Mental Illness in School: No Child Left Behind?

By Molly McVoy, M.D.

How much do I tell my child’s teacher about her depression? About his bipolar disorder? About her ADHD? Will he fall behind if the teacher doesn’t know? Will she be judged if I tell the school? When do I get testing, an IEP, special Ed? What do those mean?

Parents of children with psychiatric illness struggle with these questions and many others. Often, there are no easy answers. A child’s success at school may be one of the best predictors of future success. Giving a child and his/her family the best tools to succeed in school is one of my top priorities as a child psychiatrist.

When deciding how much to tell your child’s school about his/her psychiatric illness, consider your child’s ability to function at school rather than his/her specific type of illness. You are not required to tell the school anything; that is up to you as a parent. If telling your child’s teacher about his/her psychiatric illness will give him/her a better chance to do well, then consider telling the teacher. If your child’s illness is affecting his/her day to day functioning and behavior at school, then consider telling the teacher. Teachers are your partners in helping your child succeed. If the illness is relatively well controlled and is not affecting his/her daily behavior at school, the school may not need to know. For more information, visit the American Academy of Child and Adolescent Psychiatry.

When it comes to accessing special education services, most schools and teachers want to do everything they can to help your child. I usually recommend families listen to the principal and teachers.They are the experts in education. However, if you are dissatisfied with the educational services you are receiving, my next recommendation is know your rights, know your state’s laws. Every state must provide a free education that meets the needs of each child – no matter what those needs are. What varies widely, however, is how each state manages that requirement. The U.S. Department of Education website has basic information on your rights as a parent and offers links to each state.html. Know your state law, know your rights. Come armed with that information and work with your doctor and school for your child to succeed!

Mental Health Disparities – Focus on Asian Americans

By Felicia Wong, M.D.
APA's Division of Diversity and Health Equity works to promote diversity and cultural competence and to eliminate disparities in mental health care. They published a report on Asian Americans and Mental Health that revealed some troubling statistics.





photo courtesy Bjoern Kommerell

• While the overall prevalence rate of mental illness is similar or somewhat lower among Asian Americans than whites, Asian Americans are significantly less likely to use mental health services than other populations.
• Asian Americans are much less likely than whites to report mental health problems to friends or relatives, psychiatrists or other mental health specialists, or to physicians. It has been postulated that shame and stigma figure prominently in the lower utilization rates of Asian American/Pacific Islander (AA/PI) communities.
• AA/PI’s often consider expression of mental illness a personal weakness and are more likely than Westerners to express emotional distress through physical symptoms.
• The suicide rates of elderly Asian American women and young Asian American women (15‐24 years old) are significantly higher than that of other women of the same ages.

In an attempt to address the barriers to mental health care that pertain to the Asian American community, I created a website http://www.asianmentalwellness.com/ which I hope will dispel some of the misconceptions that the AA/PI community may have about mental health, and will provide information and links that will help raise awareness about the importance of mental health and wellness. Please share this website with those who you feel might find it useful.
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Adult ADHD? Not just a diagnosis for kids

By Felicia Wong, M.D.

There have been several posts addressing ADHD in children on our blog, but did you know that ADHD can affect adults as well? An interesting article in the Wall Street Journal discusses adult attention-deficit/hyperactivity (ADHD) disorder, a condition that may affect up to 10 million Americans, only 4.4 percent of whom know it.

According to government data, an estimated eight percent of U.S. children have ADHD, and some 50 percent outgrow it. But what happens to those who don’t?


It was only in 1980 that therapists began to recognize that ADHD could persist in adults, and even now, getting an accurate diagnosis is tricky. It is controversial topic that has people taking sides. Some experts think that too many adults (and children) are being medicated for ADHD, often by doctors who have little knowledge or experience with this disorder. Others argue that those adults who have experienced functional impairment could benefit from ADHD medications and behavioral therapy.


Some adults whose ADHD is left untreated can encounter negative consequences including high incidence of substance abuse, automobile accidents, difficulty staying employed and maintaining relationships. Yet, adults with ADHD can also be highly intelligent, energetic, charismatic and creative. Those with ADHD may have the ability to focus intently on a narrow range of topics that interest them.


Many adults with ADHD have developed skills to compensate for their distractibility. Some excel in school at an early age, and don’t run into any problems until college/ grad school or starting at a challenging new job. Suddenly, their coping mechanisms are not as effective anymore.

An excerpt from the Wall Street Journal article:

We see people from all of the professions who have managed to succeed despite the limitations,  but they have often done it at significant cost," says Dr. Solanto. "They don't have time to enjoy life. They don't get their work done in the course of a day. They have to stay late after hours, or they are doing without sleep, frantically trying to meet deadlines. It ultimately takes a toll on their wellbeing and a toll on the people around them.

Adult ADHD is tricky to diagnosis and deciding whether to get help for it can be difficult as well. The symptoms that traditionally describe ADHD: restlessness, impatience, procrastination, chronic lateness, and difficulty getting organized, focusing, and finishing tasks are common in busy adults. But how can one tell if it’s just stress, or too much caffeine that is causing their symptoms? What about the stigma and perceptions associated with ADHD? What does it mean to suddenly discover at the age of 40, that you have ADHD?


The key word in determining whether an evaluation should be considered is impairment. As Dr. Jaksa from the article puts it, "Everyone gets distracted. Who's not late occasionally? But if you are chronically late, you lose your job and maybe your friends as well."


Experts say that those who suspect they have ADHD should have a thorough evaluation, with a psychologist or psychiatrist who specializes in the disorder, looking at how they functioned in early childhood, in school and social settings and personal relationships. Once ADHD is diagnosed, most experts recommend treatment with both medication and behavioral therapy.


Here are some adult ADHD key points:


• Adult ADHD can be comorbid with bipolar disorder, anxiety, and depression, further complicating diagnosis and treatment.


• For adults diagnosed with the condition, treatment can consist of behavioral therapy, medication, or both.


• People who think they may have ADHD should be evaluated by a psychiatrist who understands the disorder.


A recent study published in the August 25 issue of the Journal of the American Medical Association, cognitive behavioral therapy (CBT), "a form of psychotherapy that focuses on changing patterns of thought and behavior that are counterproductive, can help" adults with ADHD. For more information on that study and recent news about Adult ADHD – please visit the following links:


Los Angeles Times (8/24, Healy)


CNN (8/24, Landau)


HealthDay (8/24, Gardner)


Reuters (8/25, Pittman)


WebMD (8/24, Hendrick)


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Concluding the Mental Health Checkup: Personal Statement

By Gina Duncan, M.D.


Over the last several days, I provided a list of nine topics to reflect upon as you consider how you’re taking care of your mental health. Finally, to complete our mental health checkup, does the following statement apply to you:

“I am pleased with myself and where I am in my life. I acknowledge my past mistakes, but do not feel overburdened by them or unable to move forward. I am self-aware. I cannot always control my external circumstances, but I feel good about the way in which I am meeting the challenges I face, and I feel confident in my ability to succeed. I don’t expect myself to be perfect, but I do know that I am a person of worth who has something to offer this world. I have relationships that are meaningful, I contribute to others in ways that are fulfilling, and I feel in tune with myself and in sync with my surroundings.”

I want to encourage all of us to not just strive to “cope” with the stresses of everyday life, but to thrive.

What does mental health mean to you?

Mental Health Checkup: Mood, Concentration, Balance, Energy

By Gina Duncan, M.D.

I’m rounding out my list of topics to consider in a personal mental health checkup. Keep in mind, this list is not exhaustive. It’s meant to provide a starting point to help you examine how you’re doing emotionally and mentally.

Mood — Do your moods feel pretty stable, or are you experiencing significant mood swings (either highs or lows)? Are you crying more than usual? Feeling persistently depressed for two weeks or more and any thoughts of suicide could indicate clinical depression.

Concentration — Are you able to focus on the task at hand, whether at work or at home, and get it done in a timely manner? Or, do you find yourself overrun with missed deadlines and undone chores? Often the first sign that our concentration is waning is when our productivity goes down. Poor concentration is a hallmark of attention deficit hyperactivity disorder (ADHD) but it can also be a symptom of depression and anxiety and should not be overlooked.

Balance — Is there an appropriate balance between your home life and your work life? Between family time with your kids and “date nights” for you and your spouse? Are you getting in some “me-time”, including physical exercise and spiritual pursuits? Achieving perfect balance in your life is probably not possible, but that doesn’t mean it’s not worth striving for! Juggling too many responsibilities is a prime way to end up stressed out and unhealthy.

Energy — Do you feel that you have the energy to do the things you need and want to do? Fatigue can be a sign of depression, anxiety and other mental illnesses, but it can also be a symptom of many physical illnesses including cancer, diabetes and sleep apnea. If you find that you are feeling unusually fatigued or have other concerning symptoms, it is important that you contact your doctor right away.

In my next blog entry, the last in this series, I’ll provide a statement to help you consider whether you are thriving or just coping.

Mental Health Checkup: Avoidance, Eating Habits

By Gina Duncan, M.D.

I am continuing my list of topics to consider in a mental health checkup. Remember, if any of these issues raise red flags for you, your family doctor, family member or clergy may be a good place to get advice about next steps.

Avoidance — Do you feel like you’re avoiding yourself? It may seem like a funny question, but if you find yourself going out of your way to keep from being by yourself, then that could indicate that there is something you are trying to avoid emotionally. Many people find that their feelings of anxiety or worry are intensified when they are alone, and so they find ways to distract themselves by staying busy. We can often be unaware of this subconscious strategy to protect ourselves from painful feelings. If you think that this describes you, when you have a moment, go to a quiet place where you will be uninterrupted and sit quietly for a few minutes. How do you feel? Take a moment to write it down. If you find that even the thought of spending quiet time by yourself makes you tense, write that down as well. The goal is not to avoid your problems, but to find effective ways to deal with them.

Eating Habits — Has your appetite changed? Are you eating too much or too little? And what are you eating? If you find that you’re craving foods that are high in carbohydrates (sugar) and fat, or that you’re eating larger quantities than usual, it could be a sign of emotional eating as a response to stress. While temporarily satisfying, high sugar and fatty foods ultimately zap your energy and leave you feeling lower. Not to mention that the added pounds can become an additional source of stress.

Tomorrow I’ll round out my topics for a mental health checkup by discussing mood, concentration, balance and energy.

Mental Health Checkup: Tension, Anxiety and Tuning In

By Gina Duncan, M.D.

Continuing my Mental Health Checkup series, here are some additional factors to consider as you evaluate your mental health:

Tension and Anxiety — Are you feeling tense and wound up all the time? How about nervous and anxious? Is it hard for you to unwind at the end of the day? We live in a fast-paced society and stress has become a common part of our everyday lives. If, however, you are finding that you’re unable to take mental breaks during the day where you can feel totally relaxed and worry-free even for a few moments, then that could indicate that your stress is approaching dangerous levels. Relaxation is a skill that many of us have to learn and practice. There have been some great previous posts with relaxation tips as well as ways to cope with anxiety and stress.

Writing in ajournal is one way
to stay "in touch" with yourself.

Tuned In — In general, how “in touch” do you feel with yourself? Do you feel like you’re experiencing emotions and you don’t know why, like being angry or crying “for no reason”? It’s not uncommon to get so busy that you don’t have time to process everything that is happening on an emotional level in real time. However, taking some time to write in a journal or talk to a friend can be critically important to good mental and emotional health, particularly when you find yourself in periods of great transition or change. The danger of being out of touch with yourself emotionally is that you may respond to difficult situations in ways that you later regret (such as impulsively sending off an angry email to your boss, or taking out your frustration on your kids). It is also difficult to advocate for yourself and your needs when you don’t know what those needs are. Being able to take a moment and identify that “I feel angry because _____.” or “I am hurt because _____.” can take you a long way in staying in touch with yourself.

Tomorrow I will write about avoidance and eating habits.

Could My Child Be Depressed?

By Gariane Phillips Gunter, M.D

Most of us know someone who has suffered from depression at some point in their lives. However, did you know that depression is not just something that affects adults? Depression is a serious illness that can affect anyone, at any age, including children and adolescents. When a youth is depressed nearly every part of the young person's life is impacted as well as the lives of their family. If left untreated, pediatric depression can lead to problems in school and with friends, to accidents, to substance abuse, and, in its most extreme cases, to suicide. It can disrupt relationships among family members and friends, harm school performance and limit other educational opportunities. It can lead to other health problems through its effects on eating, sleeping, and physical activity. Because it has so many consequences, it is important that depression is recognized and treated successfully. When it is, most children can get back on track with their lives.

Children suffering from depression may not have the same symptoms as adults with the same diagnosis. While adults may appear down or tearful to those around them, children may appear more irritable or complain about physical symptoms such as stomach aches or headaches. Below are differences in symptoms that may be seen in adults versus children.

Youth living with depression need a thorough evaluation and comprehensive treatment from an appropriately trained professional. Each treatment must be tailored to the individual child or adolescent. Cognitive-behavioral therapy (CBT), a form of talk therapy, has been demonstrated to significantly contribute to recovery. In addition some antidepressant medications, when monitored, can be an effective part of the treatment for pediatric depression. If you think that someone you know may be suffering from depression, please encourage them to see their doctor.

The American Academy of Child and Adolescent Psychiatry and the American Psychiatric Association released a revised and expanded version of The Use of Medication in Treating Childhood and Adolescent Depression: Information for Patients and Families, part of the ParentsMedGuide series of publications to help parents understand depression and treatment options.

Nine Topics to Consider in a Mental Health Checkup

By Gina Duncan, M.D.

Yesterday, I wrote about the concept of a mental health checkup. Over the next few days I’ll provide a list of nine topics to consider when thinking about the state of your own mental health. While not exhaustive, the topics on this list are meant to provide a starting point to help you examine how you’re doing emotionally and mentally. If any of these items raise a red flag for you, be sure to talk with your doctor. If you are concerned that you may have anxiety, depression, or another mental illness, or if you need help finding a professional to talk to, see my previous post on finding a therapist for tips.

Sleep — How are you sleeping at night? Is it restful, or does it leave something to be desired? Poor sleep can often be the first sign that there is something troubling you emotionally. When under stress or dealing with a more serious mental illness, many people find that they cannot fall asleep as quickly as they used to because of excessive worry or a feeling of not being able to “turn off” their mind, and others find themselves waking up frequently throughout the night. For some, insomnia can be put to rest with simple sleep hygiene measures such as limiting caffeine in the evening and creating a bedtime ritual. For others, common over-the-counter (OTC) sleep aids such as Tylenol PM, Benadryl, and herbal medicines like melatonin can be helpful if used in limited quantities and for a limited amount of time. [Note: although they are advertised under many different brands, most OTC sleep medicines have diphenhydramine (generic Benadryl) as their active ingredient. Make sure to read the labels so you don’t take medicines you don’t need and to decrease your risk of unsafe combinations.] It’s always a good idea to first check with your doctor before beginning any OTC sleep regimen to make sure there are no harmful interactions with other medicines you’re taking.

Tomorrow, I’ll continue the checkup with information about evaluating tension and anxiety and being tuned in to your emotions.

Time for a Checkup: Lack of Illness vs. Health

By Gina Duncan, M.D.

I recently spoke with a reporter from a Boston community newspaper who is planning an article spotlighting the concept of a “mental health checkup.” I think that this is a great idea, and something that is very much needed. Given that September is a time for new beginnings with many people going back to school and work, what better time than now to do a mental health checkup.
 

Many people go through their entire lives never encountering a mental health professional. That doesn’t mean, however, that they are mentally healthy, for the absence of illness does not necessarily equal health. Unfortunately, in our society we place a lot of emphasis on treating illness and much less on what it takes to stay healthy.

What is mental health? You can probably find many different definitions, but I would like to suggest one characteristic which I think is critical to the foundation of good mental health: knowing yourself, ie. being self-aware. I often tell my patients with depression and anxiety that they are in a position to be some of the most mentally healthy people around, because their illness has forced them to grapple with unhealthy patterns and learn new skills to cope with the stresses of everyday life. And in the process, they have come to know themselves much better. One of my professional goals is to bring the same skills that we as psychiatrists use in the office to people who would never come through our doors because they are not identified as being "mentally ill." They may be functioning and getting by, however, they are missing out on living life at the level of their "best self."

Over the next several days, I will post about important topics to consider as you do your own mental health checkup.

Reading, Writing and Anxiety? Helping Children Make the Transition Back To School

By Adair Parr, M.D., J.D.

The arrival of September signals back to school for most children. It is an exciting time of year, as it means meeting new teachers and classmates, starting fall sports and getting back into the swing of the classroom. Most children have some degree of anxiety about starting school, especially when they are just starting school, entering middle or high school or are changing schools.

Despite such worries, many children adjust to a new school year fairly easily. Other children have some initial anxiety, which they overcome in the first days or weeks of school. These feelings are particularly common among elementary school children but may be experienced by middle school or high school students as well.

School-aged children and even teenagers may express feelings of anxiety through frequent headaches or stomachaches, rather than overt worries about school. For tips on how to help transition your child to the new school year, see “The ABCs of Starting School” on Healthy Minds.

When should you seek help if you suspect that school is making your child anxious?


For some children, feelings of anxiety associated with back to school interfere with functioning either at home or at school or socially. If your child continues to have difficulty with school more than a month after school has started, it is important to seek help.


*Talk to your child’s teacher or counselor to see what they have noticed.

*If your child has significant physical symptoms, like recurrent headaches or stomachaches, schedule a visit to the pediatrician.

*Talk to your child and ask whether anything is happening at school that frightens them or worries them.

*Ask your child about bullying, which may be contributing to your child’s anxiety.

After exploring these concerns, some children will need further help and may require a visit to a mental health professional for an evaluation. A school counselor or pediatrician can help with a referral if this is the case. A child’s main job is to learn; untreated anxiety can interfere with social and academic development.

Anxiety is commonly treated with cognitive behavior therapy but some children require medication. By being attentive to the many changes associated with starting school, you can help your child with this important transition.

Does the sandman still come to your house?

By R. Scott Benson, M.D.

Keeping children up at night?

Some worrisome stories were on the evening news last week; but the part of the news broadcast that caught my attention were six ads for medication to promote a peaceful night of sleep.

These ads are having their desired effect as I have more and more families expressing concern about their children’s sleep. They read the stories about shifting school start times to improve teens’ school performance, but the first question they ask me is usually about the latest new medications.

Research is clear: there are many things that should be done before we reflexively open the medicine cabinet.

1. Consider the impact of 24-hour access to electronic communication tools. Does your child keep a cell phone in their room overnight? To talk to whom? 
2. Remove televisions and computers from children’s bedrooms. There is strong evidence that easy access to these devices interferes with sleep.
3. Watch out for shifts in sleep schedules on the weekend. Most of us thought we could stay up late on weekend nights, make up for the sleep by staying in bed until noon on Saturday, and sleep in again on Sunday. But it only takes these two days to reset your biologic clock. No wonder that Monday finds a body at school but the mind is home in bed.
4. Plan evening routines so your child finishes activities (including homework) more than an hour before planned bedtime. It takes a while to settle after an hour of frustrating work on spelling words.

The first step in evaluating any concern about sleep is keeping a careful sleep diary. There are samples available at SleepEducation.com, the website of the American Academy of Sleep Medicine. The University of Michigan has a wealth of material on their website devoted to children’s sleep problems.

Sleep tight.

TXT me when U get there: Helicopter parenting as kids go off to college

By Tristan Gorrindo, M.D.

Thousands of teenagers have headed to college and for many it is the first time that they lived away from home. And while this process of separation is often anxiety provoking for the college freshman, their parents may be equally anxious.

With modern technology, it has never been easier to stay in touch. Text messaging, cell phones, social networking websites, video chatting and email, have all made constant contact simple and expected. But at times it can go too far. In my clinical practice I have heard stories of parents who call each morning to wake their child up for class; parents who panic if they don’t get at least two text messages a day from their child; or, even parents who require that their child parade new college friends in front of a Skype camera before granting permission for their teen to befriend them.

But what is the developmental cost of this collegiate level helicopter parenting? Certainly parents want (and should) be involved in the lives of their child as they branch out into adulthood, but when parents’ constant checking in distracts or disrupts the process of development, college-aged kids have a problem.

The goal of moving away to college is just as much about forming one’s identity as it is about late-night cramming and classes. Further, it is a time for the young adult to develop self-reliance and responsibility for one’s actions. It’s also a time for teens to form new friendships. Well-meaning, but over-eager parenting has the ability to disrupt all of these normal developmental steps. Young adults need the chance to find others to depend on, to learn to pick up after their own disappointments, and to experiment with new behaviors without having to report back.

The exact amount of contact that parents and their college kids should have is a personal negotiation between each child and each parent. The best time for such negotiation is before a child departs for college, preferably before both parent and child are deep in separation anxiety. Parents need ground rules about how often they should expect texts from their child and guidance about how long they should wait before panicking if a phone call isn’t returned or a Skype call goes unanswered.

Kids can be asked how they would like to be contacted, and with what frequency. Establishing a regular routine around check-ins -- like calling Dad each Sunday morning on the phone for a debriefing of the past week and planning for the week to come -- can go a long way in managing parental anxiety. Perhaps, after a few weeks at school, parent and child can check-in on how these check-ins are going. With some experience at being apart, students may want to adjust the type and quantity of contact that they have with their parents.

Never before have college students and their parents had such a rich array of ways to stay engaged with one another. While kids continue to benefit from their parents guidance and interest, they also need to know that their parents believe in their new skills to pilot their own planes.

Getting Help Gets a Good Customer Review

By Molly McVoy, M.D.

A recent survey published in Consumer Reports, found that respondents reported the highest satisfaction for the combination of medication and talk therapy, when compared to talk therapy or medication alone.

The survey reported on over 1500 people treated for anxiety, depression or both. They also found that readers reported a higher satisfaction with treatment by a psychiatrist than by other mental health professionals (psychologists, social workers, and licensed professional counselors).
 
This is good news for psychiatrists and the mental health community in general. This is one indicator that the public feels treatment works and that psychiatrists help.


In addition, this consumer report supports the scientific evidence we already have – depression and anxiety treatment does work! In study after study, approximately 2/3 of patients respond to treatment for depression with an even higher percentage responding to treatment for anxiety disorders.

The bottom line is, treatment works and, it appears, most of the public knows it!