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Sandy Hook Aftermath: Mental Health As A Public Health Issue

Wednesday, January 2nd, 2013

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.

Consider the following thoughts offered by Dr. Harold Koplewicz, President of the Child Mind Institute:

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.

Psychology Concept via Shutterstock.com

 

 

 

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Behavioral Interventions For Autism: A Small Breakthrough?

Friday, November 30th, 2012

Autism is a biological disorder. That said, recent research continues to reinforce the power of behavioral interventions – and a recent study may be pointing the way to a small breakthrough. 

In October, Dr. Geraldine Dawson and colleagues published a paper showing exciting results from a relatively new intervention called the Early Start Denver Model (ESDM). Previous studies demonstrated that the ESDM leads to improvements in a number of developmental domains – including reduction of symptoms, and increases in social behavior, language and IQ performance. The latest study revealed something especially remarkable – ESDM resulted in “normalized patterns of brain activity” in kids with autism when viewing a human face as compared to other objects. Since a fundamental goal of behavioral intervention is to improve interest in the social world, these results were especially powerful – the kids who participated in ESDM not only behaved differently, but their brains were functioning differently in real time.

ESDM applies learning principles – such as those used in more traditional ABA interventions – to shape and reinforce social behaviors as they happen in the stream of daily interaction. Parents as well as therapists are trained to administer the intervention program. And it is very intensive – it takes lots of hours every week, and the recent study evaluated kids after two years of intervention. No doubt, all these features are critical reasons why it may be having such a beneficial effect.

I see this work as signaling a breakthrough in intervention in two ways. First, it reminds us that just because a developmental disorder may be biological/genetic in origin, that does not mean that interventions need to be biological to produce substantial changes in developmental patterns. Second, creative interventions that utilize learning principles within the flow of everyday interaction – and incorporate the collaboration of therapists and parents – may be particularly effective in “reprogramming” both social behavior and how the brain processes social information.

We will continue to see lots of research on the biology of autism, and this work continues to be extremely important. But I do hope that we see more and more effort (and scientific and social resources) aimed at developing and refining behavioral interventions that hold considerable promise for promoting positive developmental changes in kids with autism.

Human Brain Research and Autism via Shutterstock.com

 

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How Early Exposure To Trauma Affects Children’s Cognitive Development – And What Can Be Done About It

Monday, April 30th, 2012

Unfortunately some babies, toddlers, and children are exposed to maltreatment and trauma – they can be witnesses to physical and emotional abuse, sexual abuse, and partner violence, and also experience it directly. Prior research has shown that such exposure may have lasting negative effects on cognitive development. The lead author of a key new study – Dr. Michelle Bosquet Enlow of Children’s Hospital Boston – took the time to expand on her current findings and the implications for intervention. Below are her responses to specific questions I posed.

Could you briefly give a description of what you examined in your research?

Our research specifically studied child exposure to maltreatment (the large majority, though not all, at the hands of the mother) and domestic violence against the mother. These kinds of trauma exposures may require additional considerations compared to other types of traumas that do not involve the parent (for example, being involved in a serious car accident, death of a non-parental family member). For example, when the caregiver is the perpetrator of the trauma, the child may need to be removed from the caregiver’s custody and some of the answers below may not be as applicable.

Do we know yet what the mechanism might be that affects cognitive/brain development? How does trauma affect the developing brain especially early in life?

There are many ways that trauma may affect the developing brain. Certain types of trauma, such as physical abuse or neglect, may cause direct injury to the brain, for example through injury to the head or malnutrition. We also know that when humans face a stressor, especially an extreme stressor like a trauma, the body prepares to react to the stressor. Chronic or severe stressors can cause changes in how the body secretes and processes a number of hormones that affect how the brain functions. These effects may be particularly strong in early life when the brain is developing so rapidly. Any changes to the brain during this critical time may affect how the brain is organized, and therefore have lifelong consequences. Also, infants and young children have fewer coping resources to manage stress, given their immaturity and dependence on their caregivers. We know that caregivers have a critical role in fostering children’s cognitive development. Sensitive, warm, consistent, empathic caregiving is key. Finally, for many children, trauma exposure can lead to emotional difficulties, like depression and posttraumatic stress disorder (PTSD). This is true even for very young children. These difficulties can interfere with learning new skills. For example, a child with PTSD may be preoccupied by disturbing memories of the trauma and have difficulty sitting still and paying attention. This can make it difficult to pick up new cognitive skills.

If a baby/toddler is exposed, what can be done with respect to intervention? What could a parent or caretaker do to minimize the effects?

Caregivers are absolutely essential to children’s recovery after a trauma. First, caregivers need to make sure that they are taking proper care of themselves so that they can be most helpful to their child. Sometimes, a caregiver and child suffer the same trauma (for example, being in a car accident together). Just knowing that your child has suffered a trauma can be very upsetting to the caregiver. This may cause feelings of guilt, helplessness, depression, and anxiety and difficulties with sleep, appetite, and concentration. Caregivers should seek out help for themselves if they feel that they are having symptoms that are getting in the way of their ability to function or care for their child. They may talk to their primary care physician or seek out a counselor.  They should make sure to get enough sleep and eat right and exercise if possible.

The other really important step caregivers can take is to help the child to feel safe again. Maintaining routines, such as the same bedtime rituals every night, is very important. Keep in mind that the child’s behaviors may change—for example, the child may become more clingy, have difficulty separating from the caregiver, have nightmares or resist going to bed, or not want to eat or want to eat a lot. The caregiver should do her best to be patient and remember that these are normal reactions. The child is not trying to manipulate anyone.  If possible, the caregiver should try to minimize separations, at least temporarily. If a separation is necessary, the child should be left with someone she knows and trusts. A familiar object to keep while the caregiver is gone, like a photograph of the caregiver, may help. The child may need extra hugs and lap time to feel reassured. If the caregiver feels the need to talk about the trauma with someone, she should make sure that the child cannot overhear the conversation. However, if the child wants to talk about the trauma, she should be allowed to do so. She may need to talk through what happened and get reassurances that she is now safe. If the caregiver has concerns about the child, she should talk with the child’s pediatrician. There are counselors who treat traumatized children, even very young children. These counselors can be very helpful in giving caregivers advice about ways to help their child. For example, we treat traumatized children and their families in the Psychosocial Treatment Clinic in the Outpatient Psychiatry Service at Children’s Hospital Boston.

Any suggestions to help parents in a compromising situation seek out help to prevent exposing their baby to trauma?

If parents are feeling stressed, they should seek out help for themselves, for example by calling a parenting helpline or by talking with their primary care physician or a counselor or friends and family. Physicians and counselors should be able to help parents find resources if needed to get out of a domestic violence situation or to get help if there is child abuse or neglect. The National Child Traumatic Stress Network has helpful information regarding child trauma, including information for parents and caregivers. Their website is www.nctsnet.org<http://www.nctsnet.org>.

Image depicting overcoming trauma via therapy courtesy of Shutterstock.com

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What Is Applied Behavior Analysis (ABA) And How Does It Work?

Monday, April 30th, 2012

If your child has been diagnosed with Autism Spectrum Disorder (ASD), there is a good chance that you will be considering – or evaluating – Applied Behavioral Analysis, or ABA. This is the first of three question and answer sessions with Lauren – who was featured here last December – who offers us the combined perspective of  a mother of a child with ASD and a professional who works with children with ASD. 

What is ABA?

Applied Behavioral Analysis can be described as the science of applying principles of behaviorism – which focuses on reinforcement of behavior – to make meaningful changes in an individual’s life.  The basic premise is that reinforcement can be used to shape behaviors that are desired. All ABA methods also require that data will be collected to determine that the intervention was responsible for the change in behavior, that the results were significant, and that the skills generalized across contexts.

How does it work?

If you get a positive reaction after you do a behavior, you will most likely repeat the behavior.  For example, if you walk in to work and a coworker compliments your shirt, most likely you will wear the shirt again. Wearing the shirt again or not again is based in part on the reaction of someone else.  That’s a change in behavior based on reinforcement. In the ABA model, behavioral reinforcers are given to reward a desired behavior (e.g., making eye contact). Reinforcers are positive (think of them as rewards) – the focus is on eliciting and shaping desired behaviors in a step-by-step and systematic way. A number of reinforcers can be used. Negative reinforcement is not used –  behaviors that are not considered desirable simply do not get reinforced.

People are typically most familiar with discrete trial teachings – which are trials that are repeated with a specific beginning, middle, and end (or antecedent, behavior, consequence).  A very small amount of information is given and the student will be reinforced immediately after the behavior building upon mastered concepts. However, there are many other wonderful variations that use ABA principles to change behavior, including: writing social stories, positive behavior supports, errorless teaching, shaping, prompt fading, visual schedules, transitional countdowns, differential reinforcements, modeling appropriate behavior, and task analysis.   For example, The Berenstain Bears books are perfect examples of social stories, which is an approach used in ABA.  They discuss an inappropriate behavior in the beginning and how to replace with an appropriate behavior successfully.

All of the above ABA techniques can be used to change a behavior of a child to improve their life. That’s where ABA is very different from what most people think – as they may assume it is only discrete trials, but it’s not.  A true ABA therapist knows how to utilize all the different methods and does not only use discrete trials. This process is guided of course by the child’s age and cognitive level of functioning. But no matter what the mix, all of the variations use the principles of ABA to help kids with ASD continually develop new skills.

Symbol of autism awareness via Shutterstock.com

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