Mental health is one of the 4 public health topics being discussed in the aftermath of the Sandy Hook shooting. Should it be part of the equation for trying to reduce the likelihood of future school shootings? The answer is yes.
The focus here, though, is not exactly going to be about the usual topics you’ve been reading about, all of which carry their own importance, such as: the need for better mental health screening; the importance of making mental health services more accessible to those who need it; failures in the system which make it difficult to continue with treatments. While these issues are important, we need to expand our thinking about “psychiatric disorders” with respect to preventing future shootings. Although there are empirical links between psychiatric illness and violence, the vast majority of individuals who suffer from any one diagnosed psychiatric disorder are not going to commit mass murder. Put another way, there isn’t one simple diagnostic test that would offer enough precision to tell us who may be at risk for that kind of behavior.
Our focus needs to be placed on promoting the healthy all-around development of youth, starting early in life, and parallel efforts to recognize signs of distress and maladaptive functioning and to do something meaningful about that. Psychiatric evaluation and diagnosis is part of the process, but experienced clinicians don’t treat disorders – they treat people. They know how to get a full picture of a youth’s life – how they behave at home and in school, how they interact with kids and adults, how they manage their emotions, what kinds of thoughts they have in their heads. Intervention for troubled youth is not simplistic, and there are many types of factors to consider. It takes a multidisciplinary effort to attend to numerous dimensions of development (cognitive, emotional, social, educational, neurological). And it’s critical to understand that key developmental stages (e.g., starting school, entering adolescence, transition from high school) offer particularly powerful windows into seeing which kids are making good transitions, and which kids may be troubled. They are important check points for evaluation and intervention – and looking for red flags in a kid’s developmental trajectory.
We know that when we see someone suffering we shouldn’t look away. And when we see young people coughing, wheezing or bleeding, we insist that they get attention. But when we see young people with disturbing behavior, or young people in clear emotional distress, we ignore them and hope these problems will go away.
The first signs of 75% of all psychiatric disorders appear by the age of 24. We need to be on the lookout for signs of distress in young people to get them help as soon as possible. Research shows that early intervention improves the outlook for anyone with a psychiatric disorder—and drastically reduces the likelihood of violence.
To achieve this type of vigilance and action, we need a dedicated effort that includes better information provided to parents and school systems – and an infrastructure that provides the ability to coordinate with developmental and mental health experts to deliver the best supported interventions. It will take money (something that’s not exactly flowing these days at the national level) and it will take commitment. It needs to start at most local level and eventually spread to a national level.
So where do we go next? Since the Sandy Hook shooting, some have argued that mental health is not the issue – that our focus should be on gun control because we don’t see this type of violence in other countries who have similar rates of mental illness. I get that perspective – but I still believe that we are failing if we have individuals who are so socially isolated and filled with anger and rage that they commit murder-suicide. Trying to apply our best efforts to reduce the likelihood of having youth and adults in our society who get to that point is not the full answer – but it’s part of the equation.
Tomorrow, I will address gun control as one of the 4 public health issues we are all discussing.
Coping with divorce is a challenge for kids at any age, but especially so when they are very young. To this end, the Sesame Workshop has launched a comprehensive multimedia kit, called Little Children, Big Challenges: Divorce, which offers a variety of extremely helpful tools to help young kids (the target being between 2 and 8 years of age) and parents navigate the challenges. A focal point is one of the Sesame Street characters – Abby Cadabby – who shares with her friends that her parents have been divorced for some time. This perspective allows Abby to share her experiences and ways in which she has learned to cope with divorce in a very specific manner (see the image of her showing pictures of the two houses she lives in) that will resonate with youngsters.
Jeanette Betancourt, Ed.D. (Vice President, Outreach and Educational Practices) shared with me via phone a number of the key points that inspired this important initiative at the Sesame Workshop. Most importantly, the multimedia kit will help kids who have gone through divorce (as well as kids who are just experiencing it now) understand that they are not alone (which is a typical feeling for very young kids). Based on the research done at the Sesame Workshop, Dr. Betancourt explained that the goal is to help kids with their biggest concerns they have – especially in terms of what’s really going on in their heads even if they don’t typically say it. The tools will help kids understand big issues like:
divorce is a grown-up problem that the parents tried to fix, but couldn’t
kids don’t cause parents to divorce (for example, it’s not because a kid didn’t pick up their clothes)
the parents still do love their children (even if they aren’t living with them all the time)
why some things – like where everyone lives – will change and how to handle that
Parents will also find very helpful and supportive tips, including:
the need for kids to maintain a routine (including bedtime, basics like when they brush their teeth, etc) across multiple houses
the importance of being truthful (including saying that the parents will not be getting back together)
why it’s essential for both parents to maintain good communication in terms of consistent parenting (with respect to things like praise and discipline practices)
The power of the approach taken by the Sesame Workshop is that they are promoting coping strategies that will help kids feel safe, secure, and loved, despite the enormous challenges that divorce can pose for families. Dr. Betancourt emphasized that this developmental foundation, set in the early years, will help young kids now and later in life as well. So I would strongly encourage any family who is dealing with divorce to put all of the tools from this initiative to good use – especially given the engaging way in which the Sesame Workshop can promote coping skills in toddlers and young children.
We all know that depression is very common in women, and that it can have a profound effect on parenting when a mom is affected. But even though depression affects more women than men, this doesn’t mean that it is rare for a man – and hence a dad – to get depressed. And since some of the symptoms can differ by gender, it’s worth knowing some of the signs that men might show that could signal depression.
There is a terrific feature on Yahoo! Health that provides 12 symptoms of depression in men – I strongly suggest that you click here to read it. The list includes fatigue, sleep problems, physical problems, irritability, indecision, difficulty concentrating, anger/hostility, stress, anxiety, substance abuse, sexual dysfunction, and suicidal thoughts. Below I provide a short summary and some comments.
Let’s start with what you won’t find on the list – sadness and crying. This is potentially the biggest gender difference you will find in terms of depression symptoms. Of course, not every woman who is depressed is teary or overtly sad, but it’s very common for this to be the case (especially when a woman is deep into a depressive episode). This does not seem to be the case for men. So it’s important to recognize that a man may be depressed even if he doesn’t appear to be very sad.
Some of the symptoms overlap with those you see in women. Fatigue and sleep problems can be common. Keep in mind that sleep issues can involve either not getting enough sleep, or getting too much sleep. Physical problems (aka somatic symptoms) are also common – including backaches and headaches. These are not imagined – they are truly physical symptoms. You can count sexual dysfunction in here as well.
Cognitive problems – difficulty concentrating, indecision – can also be a red flag, especially if they are observed in conjunction with other symptoms.
Problems with emotional regulation can be telling, but again not so much in terms of sadness – rather they manifest as irritability and anger/hostility. Look for changes in these negative emotions (which may signal the onset of a depressive episode). Men can also experience and report high levels of anxiety. While this is true for women as well, keep in mind that it may not be accompanied by sadness. In addition, as indicated in the Yahoo! Health feature, men may say that they are “stressed” – and sometimes this can be their way of saying “depressed” (perhaps without even knowing it).
Substance abuse can also signal depression in men. While, again, the same may be true in women, it’s important to remember that these kinds of signs in men may be there even without what you might think of as the classic signs of depression. And, of course, any report of suicidal thoughts should be taken seriously.
Every individual is different, so the main thing is to see if some of these symptoms come together at the same time (or close in time) – and if they seem to be getting worse. Remember, depression is an episodic disease, so you will see notable increases in symptoms that happen before the onset of a severe episode. Do keep in mind that each of these symptoms don’t necessarily indicate depression – rather, it’s the combination of a number of them that makes you consider depression.
There are two truisms that apply equally to men and women: depression is a disease, and effective treatments exist. So if you suspect that a man may be suffering from depression based on observing some of these symptoms, it’s important to support evaluation and treatment.
There is much ongoing conversation about an article in the New York Times which featured a pediatrician who reports giving kids who are struggling in school Adderall – which is prescribed for kids with ADHD – without first diagnosing them with ADHD. His rationale is that he does this for kids who are in low-income families who do not get sufficient support for their academic development or for services to help them if they have problems. He notes that this is a short-cut he takes because he knows that society, overall, does not invest nearly enough resources into giving kids the proper social and academic resources they should get. This practice was aptly captured by Stephen Colbert who coined the term “meducation” to refer to this practice of giving pills to kids to improve their school performance.
A lot can be said about this (and much has been already written). I’ll make three points.
First, it’s dangerous practice to give kids medication for anything unless a clinician goes through the proper steps to make a meaningful clinical diagnosis. For ADHD, there is a series of steps which include:
gathering information from a number of sources, including parents, teachers, and sometimes the kids themselves (because kids with ADHD don’t just show problems in school or in home – the problems should appear across a number of contexts)
using that information to consider a diagnosis in relation to the standard criteria (it’s not just a subjective impression)
assessing symptoms of a number of other conditions such as anxiety, sleep problems, and learning problems like dyslexia (because symptoms of ADHD can be seen in kids with a number of other clinical conditions)
Without taking these steps, it’s just not acceptable practice to make a diagnosis. It would be like seeing that a kid is sneezing and has a runny rose and assuming they have the flu. Now it’s acknowledged that we don’t have biological markers that allow us to diagnose ADHD – it’s a behavioral syndrome. But ensuring that a kid meets the criteria that have been established is the best available way of identifying kids who could greatly profit from intervention – and it’s also a way to make sure a kid isn’t just slapped with a label without going through a rigorous diagnostic process.
Second, even when a child is diagnosed with ADHD, it is not a given that they will go on medication. A number of behavioral methods are available and should always be considered (and in my opinion used). And when a decision is made to go on a medication, the dosage, potential side effects, and impact on symptoms needs to be tracked carefully and consistently. Drugs like Adderall can be used safely but only with sufficient monitoring.
Third, giving kids medications to try to solve social problems is just not right. We shouldn’t be messing around with kids’ biology to circumvent the lack of adequate resources, overcrowding of classrooms, and the multitude of other factors that can undermine a kid’s academic progress. These are, without question, very hard problems to solve. But rather than giving kids pills, it’s interesting to note that Paul Tough’s new book begins to explore the utility of giving kids psychological boosts via social initiatives that may turn out to have real educational advantages.
There are kids in the world who have the severe level of symptoms that are consistent with a diagnosis of ADHD. I would guess that it’s about 2% of school-aged kids (prevalence estimates land somewhere around 9%, but estimates of kids with severe levels of symptoms are typically less than 2%). Routinely treating kids who suffer from social disadvantage with a medication that should be reserved for kids with the most severe symptoms is just not the solution anyone is looking for.
I’ve been writing a lot about the complexities of determining how genes influence our behavior. The latest view from the genetics field is that the picture is getting more and more murky with increasing attention given to the multitude of ways in which DNA gets expressed. Despite that, we continue to get bombarded with suggestions that single genes are completely deterministic for highly complex human behaviors, like for example wanting to be a mom (click here for my take on the “mom gene”). The reality is that DNA is important and can be influential – but it is typically far from deterministic and all kinds of experiences can shape how DNA is expressed and have effects that go beyond what resides in an individual’s genome. There is no greater example of that than considering how identical twins can end being very different people even though they have the same DNA. To that end, blogger/editor Heather Morgan Shott (from High Chair Times, one of my personal favorite blogs out there) and her twin sister Erin Diebert graciously agreed to answer some questions on their experiences growing up as twins – and their recognition that they were, in fact, different people.
Note: Not Heather and Erin
1) Were you guys very similar when you were young? Did people confuse you? Were you dressed alike?
ERIN: Heather and I played together a lot before we entered elementary school. My mom dressed Heather and I exactly the same through first grade. After first grade, we chose to dress differently. Some people confused Heather and I.
HEATHER: We had very different personalities from birth. I was very impatient and wanted things the way I wanted them immediately, and Erin was more patient. I was the extrovert, she was the introvert. She worried a lot, and I was more carefree. As we grew older, some similarities did emerge; I suspect it’s a nature vs. nurture thing. Our differences as babies and toddlers were our natural personalities, whereas traits emerged as we got older based on how we were parented. We’re both worrywarts who try too hard to please other people (our mom is impossible to please and very highly strung). We’re both ambitious (we were raised by a single mother who worked two jobs to support the family).
Our mom did dress us alike until first grade—that’s when we started Catholic school and were forced to wear uniforms. I suspect that she just decided to let us wear what we wanted when we weren’t in the classroom. And indeed we developed our own styles. Erin dresses for comfort, I dress for style.
People have confused us and excessively compared us. In college, we have totally different majors (and therefore different classes) and it wasn’t unusual for a professor to mistake one for the other out on campus. (We went to the same college.) The comparisons started around puberty when Erin became the “chubby” twin. It was awful. She struggled with her weight for some reason, whereas I didn’t and people always brought it up.
2) Did your parents make a point of raising you differently? Did you have different teachers?
ERIN: When Heather and I entered Fourth grade, we were put in separate classes.
HEATHER: We also had very different interest emerge, and those led us in separate directions. I was super immersed in the tennis team and the school paper. Erin was more introverted and spent her time studying. I excelled in English, Erin was excellent at science and math. And frankly our parents were so steeped in marital troubles for most of our childhood, even beyond the time they divorced (we were 8) that I don’t think they gave much thought to the importance of raising us to be individuals.
3) When did you start to notice (or looking back see now) that you were different people (different interests, abilities)?
ERIN: Heather and I knew that we were different very young, however, we enjoyed playing together when we were young. We felt very fortunate to have an instant “play date.”
HEATHER: Our differences were very well defined by the time we hit middle school. I was perceived as the mischievous one (and, OK, I was) whereas Erin was the one who always followed along. For example, one time Erin and I were preparing to be spanked. I decided that we’d both put a book down our pants so that the whacks didn’t hurt. My mom took Erin to spank, my dad took me. Fortunately for me, my dad thought my little trick was hilarious and he removed the book and hugged me. Erin, on the other hand, got whacked twice as hard. I was also the one who was in charge of setting up all the social plans, while Erin followed along. Erin, on the other hand, made sure that we signed up for ACT prep classes, etc. She kept me on track academically—or, at least, much more on track than I would have been at that age left to my own devices. I just wanted to write, I didn’t care about most of the subjects in school!
4) Did you guys try to “deidentify” when you were young? Or during your teens? (Some twins deliberately try to carve out individual paths)
ERIN: We tried to deidentify from fourth grade and older.
HEATHER: Agreed—especially me. I was the rebellious twin.
5)Any other insights on why you are different?
ERIN: Heather is very outgoing and confident. She joined a sorority in college. I’m also outgoing, but can be introverted at times. Heather likes to stay up late. I usually go to bed earlier. I have a medium group of close knit friends. Heather has many friends, some of which are close friends.
HEATHER: At this point, a lot of our differences have to do with nurture. Erin still lives in the town where we grew up (Columbus, Ohio); I’ve lived on the East Coast for over 14 years. I like big city life, and she prefers a more quiet existence.
6) How do you think you are very similar?
ERIN: We are both very compassionate and have had to deal with some very difficult issues going up. Our parents got divorced when we were 8. Our father chose to be out of our lives starting when we were in our early pre-teen years.
HEATHER: Agreed, along with a couple of points that I made above.
Thanks to Heather and Erin for sharing their stories and insights!