of how change happens, and sad lives become happy ones. Is it the “love cure”? Yes, the “love cure” with a “push”.

Sonia Nazario

http://www.enriquesjourney.com/about-sonia/bio-2/

 

The best talk I have ever heard. She presented her investigative reporting about a boy named Enrique who fought incredible odds to find his mother in the United States. He traveled through five countries, as a twelve-year old, in search of his mother. As Ms. Nazario says, storytelling is the best way to help people understand, and indeed, she told an amazing story. What was gripping and sad about her tale was that she mirrored his journey, herself, so that she could convey the determination and the tenacity that these children, these young people, who cross multiple borders in search of a parent. Her emphasis on wanting to tell Enrique’s story, mirrors my daily attempt to understand my patient’s story. It is through understanding the narrative, the tale, that we connect as human beings, and we reach out to each other. If we do not take the time to understand the story, then we miss out on understanding the common humanity. I cried and cried as she illustrated the danger that Enrique faced, day after day, and yet he persevered, and yet she persevered in parallel. Sonia first told her own immigrant story, and then told Enrique’s story, and at the end she tied them together, as if they were one tale, as if there were more commonalities than differences. She was right. The deeper you dig, the more the differences drift apart. Rarely, am I that moved by one speaker. Sonia Nazario did that for me.

Toxic Stress

“Toxic stress response can occur when a child experiences strong, frequent, and/or prolonged adversity—such as physical or emotional abuse, chronic neglect, caregiver substance abuse or mental illness, exposure to violence, and/or the accumulated burdens of family economic hardship—without adequate adult support. This kind of prolonged activation of the stress response systems can disrupt the development of brain architecture and other organ systems, and increase the risk for stress-related disease and cognitive impairment, well into the adult years.”

http://developingchild.harvard.edu/topics/science_of_early_childhood/toxic_stress_response/

See also…http://opinionator.blogs.nytimes.com/2013/10/30/protecting-children-from-toxic-stress/?gwh=4A5E6CBAAE9D19C51946C9B4A47C3B49

Parents may facilitate development, but more likely they need to “get out-of-the-way,” as I like to say. Getting out-of-the-way means protecting kids from what is now labeled as “toxic stress”. Children are biologically programmed to develop and mature, and with a basic environment of positive affirmations, good attachments, and provisions for food, sleep, friends, and education, most children and grow and flourish and reach their biological potential. However, in the face of tension, violence, or deprivation, then the child must go into what I call “brain freeze” and this stunts the development of the brain, in terms of understanding and knowing how to please oneself. Psychotherapy steps into to deal with toxic stress, but this requires many hours of trying to understand what happened in the preverbal period, where most memories are implicit and not explicit, Uncovering the trauma, so the adult can return to the developmental train where they learn to love themselves is a lengthy process, involving struggle and psychological pain.

Emily, fifty-six, youngest of eight children, always felt like she was a “burden” and consequently, never experienced love from her mom. As a result, Emily spends her time feeling angry, at little things and big things. She is angry with her husband, her children, her friends and her co-workers. She collects all of their misdeeds and she stew over them, simmering with ill feelings day in and day out. By Emily’s account, all of these people in her life are trying to make her feel better. I suggest an alternative viewpoint that Emily is really angry at her mom, for depriving her of a loving environment, and now that anger is transferred on to the meaningful people in her life. “It is a struggle for me to see that,” she says, as she cries. “The struggle is a good one,” I say, highlighting that understanding projection is a struggle, and it is hard to see when a feeling is being displaced. “The struggle implies that you are trying to see another point of view, and in that angst, there will be growth and understanding. Emily’s toxic stress hit her pretty hard, such that the only way she can handle a feeling is to throw it out to someone else and then feel victimized by that feeling, rather than owning that feeling and then trying to metabolize it. The toxin is the neglect. The anti-toxin is her awareness of it.

Mental Retardation Leaves: Intellectual Disabilities Enter…From MR to ID….Freud Returns

Mental Retardation no longer exists. It has joined Asperger’s in the ‘remember when’ category. In comes intellectual disability, (ID), to remind us of Freud’s understanding of the id. A mere coincidence, I understand, but too close for my taste. In parenthesis the DSM 5 adds intellectual developmental disorder (IDD). So, the IQ test is no longer the defining feature of intellectual disability. One must consider functioning level. There are three domains of functioning: conceptual, social and practical. The conceptual domain includes skills in language, reading, writing, math, reasoning, knowledge and memory. The social domain refers to empathy, social judgment, interpersonal communication skills, the ability to make and retain friendships and similar capacities. The practical domain centers on self-management in areas such as personal care, job responsibilities, money management, recreation and organizing school and work tasks. So, what is my take? Much ado about nothing. A good assessment has always been a key feature in understanding disability. This assessment has always included understanding the impact of the disability on day-to-day life. Does the label change help parents? I do not think so. Does it help professionals approach the problem in a more comprehensive way? No. Was it important for my peers to spend countless hours debating this change to DSM 5? Maybe. They argue that this change brings the terminology in line with  the World Health Organization’s International Classification of Diseases and the American Association on Intellectual and Developmental Disabilities and the US Department of Education. The name does suggest a spectrum of children, who for a variety of reasons, have developmental challenges, requiring them to have much-needed services to maximize their developmental potential. In this way, creating this umbrella does make sense.

Re-Posting A Popular Post: The Report Card

Betsy, age ten, a patient of mine  since she was six years old, comes into my office with her mom, Gloria.  Betsy and I play catch and talk about her summer. She tells me about the books she is reading, her friends, shesays that she hates camp, and she is nervous about going back to school next month. Given Betsy’s long history of anxiety, poor eye contact, poor social relationships, poor behavior at school, I am  pleased at our relaxed interchange. The appointment winds up with our usual routine. Gloria  and I make the next appointment. Gloria reaches into her purse, and says “here  is Betsy’s report card. It is really good.” Gloria has handed me Betsy’s report cards for years, but this is the first time she announced it in front of Betsy. Dramatically, Betsy became irritable, angry, and rude. She grabbed the envelope out of my hand and said “this is none of your business.” Gloria says, “Betsy, I have given her report cards for years.” Betsy gets more upset. “She is not related to me, so she should not see my report card,” Betsy screams. Gloria responds “but it is a really good report card, what is the problem?” “It is just none of her business,” Betsy screams louder. “Just pay her and let’s go,” Betsy says.

Why did Betsy get so mad about me seeing her report card? I speculated to myself that this is an issue of intimacy. Betsy and I, although we have known each other for many years,  is not comfortable sharing herself with me in that way. As such, she felt violated that her mom exposed a part of herself, her report card, that she was not ready to share. I understood Betsy’s discomfort and I felt bad that I was a party to it. At the same time, at the time of the interaction, I was surprised by her strong reaction. Betsy’s sensitivity helped me understand her relationships. She enjoys interacting with others, but she is also afraid that getting too close to people could result in painful humiliation. Even though her report card was good, she seemed afraid that my reaction would make her feel bad. Betsy’s anger might have protected her from having to suffer from my unsatisfactory response to her school evaluation. In another context, Betsy might be seen as bipolar, or quick to anger, but had this happened, Betsy would have been misunderstood. Her hair-trigger response was not a “manic” experience; rather it was a response which protected her ego. In the end,  Gloria and I felt sad that Betsy was so upset; it was a hard learning experience.

Play Class: Update

My class is called the “Clinical Practicum,” but I would like to rename it the “Play Class.” I love that I am teaching students, hovering thirty, with so much education under their belts (along with huge debt), and yet we are talking about how to play, both for our own enjoyment and for the therapeutic benefit of our patients of all ages. We lament together how play has somehow gotten lost in our society of overscheduled children and adults. “What happened to the public schools?” One student asked. This seemed to be the central question. With parents extremely anxious about where their child goes to school, has come a pressure on children to justify the additional effort of either a private school or a public school which is a burden geographically. Now that most children are driven to school, this creates a dependency on adults in which the child is then driven to after-school activities. The social norm, at least in West LA, seems to dictate that if the child is not learning a new language, involved in a sport, and learning an instrument, then he/she is somehow going to suffer as he/she enters into the “real world.” “We need to remind parents that children need play time to expand their imaginations and develop creativity.” I say firmly and repeatedly. “Yes, but we don’t have time to do that with our fifteen minute appointments,” they respond with frustration. “Yes, so we need to lobby for more time with patients.” I say, again, feeling argumentative, even though we are all on the same page. “There are not enough child psychiatrists to play with all the children that need our help,” another student says. “Yes, that is true, but we can promote the value of play such that we can help other professionals play with children in a therapeutic manner.” I say, alluding to the idea that our job needs to be much broader than psychopharmacology. The class ends with what I call “positive frustration.” We all want to see the field change. We all want to play with our patients.

Re-Posting With A Question: Why Is This Post So Popular? ‘Advocating For Kids’

“I can’t deal with that one,” a father says to me as I cringe at the expression “that one”. “You mean Samantha,” I say naming their nine-year old daughter so as to point out that the phrase “that one” conveys tremendous hostility and resentment. “Yes, Samantha has made my life a living hell. She is all I talk about in my therapy. She has made me more crazy than my parents, than my wife, or my work.” This father, Liam, explains to me, causing me to feel for Samantha and wonder how Samantha integrates her father’s resentment of her into her budding self-esteem. I am caught between wanting to explain how his resentment might be deleterious to Samantha’s sense of herself and wanting to support Liam in expressing his feelings about raising what he perceives to be a very difficult child. Having known Liam for ten years, I feel our relationship can tolerate me taking what I imagine to be Samantha’s point of view. “It must be hard for Samantha to feel that she has caused you so much grief,” I say, conveying that Liam’s attitude could be hurtful to Samantha. Liam gets angry and hurt. “Are you saying that I am hurting my child?” he says as tears roll down his face. “I am saying that all parents hurt their children unwittingly, and the job of parents is to become aware of that when that happens so that one can straighten things out, as best they can.” I explain, trying to say that parenting is challenging, resulting in both positive and negative outcomes, always. Liam seems to calm down. “Today might be a hard day,” I say as we close our visit. “You did not do anything wrong,” he says. I needed to hear that.

Loving Dr. Seuss