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What the Heck is Work-Life Balance?

work-life balanceIs it me or does the term “work-life balance” conjure up images of a parent putting in 40 hours at a rewarding job, then coming home, energized from a day of doing important things, and realizing an effective balance of completing household and parenting tasks, having fun with family and/or friends, soaking up the meaning of being a spouse and/or parent, eating a balanced diet, being physically active and getting a good night of sleep? Well I’ll tell you that in my 22 years as a psychologist and husband, and 17 years as a parent, I’ve never seen it. Actually, I think this concept has more value for employers (e.g., to be flexible with schedules and methods for reaching agreed upon goals) than it does for we working parents. One of the things I do in my parenting book is give accounts of what I believe are more typical sorts of days for working-parents. Click here to read one of these (hopefully both humorous and realistic) illustrations.

Rather than using terms like “work-life balance” I prefer a term like “living on the working at home momhigh road.”  IMHO these are the characteristics of a working parent living a high road life:

• In my vocational life (whether that be in the home or otherwise) I’m using my top strengths to resolve or address important human problems or needs, regardless of how the culture at large values these contributions. And, my kids see me living this way.

• I’m making (not finding, making) time each week to spend one-on-one with my spouse/partner and each of my kids who are living at home (I like to think of one hour as the floor). And, my kids see me living this way.

• I’m in the fight to have healthy habits (i.e., a balanced diet,  ≥4/5 hours a week of physical activity and about 8 hours of sleep a night); this doesn’t mean I become a paragon of fitness, speaking with an Arnold Schwarzenegger accent. It just means that I prioritize this goal and hit these marks more than I miss them. And, my kids see me living this way.

chaos• I’m comfortable with chaos. I said to a colleague recently: “Bill, just one week I wish I could get everything done that has to get done that week.” He replied “Well, Dave, that’s the week that we hold your wake.” High road life is engaged. And, at this place and time in the universe, that comes with chaos. I’ve never seen a working-parent, on the high road, who has everything zipped up and buttoned down. But, if I tell myself that I must be doing something wrong if my life is chaotic, I may be suffering needlessly.

• I’m routinely asking myself, “what’s the loving thing to do (and that means towards myself too)?” And, more often than not, I pull that off. And, my kids see me living this way. (Tapping into your internal well of wisdom can help.)

• I experience injustice but get the most out of that. To be in the world is to have the world in me; and, the world is filled with injustice. Do you know anyone, who has been impactful in this world, who has not experienced injustice? Doesn’t it also sometimes seem like those that get the most done experience the most injustice (just a wonderment of mine)? But, at the end of the day I morph the injustice into an actualization of this formula: crisis = pain + opportunity. I realize that, as a poet put it, pain is like a dragon guarding treasure. Andhappy black woman background, my kids see me living this way.

• I make (not find) time for self-care. What this means varies wildly. It could mean killing two birds with one stone in doing physical activity. It could mean hanging out with friends. It could mean a rich spiritual life. But, I have a plan for self care and, like most priorities, I hit the mark more than I miss it. And, my kids see me living this way.

• More often than not, my parenting promotes those factors that promote resilience in kids. I don’t have space here to review them but the top research supported ones are in my parenting book.

black man pointing, happy face• There are other aspects that may not be a part of everyone’s high road, but can facilitate getting there or staying there: humor, being stupid with friends, buckets of forgiveness (the unilateral and unconditional type is the purest sort), turning the other cheek (not the same thing as letting oneself be bullied), praising beauty and strength and savoring gifts. And, my kids see me living this way.

So, if your striving to do these things, and win more battles than you lose, you may be firmly planted on the high road, even though the last thing you often feel is that you manifest work-life balance ;-).

Defiance in a Young Child Needn’t Be Tolerated (usually)

defiant boyAn important study was published a couple of months ago in the Journal of the American Academy of Child and Adolescent Psychiatry titled “Psychosocial treatment efficacy for disruptive behavior problems in very young children: A Meta-analytic study.” The first author is Boston University professor Dr. Jonathan Comer. This study of studies examined 36 studies investigating 3,042 children. The high points from this study support the headline for this entry.

Backdrop for the study

The authors first reviewed some key findings in the research literature:

• About 10% of preschoolers meet criteria for a disruptive behavior disorder. These conditions exist across cultures and are associated with debilitating outcomes (e.g., profound family disruption, continued psychopathology).

• The rates of psychotropic medication treatments for preschoolers has experienced between a two and five fold increase despite the fact that “…controlled evaluations of the efficacy of antipsychotic treatment for early child disruptive behavior problems have not been conducted…(and) potential adverse effects of antipsychotic treatment in youth, including metabolic, endocrine, and cerebrovascular risks, have been well documented.”

• While only a minority of children with disruptive behavior problems have ever tantruming girlgotten evidence-based treatment, there is evidence of a decreasing trend of kids getting needed mental health care.

Results

When considering if interventions work, researchers calculate an effect size. A “0” score means no effect; .2 means a small benefit; .5 is a moderate benefit and .8 represents a large benefit (what one well known statistician described as “whopping”).

The average effect size was .8! Remember, this is across 36 studies and more than 3K kids.

• The largest effect sizes were found for treatments that took a behavioral approach (see the commentary section below).

bipolar child• There is evidence that many treatments offered to youth with disruptive behavior problems are not the ones with the most evidence supporting their use; moreover, when these treatments are compared to evidence-based behavioral treatments there is a large difference in favor of the behavioral treatments. As the authors note “…widely used approaches rarely show support.”

• “Treatment effects were consistent across samples of varying compositions of racial/ethnic minorities.”

• “These findings provide robust quantitative support for consensus guidelines suggesting that psychosocial treatments alone should constitute first line treatment for early disruptive behavior problems. Against a backdrop of reduced reliance on psychosocial treatments in this age range, and increased reliance on pharmacological treatments in the absence of controlled safety and efficacy evaluations, the present findings also underscore the urgency of improving dissemination efforts for supported psychosocial treatment options, and removing systematic barriers to psychosocial care for affected youth.”

• “Roughly 50% of U.S. counties have no psychologist, psychiatrist or social worker.”

Comment

Readers of this blog will note how much this study is consistent with a primary ball and chain runningpoint I’ve been trying to make (and quoting from my own previous entry):

“Psychological problems are akin to medical problems in so many ways: they are nearly universal by the time a kid reaches adulthood (about 90%), most of the time they are treatable in a short period of time, they are easier to treat the earlier they are caught and, if they are left unchecked, can cause very stressful and costly consequences. However, unlike medical problems, only about 20% of youth who need evidence-based mental health care get it.”

This is profound social injustice and it needs to stop!

character holding checkmark-bulletWhat can you do to help?

• Ask your pediatrician if s/he screens all children for mental health problems in her/his practice on well visits. If not, ask him or her to reconsider. If s/he says that s/he doesn’t screen because s/he would have no one to refer such children to, make a counterpoint and a suggestion. The counterpoint: parents deserve to know if their child could benefit from a mental health evaluation. So, even if no help can be found, the problem has been upgraded. The suggestion: contact your state’s psychological association and ask if they can help to identify a provider to whom your pediatrician may refer; it is highly likely that that they will be passionate in their efforts to assist. Should you convince your pediatrician to grow in this way, a quickly administered pediatric mental health screening tool is available in the public domain (i.e., it’s free): Pediatric Symptom Checklist.

• If your child’s defiant or disruptive behavior is causing anyone distress, get him or her help for it today. Besides tapping your state’s psychological association, you may also try here .

• Ask the mental health professional you interview at least two questions:

√ “In what types of problems do you specialize?” (This is a better question than question mark over brain“do you specialize in working with children?”) If you hear kids listed, that’s good. If not, ask if s/he knows of someone who does. Of course you may live in a community where this person is your only choice. So, you can ask if s/he has had success treating this problem.

√ Once you identify a viable clinician, ask “You obviously can’t know if my child has Oppositional Defiant Disorder at this point, but what is your treatment approach when you have diagnosed a child with Oppositional Defiant Disorder(ODD) and that’s the only problem?” There are synonymous terms for a good answer: “behavior modification,” “parent training,” (an unfortunate term in my view but it’s used), “behaviorally oriented family therapy,” and “behavioral treatment.” The clinician might also name some specific treatment manuals/approaches such as “Parent-Child Interaction Therapy,” “Incredible Years,” “Helping the Noncompliant Child,” “The Triple P-Positive Parenting Program,” and “The Defiant Child Program.” I would be very concerned if the first line of approach were a different one, including the use of medication treatment.

key in lockJust to give you an idea of what you might be in for, when I have a child who has ODD, and that’s the only problem, the treatment phase of the work (i.e., not including the evaluation phase), takes 8 sessions. In my own practice this cures the problem over 90% of the time. And, the two most common reasons I’ve found it doesn’t work are (1) the parent(s) don’t apply the techniques, usually because of personal pain and limitations or (2) there was another or different problem interacting with the ODD (e.g, the child really was suffering from an emerging case of bipolar disorder, the child was privately sniffing glue on a regular basis, a parent was substance dependent but tried to hide that). If a child truly has just ODD, and the parent does the techniques, it works.

The truth I/m reviewing here still seems to be too much of a secret, at least from most parents, teachers and pediatricians I’ve known. This leaves kids, parents and families suffering needlessly. As Jerry Garcia once noted: :Somebody has to do something, and it’s just incredibly pathetic that it has to be us.”

In closing let me share that you can also find multiple behavioral strategies in my parenting book as well as suggestions for identifying, and affording, quality mental health care.

What Can I Expect If I Take My Child to See a Psychologist?

upset characterA recent national study indicated that by adulthood about 90% of youth will have qualified for a mental health diagnosis at one point or another. However, only about 20% of these kids get any kind of mental health care. So, if your child is showing some distress s/he is in a huge club. But, if you’re getting him/her help for it, you are in an elite club.

Different mental health professions may go about their work in different ways. This blog entry is meant to characterize how an evidence-based psychologist might proceed. (While there are always exceptions, psychologists are the doctorally trained mental health professionals who most commonly provide talking treatments.)

The first thing the psychologist will do is an evaluation. These are the elements I believe constitute a cost-effective, evidence-based evaluation (each of these elements has been endorsed by the Pennsylvania Pediatric Mental Health Task Force):

• A family interview (who is in this interview can vary but often both birthboy umbrella pointing parents and the child of concern are included)

• An individual interview with the youth of concern

• The completion of behavior rating scales

• A review of relevant records (e.g., school records)

• A feedback session that reviews a diagnostic impression, addresses key issues (e.g., causes, prevalence, prognosis) and recommends a treatment plan

What follows are some common concerns I’ve heard from parents who are considering getting mental health care for their child.

If I take my child to see a child psychologist s/he might suffer self-esteem damage (e.g., mom thinks there is something seriously wrong with me).

boy head on handExperienced psychologists know that this is a concern and have procedures in place for helping (e.g., assessing for your child’s strengths, making the experience enjoyable). Moreover, the symptoms that are troubling your child are far more likely to be causing, or to cause, self-esteem damage than interacting with a highly trained, caring and kind adult.

I’m not comfortable signing up for a long course of treatment.

Most research-supported treatments, for most problems, are designed to be short-term. Sure, there are instances where a longer course of care is indicated. In medical pediatric practice short-term treatments are more common than longer-term treatments; the same thing is true in mental health pediatric practice.

Treatment is too expensive.

I’ve been doing this work for over 20 years. I’ve never seen an instance where aconfused child way wasn’t afforded to those with the will to be persistent. Please see this blog entry for a list of strategies. Moreover, the toll from untreated symptoms can be devastatingly higher.

I don’t want to weaken my child (e.g., encourage senseless whining, create dependency, promote externalizing responsibility).

Evidence-based psychotherapy is designed to make itself obsolete as soon as possible, to promote healing and to instill resilience. Alternatively, psychological symptoms often weaken functioning, dampen the human spirit and lower the ceiling on interpersonal, educational and vocational outcomes.

My kid doesn’t want to come in. There’s no point in doing this if s/he won’t cooperate.

black kid skateboardMost kids and teens are neutral or opposed to the idea of mental health care. Actually, if a kid is interested in counseling it suggests either that he or she is very psychologically minded and/or is in a great deal of pain. I tell parents new to my practice not to worry about this. It’s their job to get their kid to my office. It’s my job to make the time worthwhile.

The final chapter of my book Working Parents, Thriving Families, goes into much more depth on this topic, including describing what the most common evidence-based treatments entail and how to tell if your child is getting quality care. Please also see these related blog entries:

Seven Common Myths About Counseling

Signs that a Kid Needs Mental Health Services

Mental Health Concerns are Nearly Universal by Ag2 21

Ignoring Kids’ Mental Health Needs is Expensive

I’ll close by stating that I travel widely within my profession. My experience suggests that the average child psychologist is an extremely devoted and mission-driven person who really cares about kids and doing right by them. If you’d like to check this assertion out for yourself, click here.

Are Meds Alone Sufficient to Treat My Child’s Psychiatric Symptoms?

teenandmedicationMany parents wonder about the efficacy of using only medication to treat their child’s psychiatric condition. While a full treatment of this question far exceeds the scope of a blog, it’s possible to briefly summarize some important themes and issues.

Clinical work limited to an initial interview and medication therapy risks misdiagnosis.

This is an example of an evidence-based, cost effective and clinically effective, outpatient evaluation for a child’s or teen’s mental health symptoms (assuming medical causes have been ruled out): a family interview, an interview alone with the youth, the collection of parent, teacher and child behavior rating scales and a review of relevant records. This is complex business and I worry about the accuracy of a diagnostic formulation if one or more of these elements is missing. Moreover, it is possible for a child to improve on a given medication without the child actually having the disorder that the medication is supposedly treating (e.g., low doses of stimulant medication will often improve the concentration of any child, regardless of whether or not that child has ADHD. Of course, sometimes it isn’t possible to do more than a brief interview and a medication trial, but if it’s possible to add the other elements that would probably be advisable in most instances.

Treatment with medication alone is rarely indicated.medication

There are some mental health conditions in youth for which medication treatment will almost always be a part of an evidence-based treatment plan (e.g., ADHD, bipolar disorder, schizophrenia). However, the best designed research studies on these conditions almost always indicates that evidence-based talk therapies (usually behavioral treatments) significantly improves the efficacy of the medication treatment (e.g., decreasing the dosage of medication needed, speeding along the management of the symptoms, strengthening the degree of  improvement, reducing the odds of suicidality). Moreover, in the very large majority of instances, children with a psychiatric diagnosis have at least a second diagnosis as well, and many of these co-occurring conditions are either best treated with evidence-based talk therapy alone or are  better treated when evidence-based talk therapy is added to the treatment plan.

Certain diagnoses, while perhaps improved with medication treatment, may not need such if evidence-based talk therapy is tried first.

teenfamilytherapyFor example, for mild to moderate depressive disorders and anxiety disorders, cognitive-behavioral therapy or other evidence-based treatments (e.g., interpersonal therapy for adolescent depression) may sufficiently manage or heal the presenting symptoms without the need to add medication therapy to the treatment plan. While these treatments take more effort than swallowing a pill, they may be preferred by parents who wish to avoid artificially altering their child’s brain chemistry when talking treatments may do the job as well or better.

There are many instances when the science on medication treatments leaves important questions unanswered.

There are many unanswered questions about the pros and cons of providing childmedicationmedication therapy to very young children as there are regarding the long term consequences of being on the same medication and the degree to which medication treatments alter the development of a youth’s brain. If a child needs medication treatment in order to avoid significant here-and-now impairment, most would agree that such questions often need to take a back seat.  But, if a youth’s symptoms can be effectively treated either by not taking a pharmaceutical, or by taking a lower dose, that would appear to be a preferable choice in many instances.

The short-term conveniences affiliated with medication treatments should give us all pause.

I believe the best available evidence would support the position that effectively moneyandpillsdelivered talk therapies for youth spares money, aggravation and pain over the long run. However, in the short run, talk therapies may offer more hassles (e.g., additional costs and inconveniences) than medication treatments. Moreover, considering only short-term costs may create incentives for decision makers (e.g., insurance companies, clinicians with capitated insurance contracts, hectic parents) to gravitate towards treatment plans that only include medication therapy. Such factors should cause us all to pause and reflect on both the available scientific evidence and issues affiliated with longer term consequences.

A take home point is that it is usually a good idea to have a mental health professional on your child’s treatment team who is aware of the relevant science and clinical practicalities and who can help you to effectively navigate your choices. If you’re interested in speaking with a psychologist more about these matters, please click here.

Seven Myths about ADHD

child trying to get through glassThere are three kinds of ADHD: a child has significant concentration problems but is not significantly hyperactive (ADHD, Predominantly Inattentive Type), vice versa (ADHD, Predominantly Hyperactive/Impulsive Type) and both (ADHD, Combined Type). About 75% of kids with ADHD have ADHD, Combined Type while the large majority of the rest have the inattentive type.  Below are seven common myths about ADHD. Following those I list core guidelines for evaluation and treatment.

Myth: ADHD is not a real disorder. This is akin to saying that diabetes isn’t a real disorder or asthma isn’t a real disorder. To my knowledge, no reputable scientist or professional organization subscribes to this position. About four to six percent of youth suffer from this biological disorder. Studies of the brain indicate that these youth show poor functioning in the parts of the brain responsible for impulse control and sustained attention to boring tasks.

Myth: ADHD, Combined Type can be caused by poor parenting or being upset male college studentraised in adverse circumstances. While significant attentional problems can be caused by an assortment of problems (e.g., trauma, depression, anxiety), the degree of sustained hyperactivity required to diagnose ADHD is usually not caused by environmental stresses (I say “generally” as even a broken clock is right twice a day, but I’ve never seen a case like this or read about a case like this). ADHD is a biological disorder caused by either genetic transmission (i.e., it runs in the family) or significant insult to the brain (e.g., mom smoking cigarettes during pregnancy).

Myth: ADHD is caused by what a child ingests. Certainly what a child eats could affect just about any condition. Moreover, correcting an unbalanced diet, or eliminating allergens or toxins, would be part of a helpful treatment plan for just about any disorder. However, nothing that youth put in their mouths has been established as a primary cause of ADHD.

girl paint all over herMyth: A positive response to medication treatment proves that a child has ADHD. Many children will experience improved concentration on low doses of stimulant medication, whether they have ADHD or not. Our culture is replete with examples of people, who do not have ADHD, using stimulants to accomplish some desired effect (e.g., pilots during the Korean war took dexedrine in order to be able to focus better during long bombing runs).

Myth: Youth suffering from ADHD, who are treated with stimulant medication, are at higher risk to develop substance abuse problems as a function of taking the medication. Actually, the exact opposite seems to be more likely: having ADHD, and not receiving effective treatment for it, seems to double to triple the odds of substance abuse in adolescence. Moreover, the number one cause of death and serious injury among teens and young adults are accidents and youth with untreated ADHD are at a much higher risk to experience those.

Myth: ADHD can be treated effectively by enhancing a child’s motivation. defiant boyAs I wear corrective lenses I use the following analogy with my clients: “if I told people I wasn’t willing to wear glasses but was interested in other treatments, they might try to make the light brighter for me, cheer me on, or suggest that I get closer to things I’m reading. However, nothing is going to help nearly as quickly and effectively as my just putting on my glasses. And, my not putting on my glasses could eventually make me think that my problem with reading is a problem with my effort. And, if I go there in my thinking, I’m probably going to make myself very, very upset and sick.”

Myth: People outgrow their ADHD. It is true that a small percentage of youth with ADHD reach the point that their symptoms are not significantly impairing in adulthood (these are usually the milder cases with multiple protective factors at play). So, in that case this myth has some truth to it.  However, testing on those individuals will usually document the lingering presence of the disorder; it’s just not causing impairment anymore, secondary to the protective factors and brain maturation.

adhd

Evaluation guidelines

Keep in mind that in order to qualify for an ADHD diagnosis a child must show unusual and impairing inattention (usually to tasks that bore him or her) or hyperactivity/impulsivity at both school and home for a period of at least six months. The common standard for “unusual” is the 93rd percentile (i.e, having the symptom worse than 92% of the youth’s peer group). Moreover, the onset of the first impairing symptom should be before the age of seven and no other viable theory can explain the symptoms that are being demonstrated (i.e., ADHD is a diagnosis by exclusion).

The methodology for determining the presence of the disorder is determined by a cost/benefit analysis. As I consider the myriad of factors at play, I’d suggest the following be the default standard for ADHD evaluations: a family interview, a child/teen interview, the completion of parent, teacher and child–if the child’s reading level is sufficient–behavior rating scales, a comprehensive review of school records and a review of any other relevant records. (The behavior rating scales should include broad-band measures that endeavor to assess for a spectrum of disorders as well as narrow-band measures that try to rule out ADHD specifically.) If one of these elements is missing, I’d worry about the increased odds of an inaccurate finding. If these sources of information leave the diagnosis in doubt, I’d suggest adding a computer based continuous performance test (e.g., the Test of the Variables of Attention). (There is a reasonable argument to be made for including a continuous performance test  in every evaluation for ADHD, so I wouldn’t differ with those clinicians who do.) In instances where a learning disability is suspected, additional cognitive and achievement testing would usually be in order.

anxious teen african-american

Treatment guidelines

The large majority of children with ADHD have at least one other co-occurring condition (e.g., Oppositional Defiant Disorder). The configuration of the co-occurring problems would normally have a substantive impact on an evidence-based treatment plan. However, for ADHD itself, medication is the primary treatment of choice (i.e., the scientific evidence supporting its efficacy is overwhelming). It is also very common to need behavioral treatments, at both school and at home, to augment the primary treatment. As a primary treatment, the following would typically not be indicated: dietary manipulations, chiropractic treatments, play therapy, art therapy, music therapy or basically any interventions that does not have a sound scientific foundation to support its usage as a first line intervention.

For more science-based information on ADHD, consider any of the following websites designed for lay people:

www.chadd.org, www.add.org or www.help4adhd.org

Also, on 12/4/12, from 1 to 2 PM EST, there will be a Twitter chat on ADHD. (I will be one of the panelists.) This will be hosted by Dr. Richard Besser, Chief Medical Editor for ABC news. Just go to #abcDrBchat at that time.

Ignoring Kids’ Mental Health Needs is Expensive

With most of the Affordable Care act being upheld this week by the Supreme Court, it seems like an apt time to review an example of how costs rise when kids’ mental health needs are not sufficiently addressed.

A few months ago The American Journal of Child and Adolescent Psychiatry published a national study regarding the cost of pediatric (age ≤ 18) usage of emergency room visits in the U.S. from 2001 to 2008. (As many know, ER and hospital care is usually much more expensive than outpatient care. Moreover, mental health problems are more likely to be treated in this more expensive setting when a youth’s outpatient needs for care have not been adequately attended to.) The abstract can be found here. Some high points:

• Of the 73,105 visits, 1,476 were for mental health issues. When appropriate statistical adjustments were made, it was estimated that there are 480,700 emergency department visits for mental health issues in the US each year.

• 21.8% of the mental health contacts arrived by ambulance compared to 6.3% of other kinds of contacts; they also stayed longer  (median 169 minutes vs. 108 minutes) and had a higher rate of admission into the hospital (16.4% vs. 7.6%).

• The rate of usage was not significantly different across gender and between Caucasian and African-American kids; however, the usage rates for Hispanics was lower than non-Hispanics.

• Quoting the authors: “Depressive disorders were the most common principal diagnoses, followed by anxiety and disruptive behavioral disorders or ADHD.”

• Following appropriate statistical adjustments, the researchers determined that 1/3rd of the mental health related visits to hospitals result in a hospitalization.

• Additional collateral costs (e.g., the need to have security personnel monitor the youth, the fact that many arrived with escorts that had a professional role in the child’s life) were also noted.

• Quoting the authors: “Probability of extended stays for mental health visits rose over the period that we studied. By 2008, the odds of an extended stay (> 4 hours) was almost twice that in 2001, and we did not observe comparable growth in the duration of non-mental health visits.”

The authors also acknowledge that their rates may represent underestimates of usage as they used stricter criteria for defining a mental health visit than have other investigators that have examined this area.

For me this study place another brick in the wall that demonstrates the tremendous costs–financial only being one of them–that accrue when we neglect the mental health needs of our children and teenagers. If you’d like to read more about this, please see Chapter 10 of my book Working Parents, Thriving Families, or any of the blog entries below:

Signs That a Kid Needs Mental Health Services

Seven Common Myths About Counseling

Affording Mental Health Care

Mental Health Concerns Are Nearly Universal By Age 21

Earlier this year a landmark study on the prevalence of psychological disorders in youth was published in the Journal of the American Academy of Child and Adolescent Psychiatry. Examining youth living in 11 counties in the southeastern US, it is the first to track kids’ mental health status from ages as young as 9 through age 21 (a total sample size of 1,420). The authors–Drs. William Copeland, Lilly Shanahan and E. Jane Costello and Ms. Adrian Angold–note some key findings in their report:

• Assuming that there was no incident of psychiatric disorders among the missing cases (an unlikely event), 70% of the sample met criteria for a mental health disorder, at some point, by age 21. (This is referred to as the unimputed number.)

• If one were to assume that the rates of psychiatric disturbance are the same among the missing cases, the frequency of a mental health disorder by age 21 rose to 82.5%. (This is referred to as the imputed number.)

• Child participants entered the study at one of three different ages: 9, 11 and 13. Among the youngest cohort (i.e., entered the study at age 9), the rates of having a diagnosable mental health problem by age 21 was “higher than 90%.” The authors note “This suggests that the experience of psychiatric illness is not merely common but nearly universal.”

• When examining the imputed analyses, these were the most common disorders: substance abuse–42%, behavioral disorders (e.g., ADHD, Oppositional Defiant Disorder)–23.5%, anxiety disorders–20.9% and mood disorders–14.8%.

While all research studies have their flaws, and this one is no exception (e.g., an under representation of African-American and Hispanic children), this study numbers among those contributing to the notion that mental health disorders and physical disorders, as they manifest in youth, have many similar characteristics:

• The odds of having at least one by adulthood are nearly universal.

• Most are not chronic or severe.

• Most can be cured or effectively managed through evidence-based interventions.

• Most will either worsen, or promote needless suffering, when they go unrecognized or untreated.

However, there is a key way that mental health and physical disorders in youth are substantively different. As the authors indicate: “Only about one in three individuals with a well-specified psychiatric disorder received any treatment at all, and even when treatment was obtained, it rarely conformed to best practice recommendations.” I find myself wondering when we will grow weary and intolerant of this needless suffering that our babies endure.

If you, as parent or caregiver, would like to find an ally in your neighborhood to help you to understand whether a child or teen under your charge could use help along these lines, click here. To read a consumer guide for child mental health services, see Chapter 10 in my book Working Parents, Thriving Families: 10 Strategies That Make a Difference.

You may also find value in reviewing posts I’ve written on related topics:

Affording Mental Health Care

Signs that a Kid Needs Mental Health Services

Seven Common Myths About Counseling

Millions of Teens are Suffering Needlessly

51 Truths (as I see things anyway)

I recently saw a blogger use the occasion of his birthday to write a list of tips that equaled his years. I thought that such a good idea that I didn’t want to wait until my birthday to do something similar. So, this is my top 51 truths. One caveat–which I feel somewhat apologetic for and which will be obvious as you read on: while the large majority of these statements are supported by research findings, others are merely personal beliefs that are not testable by science.

1. Self-care is an act of love towards one’s children.

2. Effective discipline = effective teaching.

3. Self-entitlement has many faces, but two common ones are expecting others to protect one from the consequences of one’s choices and expecting that others, if they are fair, will give one the outcome that one wants because one is a good person who tried hard.

4. Behind just about any action of abuse or neglect is pain.

5. At the end of everything, how well we love is what matters the most.

6. Avoiding avoidance is generally advisable when the avoided thing, person or situation is not truly dangerous.

7. More determinative of mood is what we think about what has happened, not what has actually happened.

8. Being kind to others is a great mood enhancer.

9. We loose IQ points when we get angry.

10. Show me someone who is not engaged in an internal battle and I will show you someone whose life is in shambles.

11. Being in a successful long-term marriage is one of the most difficult things a human can try to do.

12. The greatest pain is having one’s child die.

13. The opposite of love is not hate, it’s fear.

14. We get use to just about anything. One of the many things this teaches us is that we need to mix things up lest our sex life become mundane.

15. Single parenting in a two-parent household is a symptom.

16. Becoming physiologically and psychologically calm on a daily basis promotes many health and psychological benefits.

17. “Physical activity” is a much more effective term than “exercise.”

18. Fast food is generally poisonous, though it may take a long time for the effects to become obvious.

19. We are suffering from an epidemic of sleep deprivation, across the lifespan.

20. The large majority of kids, teens and adults who could benefit from evidence-based mental health services do not get it. This truth is even harsher for minorities and the poor.

21. We parents love our kids so much it makes us lunatics some of the time.

22. The practice of a spirituality correlates strongly (and positively) with multiple physical and psychological benefits.

23. If Heaven exists (and I believe it does), there are no institutions there.

24. When we don’t know what is motivating another person’s irritating behavior, our own mental health is nurtured when we assume she or he has good cause.

25. Adaptive rituals produce positive illusions.

26. Men are generally simpler creatures than women.

27. There are many more ways to promote misery than there are to promote happiness.

28. Corporal punishment can usually be aptly labelled “undisciplined discipline.”

29. Willpower, when used in isolation, is not a very reliable tool for changing harmful habits.

30. The more we learn the more nuanced we become.

31. Understanding how well a person can do things when he or she doesn’t feel like it can tell you a great deal about his or her success in both vocational and personal arenas. This is why teaching such skills to our children is a top parenting activity.

32. Heaven exists outside of space and time, which makes it very difficult for us to think and talk about what it is like.

33. Crisis = (pain/2) + (≥ opportunity/2).

34. Using addiction to deal with pain is like drinking ocean water when on a life raft: certainly understandable but it makes things worse.

35. We parents are shepherds, not sculptors.

36. Having kids quadruples the importance of having a good maintenance schedule for a committed relationship. (I’d write something higher than quadruples but I had a hard enough time spelling quadruples.)

37. If swimming is the activity that uses the most physical muscles forgiveness is the activity that uses the most psychological muscles.

38. What an apple is to a pediatrician, positive one-on-one attention is to a child psychologist.

39. Simultaneously pursuing self-interest and effective political service is like trying to iron clothing underwater.

40. Addiction is a jealous, cunning and harsh mistress that isn’t satisfied until its victim is left with nothing else.

41. An important mistake we make in thinking about race is to suppose that being impacted by someone’s race is the same thing as being racist.

42. Show me someone who is critical and unloving towards others and I will show you someone who is critical and unloving towards himself or herself.

43. Though they vary, we all have our limitations and when we exceed them we break.

44. No engaged parent can be generally happier than his or her least happy child.

45. Improving someone else’s life, without them knowing one did so, is glorious.

46. Well-conceived mission statements can help one to make many decisions about how to spend one’s time and resources.

47. Considering a difficult decision from the context of one’s deathbed can promote clarity.

48. That which is loving is of God. That which is not loving is not of God.

49. Empathy tends to soften anger.

50. Going through an effective psychotherapy is like being reborn.

51. Show me a spiritual person who is generally physically active, getting enough sleep, eating a good diet, executing his or her top talents in service to others, and being loving in his or her personal relationships and I will show you someone who is wise.

I enjoy receiving all comments, but would especially  welcome others sharing truths I have left out. Also, if anyone would like me to do a subsequent blog post on any of these assertions, I’d enjoy hearing about that as well.

The Best Marriage Advice I’ve Ever Heard

The best marriage advice I’ve ever heard didn’t come from a research study on couples, or from a book on marriage therapy or from a workshop by a marriage counseling expert. No, the single best advice I’ve ever heard came from a couple I worked with when I was practicing in Chicago in the mid nineties. This couple was not seeing me for marriage counseling but for the treatment of their nine year-old daughter, who was suffering from a severe case of depression and a moderate case of defiance.

Mood disorders, when they persist in children, tend to demoralize parents and stress marriages. The demoralization happens because the sorts of interventions that parents typically try not only don’t work but often seem to make things worse. The marital stress subsequently occurs when parents start to oversubscribe responsibility for their child’s problems onto their partner (e.g., if only you would do x or not do y maybe our child would not have these difficulties).

The couple I’m referring to experienced the demoralization but not the marital problems. After a year’s worth of treatment, which included behaviorally oriented family therapy, individual cognitive-behavioral therapy and medication (the nature of these treatments is described in my book Working Parents, Thriving Families), their daughter was no longer symptomatic. We had some extra time in our last session so I indulged a curiosity and asked: “You guys made it clear from the get-go that you have a strong marriage and are each other’s best friend. But I’m puzzled about something. Often when I’m helping parents to treat problems like your daughter’s I notice that they have periods when they feel alienated from each other, but I never saw signs of that in the two of you. Actually, you seemed to remain close throughout all phases of our work, even though there were some very rough patches.” As they nodded in agreement I asked: “What’s your secret?” To which the husband instantly answered (because they had thought and talked about this a lot): “We know the other person is not crazy.”

The couple elaborated that when the other person acts in a way that is grating they just assume that she or he has good cause. So, instead of just concluding that their partner is being a jerk, or selfish or unfair, they conclude (1) that she or he has an understandable reason for acting that way and (2) that she or he will rebound soon enough, especially if their own response involves patience and empathy instead of irritation and counterattacks.

Clearly there are multiple and important strategies that go into having a successful long term relationship (e.g., making time to have fun with each other, working on having a satisfying sex life, etc.), but I was struck by the truth of this couple’s insight and how well it was working for them. They also helped me to connect the dots and realize that this sort of way of being in a relationship captures a lot of the good outcomes that happen when communication training goes well. So, those of us in marriages that have existed since there has been dirt would do well to consider the wisdom of this couple’s insight.

Mom Arrested for Giving Her Daughter Xanax: CBT Can Help to Avoid Such Sad Stories

According to a story this week in the North Platte Telegraph, a mother in Nebraska was arrested for intent to deliver a controlled substance after she gave Xanax to her 15 year-old daughter (the story indicates that daughter later gave it to a friend). I know no more about this story than what is contained in the above link. But I find myself wondering how much each of the following factors contributed to this unfortunate arrest:

√ The pharmaceutical industry markets directly to the public. The marketing budget of this industry far exceeds the public education budget of any mental health association that tries to teach the public about how psychological pain can be understood and relieved.

√ Studies vary but between one in ten and one in four youth suffer from an anxiety disorder (e.g., this graph, from the National Institute of Mental Health, demonstrates the high rates in teenagers).

√ Between 2/3rds and 90% of these kids receive no care. And, even when they do receive care they’ve often been suffering for years first and/or the care is truncated (my blog post discussing some of these issues regarding teens can be found here).

√ Many people, including primary care physicians and teachers, do not know what cognitive behavior therapy (CBT) is or that it is the number one researched talking therapy for relieving anxiety in children and teenagers.

This author knows of not one authoritative association or legitimately published researcher who recommends that anxiety disorders be treated by medication alone, in any human, at least when the afflicted person is able and willing to take part in talking therapy. Moreover, many kids successfully treated with CBT do not need medication to help manage their anxiety-based symptoms.

Cognitive behavioral therapy, which is a time-limited intervention, involves learning a collection of strategies for manipulating emotions and thoughts. Some of these strategies involve recognizing and adjusting thoughts (i.e., the “cognitive” part of the term), while others involve adjusting behaviors (the “behavioral” part of the term). In the case of anxiety treatments there are often two phases. In the first phase the child or teen learns the cognitive and behavioral strategies for defeating anxiety. (In my practice I’ll teach anywhere between five and ten strategies depending on the youth’s problems and situation.) In the second phase the youth then deliberately puts herself or himself into those developmentally appropriate situations that tend to evoke anxiety (e.g., getting on a school bus instead of being transported to school) and uses the techniques to conquer the anxiety. The work is finished once the youth is able to defeat all such fears. Often at termination both the youth and her or his parent(s) cannot believe how far she or he has improved in a relatively short period of time.

These treatments can be delivered to a child by himself or herself (with intermittent parent sessions so that the parent(s) are in a position to coach the strategies once the treatment is over), in groups of youth or together with family members. To identify a mental health professional who might be available to deliver this treatment in your area, click here. Below I have also listed links to three related blog entries.

Affording Mental Health Care

Signs that a Kid Needs Mental Health Services

Seven Common Myths About Counseling

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