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May 31

What to Do When Co-Parenting Doesn’t Work


Virginia Gilbert, MFT In a good-enough divorce, exes work through feelings of anger, betrayal and loss and arrive at a place of acceptance. Frustrations over the other parent’s values and choices are contained and pushed aside, making space for the Holy Grail of post-divorce life: effective co-parenting.

Co-parenting is possible only when both exes support their children’s need to have a relationship with the other parent and respect that parent’s right to have a healthy relationship with the children.

But some people never get to acceptance. They become, essentially, addicted to anger. They convince themselves that the other parent is incompetent, mentally ill, or dangerous. They transmit this conviction directly or indirectly not only to the children, but also to school staff, mental health professionals and anyone who will listen.

High-conflict exes are on a mission to invalidate the other parent. No therapist, mediator, parenting class, or Gandhi-esque channeling will make an anger-addicted ex take off the gloves and agree to co-parent.

If this scenario feels familiar, and you are wondering how you’re going to survive raising kids with your high-conflict ex without losing every last one of your marbles, I offer you this counterintuitive suggestion: Stop trying to co-parent!

Try Parallel Parenting instead.

What is Parallel Parenting?

Parallel Parenting is radical acceptance. It means letting go of fighting reality. Divorce is terrible enough, but to have a divorce that is so hellish as to make co-parenting impossible is another kind of terrible altogether.

It’s helpful to conceptualize Parallel Parenting as an approach many Alcoholics Anonymous folks use when dealing with the addict in their lives: they stop going to the hardware store looking for milk. Why are you trying to have a reasonable conversation with someone who isn’t reasonable, at least with you? Stop expecting reciprocity or enlightenment. Stop needing the other person to see you as right. You are not ever going to get these things from your anger-addicted ex, and you can make yourself sick trying.

How to Practice Parallel Parenting

You tried to co-parent so your kids would see their parents get along, and to make them feel safe. That didn’t work. Now you need to limit contact with your ex to reduce the conflict in order to make your kids feel safe — and to keep yourself from going nuts. So how do you do this?

1. Communicate as little as possible
Stop talking on the phone. When speaking with a hostile ex, you will likely be drawn into an argument and nothing will get resolved. Limit communication to texting and e-mail. This way you can choose what to respond to and you will be able to delete knee-jerk retorts that you would make if you were on the phone.

2. Make Rules for Communication
Hostile exes tend to ignore boundaries. So you will have to be very clear about the terms for communication. E-mail or texting should be used only for logistics: travel plans, a proposed weekend swap, doctor appointments. If your ex tends uses e-mails to harass you, tell him you will not respond, and if the abuse continues, you will stop e-mailing altogether.

3. Do Not Respond to Threats of Lawsuits
Hostile exes frequently threaten to modify child support or custody arrangements. Do not respond! Tell your ex that any discussion of litigation must go through your attorney. This will require money on your ex’s part: phone calls between attorneys, disclosing financial statements, etc. It is quite possible that your ex does not really intend to put her money where her mouth is, so don’t take the bait.

4. Avoid being together at child-related functions
It’s great for your kids to see the two of you together — but only if they see you getting along. So attend events separately as much as possible. Schedule separate parent-teacher conferences. Trade off hosting birthday parties. Do curbside drop-offs so your child doesn’t have to feel the tension between you and your ex.

5. Be proactive with school staff and mental health professionals
School staff and therapists may have heard things about you that aren’t true — for instance, that you are out of the picture or mentally ill. So be proactive. Fax your custody order to these individuals so they understand the custody arrangement. Even if you are a non-custodial parent, you are still entitled to information regarding your child’s academic performance or mental health treatment and the school and therapists want you to be involved. Talk to school staff and therapists as soon as possible. Do not be defensive, but explain the situation. When they see you, they will realize that you are a reasonable person who is trying to do the right thing for your child.

6. Don’t Sweat the Small Stuff
Parallel Parenting requires letting go of what happens in the other parent’s home. Although it may drive you crazy that your ex lets 6-year-old Lucy stay up until midnight, there is really not much you can do about it. Nor can you control your ex’s selection of babysitters, children’s clothing or how much TV time is allowed.

Your child will learn to adapt to different rules and expectations at each house. If Sienna complains about something that goes on at Dad’s, instruct her to speak to him directly. Trying to solve a problem between your ex and your child will only inflame the conflict and teach her to pit the two of you against each other. You want to empower your child, not teach her that she needs to be rescued.

Parallel Parenting is a last resort, to be implemented when attempts at co-parenting have failed. But that doesn’t mean you have failed as a divorced parent. In fact, the opposite is true. By reducing conflict, Parallel Parenting will enhance the quality of your life and most importantly, take your child out of the middle.

And isn’t that what a good-enough divorce is all about?

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May 29

By Christy Matta, MA No one is immune to stress at work. It comes when demands are high, with job uncertainty, when you’re expected to perform tasks you’re not trained in or skilled at and when you are working with difficult people.

But, stress at work does not come from our work environments alone. Work stress, like stress in other aspects of life, comes from external pressures and strain, as well as from our own disposition and internal experience of stress.

Individual differences affect how you think about situations in your life and how you deal with different situations. For example, one person may think of a potential lay-off as a disaster that means their life is spinning out-of-control, while another may see the same potential lay-off as an opportunity to explore new options. People cope differently when under stress, which can have a significant impact on their stress levels. Some cope by seeking support from loved ones, exercising or taking extra time for relaxation. Others find themselves doing things that ultimately increase their stress, such as becoming self-critical, over-eating or avoiding responsibilities.

Job demands can certainly cause significant stress. But your own reaction to those demands can have a significant impact on the level of stress you experience. The following are factors that influence your stress levels.

Pessimism: Do you tend to expect bad things to happen to you? If you do, you are less likely to adapt to negative situations at work in constructive ways, which worsens your work situation and increases your stress levels. If you tend to be pessimistic, when time pressures at work increase, your sense of distress is also likely to increase sharply.

Feeling under significant amounts of strain and believing that things will not work out make it more likely that you will cope in ways that don’t have positive results, thereby increasing stress even more.

Feeling out-of-control: If you tend to feel like your life is controlled by forces that you can’t influence, say people in power, fate or chance, you may feel more strain at work. Take the example of lay-offs again. A person who believes they have control over their life may respond to potential lay-offs by searching for new job opportunities, while some one who feels out-of-control of their own life is more likely to feel stuck or unable to change bad circumstances.

Feeling incompetent: When you believe you are incompetent you give up more easily when you hit a road block. Difficulties reinforce that feeling that you aren’t capable, so there is no need to keep trying. People who feel competent are more likely to keep trying in the face of obstacles and, as a result, are more likely to have positive results, which decreases stress.

Work load, job complexity and uncertainty all have an impact on work stress. But how you react to those external demands has a significant impact on your stress levels and whether you solve the problems contributing to your stress. Knowing how you tend to react to stress is the first step towards making positive changes and reducing your stress levels.

You can find more strategies to improve how you feel in my new book, The Stress Response and by clicking here to sign up for more of my tips and podcasts using DBT strategies to improve how you feel.

May 29

10 Reasons Not to Hit Your Child


There is a classic story about the mother who believed in spanking as a necessary part of discipline until one day she observed her three- year-old daughter hitting her one-year-old son. When confronted, her daughter said, “I’m just playing mommy.” This mother never spanked another child.Children love to imitate, especially people whom they love and respect. They perceive that it’s okay for them to do whatever you do. Parents, remember, you are bringing up someone else’s mother or father, and wife or husband. The same discipline techniques you employ with your children are the ones they are most likely to carry on in their own parenting. The family is a training camp for teaching children how to handle conflicts. Studies show that children from spanking families are more likely to use aggression to handle conflicts when they become adults.

Spanking demonstrates that it’s all right for people to hit people, and especially for big people to hit little people, and stronger people to hit weaker people. Children learn that when you have a problem you solve it with a good swat. A child whose behavior is controlled by spanking is likely to carry on this mode of interaction into other relationships with siblings and peers, and eventually a spouse and offspring.

But, you say, “I don’t spank my child that often or that hard. Most of the time I show him lots of love and gentleness. An occasional swat on the bottom won’t bother him.” This rationalization holds true for some children, but other children remember spanking messages more than nurturing ones. You may have a hug-hit ratio of 100:1 in your home, but you run the risk of your child remembering and being influenced more by the one hit than the 100 hugs, especially if that hit was delivered in anger or unjustly, which happens all too often.

Physical punishment shows that it’s all right to vent your anger or right a wrong by hitting other people. This is why the parent’s attitude during the spanking leaves as great an impression as the swat itself. How to control one’s angry impulses (swat control) is one of the things you are trying to teach your children. Spanking sabotages this teaching. Spanking guidelines usually give the warning to never spank in anger. If this guideline were to be faithfully observed 99 percent of spanking wouldn’t occur, because once the parent has calmed down he or she can come up with a more appropriate method of correction.

Physical hitting is not the only way to cross the line into abuse. Everything we say about physical punishment pertains to emotional/verbal punishment as well. Tongue-lashing and name-calling tirades can actually harm a child more psychologically. Emotional abuse can be very subtle and even self-righteous. Threats to coerce a child to cooperate can touch on his worst fear—abandonment. (“I’m leaving if you don’t behave.”) Often threats of abandonment are implied giving the child the message that you can’t stand being with her or a smack of emotional abandonment (by letting her know you are withdrawing your love, refusing to speak to her or saying you don’t like her if she continues to displease you). Scars on the mind may last longer than scars on the body.

The child’s self-image begins with how he perceives that others – especially his parents – perceive him Even in the most loving homes, spanking gives a confusing message, especially to a child too young to understand the reason for the whack. Parents spend a lot of time building up their baby or child’s sense of being valued, helping the child feel “good.” Then the child breaks a glass, you spank, and he feels, “I must be bad.”

Even a guilt-relieving hug from a parent after a spank doesn’t remove the sting. The child is likely to feel the hit, inside and out, long after the hug. Most children put in this situation will hug to ask for mercy. “If I hug him, daddy will stop hitting me.” When spanking is repeated over and over, one message is driven home to the child, “You are weak and defenseless.”

Joan, a loving mother, sincerely believed that spanking was a parental right and obligation needed to turn out an obedient child. She felt spanking was “for the child’s own good.” After several months of spank-controlled discipline, her toddler became withdrawn. She would notice him playing alone in the corner, not interested in playmates, and avoiding eye contact with her. He had lost his previous sparkle. Outwardly he was a “good boy.” Inwardly, Spencer thought he was a bad boy. He didn’t feel right and he didn’t act right. Spanking made him feel smaller and weaker, overpowered by people bigger than him.

How tempting it is to slap those daring little hands! Many parents do it without thinking, but consider the consequences. Maria Montessori, one of the earliest opponents of slapping children’s hands, believed that children’s hands are tools for exploring, an extension of the child’s natural curiosity. Slapping them sends a powerful negative message. Sensitive parents we have interviewed all agree that the hands should be off-limits for physical punishment. Research supports this idea. Psychologists studied a group of sixteen fourteen-month-olds playing with their mothers. When one group of toddlers tried to grab a forbidden object, they received a slap on the hand; the other group of toddlers did not receive physical punishment. In follow-up studies of these children seven months later, the punished babies were found to be less skilled at exploring their environment. Better to separate the child from the object or supervise his exploration and leave little hands unhurt.

Parents who spank-control or otherwise abusively punish their children often feel devalued themselves because deep down they don’t feel right about their way of discipline. Often they spank (or yell) in desperation because they don’t know what else to do, but afterward feel more powerless when they find it doesn’t work. As one mother who dropped spanking from her correction list put it, “I won the battle, but lost the war. My child now fears me, and I feel I’ve lost something precious.”

Spanking also devalues the role of a parent. Being an authority figure means you are trusted and respected, but not feared. Lasting authority cannot be based on fear. Parents or other caregivers who repeatedly use spanking to control children enter into a lose-lose situation. Not only does the child lose respect for the parent, but the parents also lose out because they develop a spanking mindset and have fewer alternatives to spanking. The parent has fewer preplanned, experience-tested strategies to divert potential behavior, so the child misbehaves more, which calls for more spanking. This child is not being taught to develop inner control.

Hitting devalues the parent-child relationship. Corporal punishment puts a distance between the spanker and the spankee. This distance is especially troubling in home situations where the parent-child relationship may already be strained, such as single-parent homes or blended families. While some children are forgivingly resilient and bounce back without a negative impression on mind or body, for others it’s hard to love the hand that hits them.

Punishment escalates. Once you begin punishing a child “a little bit,” where do you stop? A toddler reaches for a forbidden glass. You tap the hand as a reminder not to touch. He reaches again, you swat the hand. After withdrawing his hand briefly, he once again grabs grandmother’s valuable vase. You hit the hand harder. You’ve begun a game no one can win. The issue then becomes who’s stronger—your child’s will or your hand—not the problem of touching the vase. What do you do now? Hit harder and harder until the child’s hand is so sore he can’t possibly continue to “disobey?” The danger of beginning corporal punishment in the first place is that you may feel you have to bring out bigger guns: your hand becomes a fist, the switch becomes a belt, the folded newspaper becomes a wooden spoon, and now what began as seemingly innocent escalates into child abuse. Punishment sets the stage for child abuse. Parents who are programmed to punish set themselves up for punishing harder, mainly because they have not learned alternatives and click immediately into the punishment mode when their child misbehaves.
Many times we have heard parents say, “The more we spank the more he misbehaves.” Spanking makes a child’s behavior worse, not better. Here’s why. Remember the basis for promoting desirable behavior: The child who feels right acts right. Spanking undermines this principle. A child who is hit feels wrong inside and this shows up in his behavior. The more he misbehaves, the more he gets spanked and the worse he feels. The cycle continues. We want the child to know that he did wrong, and to feel remorse, but to still believe that he is a person who has value.

The Cycle of Misbehavior

Misbehavior Worse behavior Spanking Decreased self-esteem, anger

One of the goals of disciplinary action is to stop the misbehavior immediately, and spanking may do that. It is more important to create the conviction within the child that he doesn’t want to repeat the misbehavior (i.e, internal rather than external control). One of the reasons for the ineffectiveness of spanking in creating internal controls is that during and immediately after the spanking, the child is so preoccupied with the perceived injustice of the physical punishment (or maybe the degree of it he’s getting) that he “forgets” the reason for which he was spanked. Sitting down with him and talking after the spanking to be sure he’s aware of what he did can be done just as well (if not better) without the spanking part. Alternatives to spanking can be much more thought-and-conscience-provoking for a child, but they may take more time and energy from the parent. This brings up a main reason why some parents lean toward spanking—it’s easier.

Don’t use the Bible as an excuse to spank. There is confusion in the ranks of people of Judeo-Christian heritage who, seeking help from the Bible in their effort to raise godly children, believe that God commands them to spank. They take “spare the rod and spoil the child” seriously and fear that if they don’t spank, they will commit the sin of losing control of their child. In our counseling experience, we find that these people are devoted parents who love God and love their children, but they misunderstand the concept of the rod.

Rod verses – what they really mean. The following are the biblical verseswhich have caused the greatest confusion:

“Folly is bound up in the heart of a child, but the rod of discipline will drive it far from him.” (Prov. 22:15)

“He who spares the rod hates his son, but he who loves him is careful to discipline him.” (Prov. 13:24)

“Do not withhold discipline from a child; if you punish him with the rod, he will not die. Punish him with the rod and save his soul from death.” (Prov. 23:13-14)

“The rod of correction imparts wisdom, but a child left to itself disgraces his mother.” (Prov. 29:15)

At first glance these verses may sound pro-spanking. But you might consider a different interpretation of these teachings. “Rod” (shebet) means different things in different parts of the Bible. The Hebrew dictionary gives this word various meanings: a stick (for punishment, writing, fighting, ruling, walking, etc.). While the rod could be used for hitting, it was more frequently used for guiding wandering sheep. Shepherds didn’t use the rod to beat their sheep – and children are certainly more valuable than sheep. As shepherd-author Philip Keller teaches so well in A Shepherd Looks At Psalm 23, the shepherd’s rod was used to fight off prey and the staff was used to gently guide sheep along the right path. (“Your rod and your staff, they comfort me.” – Psalm 23:4).

Jewish families we’ve interviewed, who carefully follow dietary and lifestyle guidelines in the Scripture, do not practice “rod correction” with their children because they do not follow that interpretation of the text.

The book of Proverbs is one of poetry. It is logical that the writer would have used a well-known tool to form an image of authority. We believe that this is the point that God makes about the rod in the Bible – parents take charge of your children. When you re-read the “rod verses,” use the concept of parental authority when you come to the word “rod,” ratherthan the concept of beating or spanking. It rings true in every instance.

While Christians and Jews believe that the Old Testament is the inspired word of God, it is also a historical text that has been interpreted in many ways over the centuries, sometimes incorrectly in order to support the beliefs of the times. These “rod” verses have been burdened with interpretations about corporal punishment that support human ideas. Other parts of the Bible, especially the New Testament, suggest that respect, authority, and tenderness should be the prevailing attitudes toward children among people of faith.

In the New Testament, Christ modified the traditional eye-for-an-eye system of justice with His turn-the-other-cheek approach. Christ preached gentleness, love, and understanding, and seemed against any harsh use of the rod, as stated by Paul in 1 Cor. 4:21: “Shall I come to you with the whip (rod), or in love and with a gentle spirit?” Paul went on to teach fathers about the importance of not provoking anger in their children (which is what spanking usually does): “Fathers, do not exasperate your children” (Eph. 6:4), and “Fathers, do not embitter your children, or they will be discouraged” (Col. 3:21).

In our opinion, nowhere in the Bible does it say you must spank your child to be a godly parent.

SPARE THE ROD!There are parents who should not spank and children who should not be spanked. Are there factors in your history, your temperament, or your relationship with your child that put you at risk for abusing your child? Are there characteristics in your child that make spanking unwise?
•Were you abused as a child?
•Do you lose control of yourself easily?
•Are you spanking more, with fewer results?
•Are you spanking harder?
•Is spanking not working?
•Do you have a high-need child? A strong-willed child?
•Is your child ultrasensitive?
•Is your relationship with your child already distant?
•Are there present situations that are making you angry, such as financial or marital difficulties or a recent job loss? Are there factors that are lowering your own self-confidence?

If the answer to any of these queries is yes, you would be wise to develop a no-spanking mindset in your home and do your best to come up with noncorporal alternatives. If you find you are unable to do this on your own, talk with someone who can help you.

Children often perceive punishment as unfair. They are more likely to rebel against corporal punishment than against other disciplinary techniques. Children do not think rationally like adults, but they do have an innate sense of fairness—though their standards are not the same as adults. This can prevent punishment from working as you hoped it would and can contribute to an angry child. Oftentimes, the sense of unfairness escalates to a feeling of humiliation. When punishment humiliates children they either rebel or withdraw. While spanking may appear to make the child afraid to repeat the misbehavior, it is more likely to make the child fear the spanker.

In our experience, and that of many who have thoroughly researched corporal punishment, children whose behaviors are spank-controlled throughout infancy and childhood may appear outwardly compliant, but inside they are seething with anger. They feel that their personhood has been violated, and they detach themselves from a world they perceive has been unfair to them. They find it difficult to trust, becoming insensitive to a world that has been insensitive to them.

Parents who examine their feelings after spanking often realize that all they have accomplished is to relieve themselves of anger. This impulsive release of anger often becomes addicting—perpetuating a cycle of ineffective discipline. We have found that the best way to prevent ourselves from acting on the impulse to spank is to instill in ourselves two convictions: 1. That we will not spank our children. 2. That we will discipline them. Since we have decided that spanking is not an option, we must seek out better alternatives.

A child’s memories of being spanked can scar otherwise joyful scenes of growing up. People are more likely to recall traumatic events than pleasant ones. I grew up in a very nurturing home, but I was occasionally and “deservedly” spanked. I vividly remember the willow branch scenes. After my wrongdoing my grandfather would send me to my room and tell me I was going to receive a spanking. I remember looking out the window, seeing him walk across the lawn and take a willow branch from the tree and come back to my room and spank me across the back of my thighs with the branch. The willow branch seemed to be an effective spanking tool because it stung and made an impression upon me— physically and mentally. Although I remember growing up in a loving home, I don’t remember specific happy scenes with nearly as much detail as I remember the spanking scenes. I have always thought that one of our goals as parents is to fill our children’s memory bank with hundreds, perhaps thousands, of pleasant scenes. It’s amazing how the unpleasant memories of spankings can block out those positive memories.

Research has shown that spanking may leave scars deeper and more lasting than a fleeting redness of the bottom. Here is a summary of the research on the long-term effects of corporal punishment:
•In a prospective study spanning nineteen years, researchers found that children who were raised in homes with a lot of corporal punishment, turned out to be more antisocial and egocentric, and that physical violence became the accepted norm for these children when they became teenagers and adults.
•College students showed more psychological disturbances if they grew up in a home with less praise, more scolding, more corporal punishment, and more verbal abuse.
•A survey of 679 college students showed that those who recall being spanked as children accepted spanking as a way of discipline and intended to spank their own children. Students who were not spanked as children were significantly less accepting of the practice than those who were spanked. The spanked students also reported remembering that their parents were angry during the spanking; they remembered both the spanking and the attitude with which it was administered.
•Spanking seems to have the most negative long-term effects when it replaces positive communication with the child. Spanking had less damaging long-term effects if given in a loving home and nurturing environment.
•A study of the effects of physical punishment on children’s later aggressive behavior showed that the more frequently a child was given physical punishment, the more likely it was that he would behave aggressively toward other family members and peers. Spanking caused less aggression if it was done in an overall nurturing environment and the child was always given a rational explanation of why the spanking occurred.
•A study to determine whether hand slapping had any long-term effects showed that toddlers who were punished with a light slap on the hand showed delayed exploratory development seven months later.
•Adults who received a lot of physical punishment as teenagers had a rate of spouse-beating that was four times greater than those whose parents did not hit them.
•Husbands who grew up in severely violent homes are six times more likely to beat their wives than men raised in non-violent homes.
•More than 1 out of 4 parents who had grown up in a violent home were violent enough to risk seriously injuring their child.
•Studies of prison populations show that most violent criminals grew up in a violent home environment.
•The life history of notorious, violent criminals, murderers, muggers, rapists, etc., are likely to show a history of excessive physical discipline in childhood.

The evidence against spanking is overwhelming. Hundreds of studies all come to the same conclusions:

1. The more physical punishment a child receives, the more aggressive he or she will become.
2. The more children are spanked, the more likely they will be abusive toward their own children.
3. Spanking plants seeds for later violent behavior.4.Spanking doesn’t work.

Many studies show the futility of spanking as a disciplinary technique, but none show its usefulness. In the past thirty years in pediatric practice, we have observed thousands of families who have tried spanking and found it doesn’t work. Our general impression is that parents spank less as their experience increases. Spanking doesn’t work for the child, for the parents, or for society. Spanking does not promote good behavior, it creates a distance between parent and child, and it contributes to a violent society. Parents who rely on punishment as their primary mode of discipline don’t grow in their knowledge of their child. It keeps them from creating better alternatives, which would help them to know their child and build a better relationship. In the process of raising our own eight children, we have also concluded that spanking doesn’t work. We found ourselves spanking less and less as our experience and the number of children increased. In our home, we have programmed ourselves against spanking and are committed to creating an attitude within our children, and an atmosphere within our home, that renders spanking unnecessary. Since spanking is not an option, we have been forced to come up with better alternatives. This has not only made us better parents, but in the long run we believe it has created more sensitive and well-behaved children.

By Rick Nauert PhDSenior News Editor
A provocative new study suggests women who take antidepressants during pregnancy are at higher risk of giving birth prematurely, but that depression itself does not increase that risk. The latter finding contradicts some earlier research.

The results, reported by Yale researchers in the online journal Epidemiology, are good news for women who worry that their depression will harm their baby.

Researchers also stress that women who take antidepressants during pregnancy should not be overly alarmed.

“Women did not ask to be depressed and yet they worry that their depression may affect their baby,” said Dr. Kimberly Yonkers, professor of psychiatry and of obstetrics, gynecology, and reproductive sciences.

“This study tells them they should not worry that they are somehow compromising their pregnancy because they are depressed. And when considering whether to take medication for depression, women should understand that the risk of preterm birth is only one of many factors they should weigh.”

The study found that taking serotonin reuptake inhibitors (SRIs) during pregnancy significantly increased risk of what is called a late preterm birth.

Late preterm birth is defined as at least 34 weeks after gestation but before 37 weeks. Antidepressant use is not associated with early preterm birth, which is much more dangerous to the baby.

Findings from the Yale study contrast with several previous studies that suggested depression itself might lead to premature birth.

In the new research, the Yale team studied almost 3,000 pregnant women, including those who were diagnosed as depressed during their pregnancy. After controlling for numerous variables such as health history, age, drug use, and socioeconomic status, they found no association between depression and premature birth.

They did find a significant risk of preterm birth among women who were taking antidepressants. So should depressed women not take antidepressants?

“A woman should always consult with her doctor, but if she is symptomatic and suffering, the use of antidepressants may be indicated,” Yonkers said.

May 29

America’s Vacation Deficit Disorder


By William D. Chalmers The warning signs are all there. They are on exhibit for all to see in our national levels of: anxiety and depression, obesity and heart attacks, absenteeism and job burnout, sleep deprivation and the use of chemicals to help keep us awake.

The $64,000 question is: What would you do if you saw someone you cared for continually behaving in an unhealthy and destructive manner? Would you try to help them? Perhaps caringly intervene on their behalf? Try to maybe prod them into making some better lifestyle choices? Now, what would you do if you knew a whole group of people were increasingly behaving in an unhealthy and destructive manner; one that not only affected their own personal health and happiness, their relationships and family life, but the whole community’s productivity and well-being? Would you try to help them? It is my strong belief, as well as the collective sentiment of many medical professionals, family counselors, clinical psychiatrists and cultural scholars alike, that America is in need of an immediate intervention.

We need an intervention to help us break the destructive treadmill-like cycle we are in of denial and continued harmful behavior. We as a nation need help in confronting a serious problem on our parts. A problem, that many who care about our nation like me, have described as a national crisis that I have labeled America’s Vacation Deficit Disorder. America’s Vacation Deficit Disorder derives out of a type of collective manic obsessive-compulsive disorder. One that has most Americans working longer and longer hours without the healthy physical and psychological benefits connected with taking time off (as in taking vacations) from their hyper-paced 21st century 24/7 electronic work leash. Despite study after study unanimously showing that taking time off would allow us to better fully recharge our batteries, rejuvenate our mind and body, revitalize our workplace enthusiasm and increase our productivity too!

We simply are not taking enough time away from work. Our work-to-leisure lifestyle balance is seriously out of whack — and growing more distorted annually. If historic experience and farmer wisdom mean anything, we know that fields need to be allowed to go fallow every few seasons in order to remain healthy and productive. Not only are those rested fields easier to sow, but the crops return even more productive. Productive fields can be overworked as any experienced farmer knows. In Japan, they labeled this phenomenon karōshi, death from overwork. In America, we can witness the growing incidences of job dissatisfaction, occupational stress, absenteeism, defensive overworking, depression, workers compensation claims, job burnout and the breakdown of the family that fully, and unfortunately, articulate the symptoms of America’s Vacation Deficit Disorder.

The warning signs are all there. The end of May used to mark the unofficial start of vacation season in America that would begin and end on long weekends: Memorial and Labor Day weekends. Three glorious months worth of long weekends, road trips and family bliss. A time to relax, recharge and reconnect with the family and loved ones. Nowadays, Memorial Day weekend signals the beginning of the national lament appearing on websites, newscasts and in newspaper editorials everywhere: What has happened to that great American tradition of vacations?

Like many things in the United States, they regrettably are in decline. Most Americans take great pride in their work — and they should. Most Americans derive great happiness from their jobs — and that is a good thing too. Clearly, we remain an innovative, creative and productive workforce. We are a nation of universally recognized hard workers, with a long history of great accomplishments and achievements. Yet, the facts today display a rather ominous and disturbing picture of the average worker’s life in America:
•We are working longer hours than ever before;
•We are working more than ever before;
•We are taking our work home with us more than ever before;
•We have less time off than ever before;
•We are spending less time with our families than ever before;
•Workplace insecurity is higher than ever before;
•Job-turnover is higher than ever before;
•We are sleeping less than ever before;
•Caffeine and energy drink consumption are on the rise … along with cocaine and methamphetamines;
•Anti-depressant prescriptions are on the rise;
•Sleeping pill prescriptions continue to grow more than ever;
•Workplace-related disabilities are higher than ever before;
•Our nation’s collective health is in decline with our life expectancy officially stagnant;
•Our allocated paid vacation time off is declining more than ever before;
•Our actual vacation time taken is diminishing more than ever before;
•Our nation’s collective mental well-being is obviously suffering.

People smarter than I have started asking aloud if there are any connections between these seemingly unrelated facts? After researching them all for my new book my answer is an unrestrained, sincere and wholehearted: Yes there are! The United States has accurately been labeled the No-Vacation Nation. And the subsequent personal, economic and health costs, along with the associated spillover, or collateral damage, to America’s well-being are all adding up fast. It costs our economy billions in unproductive time, energy and medical bills. We are obviously in the midst of a national crisis and in grave need of an urgent intervention.

We need a wake up call. A sort of intervention that will help our nation move forward by sounding a very real warning alarm about our national crisis. To be sure, we seem to have a national blind spot about the whole dreadfully real issue in and of itself. And, as a result, we don’t even know how truly bad off we really are. As a nation we are marching straight into an abyss, with too many of us to count, already members of the walking wounded.

May 15

Are You and Your Spouse Financially Compatible?


And… they lived happily ever after. This is true in fairy tales, but in real life, many marriages end on a different note. The fact of the matter is many times, couples find financial disparity in their relationship, do not deal with it directly, and begin to see problems arise. Regardless of the issue, differences must be realized and discussed up front, before the financial bottom falls out.

Considering that financial problems are cited as a leading cause of divorce, it is vital to make sure you and your partner are on the same financial page. By speaking openly and honestly about finances, couples can manage their differences and find their way to compatibility.

Financial Compatibility Clues in Your Mate

The following areas should be considered in an effort to help your relationship stay “on track” financially.

Credit and debt: Disclose your credit statements to one another. How much debt do you each have? This would include credit card debt, vehicle loans and student loan obligations. Don’t hide anything, as that’s really getting off on the wrong foot. (Red flag alert if your mate is defensive or won’t talk about debt.)

Saving philosophy: What is your attitude toward saving, what is your spouse’s? It is important to be honest and realistic or any saving plan that you develop is sure to fail.

Spending attitude: What’s your approach to spending? Do you want a joint or separate checking account? Who will be responsible for each household expense? Will the dollar amount be divided evenly?

Retirement planning: What are both your views on retirement planning? Should both parties contribute to the retirement account? How much is needed?

Financial checklist: Make a list of your financial goals and achievements to date. Then, have your spouse do the same. Determine if your short and long-term financial goals match.

How to Manage if Your Viewpoints Don’t Match

Financial differences don’t have to be the catalyst for a huge fight. Just because your money beliefs don’t fit immediately, doesn’t mean you can’t both work on it together, find some middle ground and move forward to your “happily ever after.”

Ask the following of yourself and your spouse:
* What beliefs must you stand your ground on?
* What are you willing to give up for the greater good?
* What are your top 10 goals to accomplish over the next three, five, 10, 20, 40 years?
Compare both of your top 10 lists and prioritize what is important collectively.

The most important aspect of determining the financial compatibility in a marriage is discovering how you and your partner’s monetary viewpoints match up early on. If money differences are brought to the surface in time, a little compromise and strategic planning can put your relationship back on the right track.

Kimberly Foss is a Certified Financial Planner and personal finance expert with 28 years industry experience. Kimberly founded Empyrion Wealth Management (Roseville, Calif.) 22 years ago and focuses on managing the financial lives of pre-retirees, retirees and women in transition. For more information please visit Empyrion Wealth Management ( or call 916-786-7626.

May 15

Medications to Treat ADHD


By Diana Rodriguez ADHD is a behavioral disorder affecting millions of children and adults. However, ADHD can be successfully managed with a combination of therapy and ADHD drugs. There are several types of ADHD drugs that are useful, and several medications within each type. There are standards of treatment that often provide the greatest success, but they don’t work for everyone.

ADHD Drugs: Medication Classes Prescribed

The types of ADHD drugs used most often are stimulants, non-stimulant drugs including antidepressants, and high blood pressure medications. The first line of treatment and the most commonly prescribed ADHD drugs are typically the stimulants, because they often work the best.

F. Allen Walker, MD, a psychiatrist who has ADHD and who runs his own practice specializing in ADHD in Louisville, Ky., feels the stimulant class of ADHD drugs is superior to other classes in treating ADHD. “When treating patients, if you combine therapy and education with medication and you take the time to individualize the medication and dosage, that is the most effective way to treat ADHD,” says Dr. Walker. Stimulants primarily focus on increasing the neurotransmitter dopamine in the brain, particularly in the prefrontal cortex. “The theory is people with ADHD have a brain that’s a little bit thirsty for dopamine,” says Walker, and increasing dopamine levels allows an ADHD brain to function better.

Non-stimulant drugs can also be used to treat ADHD. Non-stimulant medications such as various antidepressants affect not only dopamine, but also other neurotransmitters such as norepinephrine and serotonin. Antidepressants are sometimes used in patients who are not able to tolerate stimulant medications. High blood pressure medications can help manage associated ADHD symptoms like irritability, impulsivity, restlessness, and tics, though they aren’t very successful in managing inattention.

The Most Common ADHD Drugs

Here is a list of the most commonly prescribed ADHD drugs and information about each one:
Ritalin, Mehylin, Metadate, Concerta, Daytrana (methylphenidate). This stimulant can effectively manage all of the primary symptoms of ADHD — impulsivity, hyperactivity, and inattention. Studies show that methylphenidate offers the most significant and quick reduction of ADHD symptoms and doesn’t increase tics. Potential side effects include depression, dizziness, headaches, appetite loss, insomnia, and nausea. Studies have shown that Ritalin might have a negative impact on the healthy development of the brain in children and teenagers. Concerta is an extended-release form of methylphenidate. Daytrana contains the same medication in a patch that is applied to the skin daily.
Adderall (dextroamphetamine and amphetamine). This stimulant can effectively manage all of the primary symptoms of ADHD, with all the potential side effects of Ritalin. Studies have shown a rare side effect of heart attacks, which can be fatal, particularly if mixed with alcohol use.
Dexedrine (dextroamphetamine). This stimulant can effectively manage all of the primary symptoms of ADHD, with all the potential side effects of other stimulants. Studies show some evidence that dextroamphetamine may increase tics after long periods of time when given in greater-than-normal doses and should not be administered at such levels.
Vyvanse (lisdexamfetamine dimesylate).This stimulant is known as a prodrug, meaning it is inactive until metabolized in the body. Vyvanse may prevent the potential for drug abuse that has been reported with Adderall.
Focalin (dexmethylphenidate). This stimulant comes in a capsule, which can be opened and sprinkled on foods for those who have trouble swallowing pills. Though it is known to have fewer side effects than Ritalin, this medicine may stop working earlier than needed in some individuals.
Strattera (atomoxetine). This non-stimulant drug offers the benefit of 24-hour effects, which is longer than stimulants. It can also help battle depression and is a good choice for people dealing with ADHD and depression or anxiety, but it’s not as effective against symptoms of hyperactivity as stimulant drugs. Side effects can include fatigue, irritability, stomachache, headache, nausea, and vomiting. Studies show that atomoxetine is as effective as stimulants with some additional benefits and at a lower cost than some other drugs. Atomoxetine also doesn’t have the risk of abuse and dependence that stimulant drugs do. However, it’s been found to potentially increase the risk of suicide.
Aplezin, Wellbutrin, Zyban (buproprion). This antidepressant affects the chemicals dopamine and norepinephrine in the brain and can be a very effective treatment in people who have both ADHD and depression. Buproprion can effectively manage symptoms of hyperactivity and inattention in people who don’t find relief from stimulants or who can’t tolerate their side effects. However, antidepressants have not been found to be effective at managing impulsivity. Side effects can include blurry vision, drowsiness, dryness of the mouth, and constipation. Studies have shown that some antidepressants can increase the risk of suicide. Antidepressants are not approved by the U.S. Food and Drug Administration (FDA) for the treatment of ADHD.
Intuniv, Tenex (guanfacine). Intuniv, a long-acting form of the blood pressure medication Tenex, was approved for the treatment of ADHD by the FDA in September 2009. This once-a-day treatment for kids ages 6 to 17 is a non-stimulant medication thought to engage receptors in the area of the brain linked to ADHD. In 2011, the FDA said that Intuniv could be used along with a stimulant to help children who are not responding well to a stimulant alone. Guanfacine can strengthen memory, reduce distraction, and improve attention and impulse control. Side effects can include tiredness, abdominal pain, dizziness, a drop in blood pressure, dry mouth, and constipation.
Catapres (clonidine). This high blood pressure medication can manage ADHD symptoms of aggressive behavior, impulsions, hyperactivity, and tics, but it’s not very effective against inattention. Side effects can include drowsiness, dryness of the mouth, blurry vision, heart problems, and constipation. Studies have shown that this high blood pressure medication is becoming more popular and is a safe and successful treatment for ADHD in addition to or instead of stimulant medications, but it is not FDA-approved for this use.

With patience and a knowledgeable medical professional, you can find the right medication at the right dose to help manage ADHD symptoms.

May 13

Exercise Helps With ADHD Symptoms


By Jean Rothman Exercise is great for people with attention deficit hyperactivity disorder (ADHD). For starters, exercise increases the levels of brain chemicals called dopamine and serotonin, which are lower in people with ADHD.
ADHD and Exercise: How it Helps

“Dopamine and serotonin are enzymes that help people feel good,” says Frank Coppola, a New York City-based ADHD coach. “They regulate things like mood, attention, and anger. So having more rather than less definitely helps someone with ADHD.”

Exercise also helps with alertness and sleep patterns, which can be a problem for people with ADHD, Coppola says. “Exercising tires your body, so you sleep better and feel more focused and alert the next day.”

Exercise helps you relax and quiet your mind as well. “Exercise helps cut down your chance of depression, which can accompany ADHD. It increases oxygen to the brain, improves your eating habits and can help with weight loss,” Coppola says.
Children with ADHD also need to exercise. Just as with adults, exercise increases dopamine and serotonin levels in kids, helping them be more alert and attentive, and tires them out at night, helping with sleep problems.

“Most schools have gym classes or sports teams,” Coppola says. “If your child isn’t getting exercise at school, offer them the chance of after-school activities such as gymnastics, karate, or soccer.”

All in all, exercise is a great prescription for ADHD. So strap on those rollerblades, get out your yoga mat, put on your walking shoes, and have a good time. It’ll feel good.

By Wyatt Myers If you go to the gym three times a week, but you’re not really breaking a sweat, you could be selling yourself short when it comes to both weight loss and fitness. Research shows that exercise intensity, and not necessarily length, might be the key to better fitness and overall health. For example, a study at Appalachian State University in Boone, N.C. recently found that aerobic exercise to the point where it’s difficult to hold a conversation is the key to maximizing calorie burn during — and after — a workout. Similarly, a new study published in Journal of Applied Physiology found that a shorter, harder workout can help patients more effectively manage type II diabetes than a longer, more moderate sweat session.

So if you’re wondering whether you’re working hard enough, measuring intensity doesn’t get much easier than the talk test. Simply put, the talk test is this: If you exercise at an intensity level that still enables you to carry on a conversation, it is a good and safe intensity for you. If you can’t carry on a conversation, then you may want to tone it down a notch until you can. If you find that speaking doesn’t leave you the least bit winded, it might be time to dial up your intensity (though you should check with your doctor before starting an exercise routine).

“This type of measurement is great because it requires no equipment or need to figure out or measure your heart rate,” says Debra Gray, a fitness expert in Omaha, Neb. “It has been shown to be accurate by the American College of Sports Medicine.”

Talk-Test Pros and Cons

Timothy J. Quinn, PhD, a professor of kinesiology at the University of New Hampshire, has conducted extensive research on the talk test in recent years. He has found that it has several pros and cons when it comes to measuring exercise intensity and overall fitness levels.

“The pros are that it’s simple; you can dial up or down the intensity easily. It works in every environment, including heat, cold, and altitude, and almost every population — cardiac patients, pregnant women, diabetics, and people who are overweight — can use it,” Quinn says. “The cons are that it’s not tremendously specific, so fine applications aren’t always clear. It’s hard to determine gradations, and not everyone wants to talk while exercising.”

In Quinn’s most recently published study on the talk test, he discovered that in study participants who weren’t particularly active, it yielded higher heart rates than did other methods of gauging exercise intensity. In more active participants, the talk test did not get heart rates high enough to provide an optimal workout.

Nonetheless, the talk test still managed to keep the most participants well within the safe range of exercise. Plus, Quinn and his team found it to be a safe method for prescribing exercise for the group that was studied. They concluded that the test might be more effective for beginning or noncompetitive exercisers, rather than those who are training toward specific fitness goals.

Tips for Achieving Optimal Exercise Intensity

Although the talk test may not be the most accurate way to measure exercise intensity, experts agree that it certainly holds value as a simple method for the average person to keep his or her exercise routine at a safe level.

If you want to measure your intensity more precisely, there are other strategies to keep you working hard enough:
Use a heart rate monitor. Quinn says a heart-rate monitor is the most accurate option for gauging your exercise intensity level at home. When using this electronic device, you want to hit your target heart rate, which is 50 to 85 percent of your age-based maximum heart rate while resting. To avoid risks like heart attacks or other cardiovascular events, stay within this healthy range — and don’t exceed it.
Listen to your body. As you start to exercise more, Gray says, you will start to get a feel for the results of the “talk test” by simply being more aware of your own exertion level. She suggests you ask yourself how you feel post-working, and note whether you’re perspiring or sweating. She adds, “When your heart rate and core temperature are elevated, your body will sweat to cool itself.”
Vary the intensity. To keep your workout safe while still adding some intensity, you can try interval training, or ramping effort up for a short time period and then slowing back down. “Try varying the intensity with short bursts of high intensity (30 seconds to 1 minute) and low-intensity recovery mode (1 to 2 minutes),” Gray says.
Do what you like. “Any kind of intense cardio is going to burn fat, whether it’s sprinting, running, biking, jumping, or plyometric exercise,” Rich Gaspari, a personal trainer and owner of Gaspari Nutrition, says. “If your heart rate is up, then it is considered cardio and you will burn fat.”

The most important thing,” Gaspari adds, “is staying dedicated, being consistent, staying motivated, and lastly, having fun!”

For more fitness, diet, and nutrition trends and tips, follow @weightloss on Twitter from the editors of @EverydayHealth.

May 12

Combating Side Effects of ADHD Meds


Potential ADHD Treatment Side Effects By Marie Suszynski

Here are 10 side effects associated with stimulant ADHD meds and what you can do about them:

1. Anxiety. Your child may feel anxious for the first day or two after starting the stimulant, Allan says, but this is a side effect that should go away.

2. An upset stomach. Thankfully, an upset stomach that’s caused by the medication usually doesn’t last long, Allan says. Eating a high protein breakfast can help, but you may also want to talk to your child’s doctor about treating the stomach upset with another medication, she says.

3. Difficulty sleeping. Some kids will have a harder time sleeping when they first begin stimulants, though others are better able to organize and get themselves to bed on time. “I’ve seen instances of both of those things happening,” Allan says. If your child is having trouble sleeping, switching to a shorter-acting medication (one that wears off more quickly than a long-acting one) can help to get your child to sleep on time.

4. Daytime drowsiness. In addition to having trouble falling asleep, stimulants may also cause your child to spend more time in non-REM (rapid eye movement) sleep, which is a lighter stage of sleep. That can lead to drowsiness during the day.

5. Mood changes. Initially, you may notice your child being more irritable on the new medication, Allan says. This has been the biggest side effect for Kara Wiemert’s 16-year-old sister, who has been taking ADHD meds since she was about 7 years old.

“Before she pretty much had one mood of constantly happy and overly energetic,” Boston-based Wiemert says. “She now has mood swings to the extreme where she’s almost unbearable to be around.” Unfortunately, the mood swings haven’t gone away for her sister, but her family has learned to be more understanding. Wiemert also has noticed that her sister is less moody since she found other friends with ADHD who she can relate to.

May 11

Building A Compassionate Marriage


BY ESTHER BOYKIN, LMFT At the start of the year I adopted a theme for the year. A single concept to help direct my projects, personal and professional, as well as a guidepost to help me get centered again when life got overwhelming or out of control as it inevitably does. My theme for this year is compassion. It’s a simple idea really, but I have found that not only has it helped lend some order to my otherwise crazy life, it has become an essential theme to my clinical work with married couples.

So, what is compassion exactly and how can it help bring harmony, joy and a deeper love into your marriage? Let’s start with the definition: “Compassion is an emotion prompted by the pain of others. More vigorous than empathy, the feeling commonly gives rise to an active desire to alleviate another’s suffering.”

In simple terms, compassion is empathy in action. So then what is empathy, really? For many of us, empathy is a sometimes-elusive concept. Similar to sympathy, empathy takes us from feeling bad for someone’s predicament to a place where we actual put ourselves in their shoes and feel what they are feeling as if it were happening to us.

I think Actress Rosie Perez said it best in the movie “White Men Can’t Jump” when she said, “When your wife is thirsty, empathy says, ‘I too know what it is to thirst.’ Compassion says the same thing and then gets up and gets her a bottle of water.”

If empathy is to feel another person’s suffering, compassion is to feel it and then try to comfort them as if their pain were your pain. Simple enough, right? Well not exactly.

Compassion is not about fixing. It’s about understanding and comforting. For many, husbands who have to hear their wife’s complaint about a co-worker or a problem with one of the kids now positions themselves in a role to now become the “fixer” and immediately offer solutions or make decisions to solve the perceived problem. These poor guys and gals (there are “fixer” wives out there too) are missing the most essential key to a compassionate marriage—understanding. Compassion begins with understanding on an emotional level, the reason for our partner’s suffering. The trouble is that understanding our spouse means that they have to understand the root of their suffering first.

Recognizing Compassionate Moments
Now I know that suffering may sound like an extreme description for a tough day at the office or a minor misunderstanding between spouses, but I use this word on purpose. When we are stressed, overwhelmed, upset or emotionally disconnected from our loved ones (even briefly), the emotional response is one of suffering. It is real and it is powerful and the first step to truly understanding our partner and ourselves is to acknowledge the magnitude of “minor issues” on our well-being. The interesting paradox is that the more compassionate we are with ourselves, the more we begin to appreciate that everyone around us is suffering too, and suddenly we are more compassionate with everyone.

For many, the most difficult part of living more compassionately is learning to be compassionate with ourselves and trusting that our partners will do the same. How many times have we gotten into a debate about who had a more stressful day at work? Husbands and wives are not bickering over who has a tougher day because they really think that one of them will win, there’s no prize for having the crappiest day. They are fighting for the right to be comforted. It is as if we believe that only one person can be comforted at a time and we must fight to claim it for ourselves. There are not a limited number of spots for compassion or special criteria you must meet. There isn’t a shortage of comforting unless we create one. The unfortunate reality is that suffering is everywhere and with everyone. And just as suffering is in endless supply, fortunately so is comfort and compassion.

The trouble is that we are often taught to minimize our problems. We compare our issues to someone else’s and feel that we are not worthy of compassion because our problems aren’t that bad. We tell our children, and ourselves, to stop complaining because someone else is worse off than you? How often do you chastise yourself for feeling upset about your husband’s lack of help around the house when you know that your neighbor’s husband just moved in with his mistress? This is a common response but it keeps us stuck. When we force ourselves (and our spouse) to defend our experience of suffering we build resentment and create a cycle of increasing pain. In order to move forward we must learn to shift from a mentality of shortage to one of abundance. Just as there is an abundance of pain there can be an abundance of love and understanding but we must begin with ourselves.

Putting Compassion Into Action
Of course there are degrees of suffering. Your frustration with your husband’s lack of bathroom cleaning is not the same as someone else’s struggle with infidelity; but dismissing your experience as unworthy of compassion sets you and your spouse up for even greater distress. Many times we think that by allowing ourselves to feel upset or sad or hurt by minor issues (however you choose to define that) we are being self-indulgent or giving power to these experiences. The truth is that our pain gets its power from our denial or minimization of it. Like a small area of mold in your basement, left untreated our pain only grows and spreads, it will not resolve itself without our attention. When we validate the suffering in our lives, no matter how small or “insignificant” they may seem, we are suddenly able to accept the comfort we so desperately seek and let it go. Moving on means first acknowledging where we are.

When you can gently acknowledge that your suffering over the dirty bathrooms is real, you are then able to go deeper and learn to understand more about yourself. Maybe the pain about housework is just a tangible example of loneliness you feel when your husband is preoccupied and too busy to take care of you and the house. By being compassionate with yourself first, you can help your husband understand that experience, enabling him to offer comfort to your emotional pain rather than solutions to a physical problem. Hiring a cleaning person to clean bathrooms once a week in not likely to alleviate your sense of abandonment; however hiring someone and then using that time to go on a date together could give you the comfort you seek, and keep those toilets sparkling.

This is where the magic of compassionate living happens, as you learn to be compassionate with yourself, you create a space for your spouse to be more compassionate with you. If you can learn to look at each other with compassion rather than competition, you will find that there is more than enough to go around. And as you learn to stop fighting for comfort your suffering is relieved and you are better able to offer your spouse the compassion that he seeks. And so a new cycle begins, one of understanding, validation, and loving connection. A compassionate marriage is built on the idea that everyone experiences some level of pain everyday and that by honoring that and seeking to really understand it you can grow closer to one another. And together, you can create a life and relationship in which you are able to put empathy into action and love each other more fully.

Eshter Boykin is the co-owner/founder of Group Therapy Associates

‘How reading in a second language protects your heart’

Psychologists at Bangor University believe that they have glimpsed for the first time, a process that takes place deep within our unconscious brain, where primal reactions interact with higher mental processes. Writing in the Journal of Neuroscience (May 9, 2012 • 32(19):6485– 6489 • 6485), they identify a reaction to negative language inputs which shuts down unconscious processing. For the last quarter of a century, psychologists have been aware of, and fascinated by the fact that our brain can process high-level information such as meaning outside consciousness. What the psychologists at Bangor University have discovered is the reverse- that our brain can unconsciously ‘decide’ to withhold information by preventing access to certain forms of knowledge.

The psychologists extrapolate this from their most recent findings working with bilingual people. Building on their previous discovery that bilinguals subconsciously access their first language when reading in their second language; the psychologists at the School of Psychology and Centre for Research on Bilingualism have now made the surprising discovery that our brain shuts down that same unconscious access to the native language when faced with a negative word such as war, discomfort, inconvenience, and unfortunate. They believe that this provides the first proven insight to a hither-to unproven process in which our unconscious mind blocks information from our conscious mind or higher mental processes.

This finding breaks new ground in our understanding of the interaction between emotion and thought in the brain. Previous work on emotion and cognition has already shown that emotion affects basic brain functions such as attention, memory, vision and motor control, but never at such a high processing level as language and understanding. Key to this is the understanding that people have a greater reaction to emotional words and phrases in their first language- which is why people speak to their infants and children in their first language despite living in a country which speaks another language and despite fluency in the second. It has been recognised for some time that anger, swearing or discussing intimate feelings has more power in a speaker’s native language. In other words, emotional information lacks the same power in a second language as in a native language.

Dr Yan Jing Wu of the University’s School of Psychology said: “We devised this experiment to unravel the unconscious interactions between the processing of emotional content and access to the native language system. We think we’ve identified, for the first time, the mechanism by which emotion controls fundamental thought processes outside consciousness. “Perhaps this is a process that resembles the mental repression mechanism that people have theorised about but never previously located.”

So why would the brain block access to the native language at an unconscious level? Professor Guillaume Thierry explains: “We think this is a protective mechanism. We know that in trauma for example, people behave very differently. Surface conscious processes are modulated by a deeper emotional system in the brain. Perhaps this brain mechanism spontaneously minimises negative impact of disturbing emotional content on our thinking, to prevent causing anxiety or mental discomfort.”

He continues: “We were extremely surprised by our finding. We were expecting to find modulation between the different words- and perhaps a heightened reaction to the emotional word – but what we found was the exact opposite to what we expected- a cancellation of the response to the negative words.” The psychologists made this discovery by asking English-speaking Chinese people whether word pairs were related in meaning. Some of the word pairs were related in their Chinese translations. Although not consciously acknowledging a relation, measurements of electrical activity in the brain revealed that the bilingual participants were unconsciously translating the words. However, uncannily, this activity was not observed when the English words had a negative meaning.

May 10

What Is Working Memory and Why Does It Matter?


By Annie Stuart Remember the day when someone rattled off a phone number while you just hoped against hope you’d recall the string of digits as you were dialing? That was working memory toiling away. With the advent of cell phones, you may no longer use it this way very often. But working memory still plays a central role in learning and our daily lives. If working memory is weak, it can trip up just about anyone. But it really works against a child with learning disabilities (LD). You can take steps to help a child with weak working memory, whether or not LD is a part of the picture. Start by understanding what working memory is all about.

What is working memory?

Working memory is your brain’s Post-it note, says Tracy Packiam Alloway, Ph.D., assistant professor of psychology at the University of North Florida in Jacksonville, Florida. “It makes all the difference to successful learning,” she says.

You can think of working memory as the active part of your memory system. It’s like mental juggling, says H. Lee Swanson, Ph.D., distinguished professor of education with the Graduate School of Education at the University of California, Riverside. “As information comes in, you’re processing it at the same time as you store it,” he says. A child uses this skill when doing math calculations or listening to a story, for example. She has to hold onto the numbers while working with them. Or, she needs to remember the sequence of events and also think of what the story is about, says Swanson.

Brief by design, working memory involves a short-term use of memory and attention, adds Matthew Cruger, Ph.D., neuropsychologist with the Learning and Diagnostics Center at the Child Mind Institute in New York City. “It is a set of skills that helps us keep information in mind while using that information to complete a task or execute a challenge,” he says. Working memory is like a foundation of the brain’s executive function. This is a broad and deep group of mental processes. They allow you to do things like plan ahead, problem solve, organize, and pay attention.
1 “Working memory helps us stay involved in something longer and keep more things in mind while approaching a task,” says Cruger. “And, how can you plan ahead if you don’t use working memory to keep your goal in mind, resist distractions, and inhibit impulsive choices?” But if you struggle with working memory, pieces of information may often evade your grasp like a quickly evaporating dream. You find yourself stripped of the very thing you need most to take action.

Types of Working Memory

“You can’t overemphasize how often working memory is used in the classroom,” says Cruger. Children (and adults) use two main subtypes of working memory throughout the day. Both develop at a similar rate during childhood, and often reach their highest level in early adulthood.
2 Verbal (auditory) working memory taps into the sound (phonological) system. Silently repeating that phone number while dialing makes use of this system. “And anytime kids are expected to follow a multi-step set of oral instructions, they are using these working memory skills,” says Cruger. If there’s a weakness, however, they may not be able to keep the instructions in mind while working with them, he says. This is true even when they fully understand what to do. Other tasks that require use of this type of working memory are learning language and comprehension tasks.
3 Visual-spatial working memory uses a kind of visual sketchpad of the brain. It allows you to envision something, to keep it in your “mind’s eye.” Students use this skill to do math and to remember patterns, images, and sequences of events.
4 They might use it to visualize the layout of the classroom during the first couple of weeks of school, says Cruger. “A teacher says, ‘Once you’re done with this, go to the center area, take something to do and then go to this table and work on this,'” he says. “That involves multiple steps where the child is negotiating himself in the world.” If not identified, a deficit of this type is ripe for misunderstanding, he says. For example, it might seem as though a child is simply not paying attention.
How is working memory linked with learning and LD? Working memory can be a central problem for many people with Attention-Deficit/Hyperactivity Disorder (AD/HD), says Cruger. Or, it may be one of many things that is weak among a set of attention and executive functioning problems.

Those with weak working memory are likely to have learning disorders, too. In a government-funded study, Alloway and colleagues tested more than 3,000 grade school and junior high children in the U.K. They found that one in 10 had very poor working memory. This turned out to be a reliable indicator of who would struggle in the classroom, she says. In fact, when following up six years later, they found working memory to be a more powerful predictor than IQ when it comes to learning.5 “Ninety-eight percent with poor working memory had very low scores in standardized tests of reading comprehension and math.”

These weaknesses may show up later, when executive skills of comprehension and analysis come into play, says Swanson. “Schools do a pretty good job of drill and repetition and teaching kids phonics, but when you get into things like comprehension, it can begin to fall apart.” And, if a child has a learning disability, weak working memory can add insult to injury. For example, a fifth grader who is still sounding out words while reading is relying heavily on working memory to help compensate. This puts a huge tax on the working memory system, says Cruger. At this stage, you want reading to be more automatic. You want to be able to look at a word and recognize it, he says, and not have to recruit attentional or working memory resources to the task. But for a child who needs to compensate but can’t rely on working memory, the process can become all the more painful.

This weakness may compound things, especially for those with LD, says Alloway. “I’ve worked at schools where the average 10-year-old can remember and process four pieces of information, but one with poor working memory can look like an average 5-year-old,” she says. “For this child, the teacher talks too fast, making it hard to keep up. So the child may eventually start disengaging altogether.” Combine these challenges with high anxiety, which also puts demands on working memory, and it becomes more than a double whammy. “Your emotional state can play a role in working memory performance, which can in turn influence performance on tests,” says Alloway.

How can you diagnose working memory problems?

So how can you know whether or not your child has a problem with working memory? First, watch for signs. Then, consider testing to confirm the weakness, assessing both types of working memory. Know the signs. Alloway has helped develop a 22-item checklist, standardized for grade school and junior high students and published by Pearson Assessment in the U.K. (A U.S. version will soon be available.) Called the Working Memory Rating Scale (WMRS), it helps teachers identify this problem by listing behaviors that are typical of someone with poor working memory such as:

Abandons activities before completing them
Looks like he’s daydreaming
Fails to complete assignments
Puts up a hand to answer questions but forgets what she wanted to say (This is typical for a 5-year-old, but not for an 11-year-old, for example.) Mixes up material inappropriately, for example, combining two sentences
Forgets how to continue an activity that he’s started, even though the teacher has explained the steps Alloway emphasizes that students always be compared with peers to know what is typical for a given age group. That’s because working memory develops over time. The average 5-year-old, she says, can hold and process one or two pieces of information. But a 10-year-old can do this with three and a 14-year-old with four.6 A kindergarten teacher recently told Alloway, “Now it makes sense why they don’t listen to me because I always give them about four instructions at a time!”

Consider formal testing. A school psychologist can test for working memory with tests such as the Working Memory Index in the WISC. Unfortunately many with poor working memory go undiagnosed. That’s because they learn to compensate, says Swanson. “Their knowledge base or basic skills acquired in specific academic domains, such as reading or math, helps them deal with any working memory demands related to a particular task.” Although diagnosis can help you understand what underlies any difficulties, Swanson cautions to find assessments that actually test working memory and not just short-term memory. “The test has to involve interpreting information as it is coming in.” He recommends two:
The Automated Working Memory Assessment (AWMA), a PC-based assessment published by Pearson
The Wide Range Assessment of Memory and Learning (WRAML-2), published by PRO-ED

Assess both types of working memory. From an educational perspective, it is important to know the difference between them because children with different learning needs may have very different working memory profiles, says Alloway. “A student with a reading disorder can have a weakness in auditory working memory but relative strengths in visual spatial working memory,” says Alloway. “But another student with dyspraxia may have deficits across the board but particularly with visual spatial working memory.”

Also be aware that auditory working memory usually affects learning more so than visual-spatial working memory, says Alloway. That’s because, with so much information relayed verbally in school, it’s harder for a student to easily find ways to compensate. Now that you understand the role of working memory, perhaps it’s time to seek help for your child. Without intervention that specifically addresses this weakness, students with poor working memory won’t catch up over time, says Alloway. Fortunately, there are more ways than ever to help.

May 10

Therapists Spill: 11 Myths About Therapy


By Margarita Tartakovsky, M.S. In past pieces in the “Therapists Spill” series, clinicians have shared everything from why they love their work to how to lead a meaningful life. This month clinicians reveal the myths and misunderstandings that still persist about going to therapy.

Myth 1: Everyone can benefit from therapy.

Everyone who wants to engage in therapy can benefit. Not surprisingly, people who don’t have a modicum of motivation to change probably won’t. Psychotherapist Jeffrey Sumber, MA, stressed the importance of being ready, willing and open to therapy. Some folks believe that therapy is right for everyone; that “who couldn’t benefit from a little therapy?” While I personally believe that there are a huge number of people that benefit from our services, it is my experience that unless a person is truly open and ready to do their own work, then therapy can actually create a negative experience for the person so that when they might be truly ready to make a change, their experience with therapy was less than enjoyable. …Hostile clients do not serve the client or the therapist. Our job is not to fix people; it is to support people who want to heal by reflecting their own strength back to them. There are clearly some clients who are 99 percent against changing their behaviors or thoughts, but it takes 1 percent, some thread of interest or hope, for the process to be successful.

Myth 2: Therapy is like talking to a friend.

According to Ari Tuckman, PsyD, clinical psychologist and author of Understand Your Brain, Get More Done: The ADHD Executive Functions Workbook, while friends are a vital support, a therapist is uniquely qualified to help you. It’s important to have friends to talk to, but a therapist is trained to understand these matters more deeply and therefore is able to offer more than just good advice. Life gets complicated and it sometimes takes a deeper understanding of human nature in order to move beyond the current situation. Also, because therapy is confidential and the therapist has no vested interest in what you do, it can be easier to talk openly with a therapist and really get down to what is going on.

Myth 3: Therapy isn’t working unless you’re in pain.

Therapy often gets painted as a painful and miserable process. But this picture glosses over the fact that therapy equips clients with effective coping skills to live a more fulfilling life – and can be very rewarding. As Tuckman said: Although therapy can address some pretty painful subjects, it doesn’t need to be all about pain and suffering. Therapy is often more about understanding yourself and others differently and learning how to cope with the sorts of things that most people deal with at one point or another: relationship dissatisfaction, loss, anger, uncertainty over the future, transitioning from one situation to another, etc. Even though most people go through these experiences, therapy can help you navigate them more smoothly and set yourself up for success on the other side of it.

Myth 4: Therapy entails blaming your parents.

“Therapy has come light years from the old days of talking about potty training,” Tuckman said. But while therapists don’t fixate on a client’s parents or their past, tracing their history helps provide a clearer picture of their experiences and current concerns.
According to Joyce Marter, LCPC, psychotherapist and owner of Urban Balance, LLC, a multi-site counseling practice in the greater Chicago area:

Many people come into therapy and say they want to address a current life issue or stressor but do not want to talk about their histories because they don’t want to wallow in the past. I explain that the first phase of therapy is information gathering, where the therapist asks questions about the client’s past in a process of getting to know and understand him or her.

My belief is that our past experiences often shape and mold us into who we are. We all unconsciously repeat familiar patterns until we make them conscious and work through them. You certainly don’t need to spend years in psychoanalysis to make progress in therapy, but providing even a brief psychosocial history is an important part of even short-term, solution-focused therapy. I explain to clients that it is not about blaming their parents or staying stuck in the past, rather it is about honoring their emotional experiences and increasing awareness of how these previous life circumstances are impacting them currently with regard to their presenting issue for seeking therapy. Addressing and resolving issues from the past can be the key to moving forward in the future.

Myth 5: Therapy entails brainwashing.

Amy Pershing, LMSW, a psychotherapist and director of the Pershing Turner Centers, actually heard this myth at a party. Some people believe that therapists push their ideas and agendas on their clients. However, a good clinician helps you re-discover or regain your voice, not lose it. She explained:… There is a time in therapy, especially at the beginning, when the therapist, from only their own philosophical lens, helps a client understand the workings of their mind (and, at least in eating disorders treatment, their body), educates on the allegedly normative path of human development, and identifies the patterns clients may have developed to survive traumas of all kinds.

Every therapist does this from their own unique brand of wisdom, developing tools and strategies they believe in both professionally and personally. So is therapy about making people be “in line” with how the therapist sees things? …Good therapy, to my way of thinking, always starts with creating a container. It is about building trust and safety, born from acceptance and “unconditional positive regard.”

These are commodities many clients [do] not have in abundance. The purpose of this container is not to convert, but to create space for clients to risk finding their authentic Self. To do that, sometimes clients need to use parts of someone safe to help build a bridge back to that Self. They can try on things I suggest with the goal [of] listening for their true response (“Did this work for me?”), not practicing a lesson and ultimately passing some test.

…If clients say something because they think I want to hear it, we are not done with the work. If they say something because it is true for them, we have accomplished our mission. …For those who have not participated in psychotherapy for fear they might lose their voice, I would invite them to challenge a prospective therapist with this very question. Their answer should in fact convince you that you will come away from the work not closer to being like them, but closer to being like you.

Myth 6: Therapists typically agree with their clients, since their job is to make them feel better.

A therapist’s job isn’t to placate clients. Rather, it’s to challenge them and help them grow. According to Marter: Of course, having a strong therapeutic rapport or positive working relationship is the key to success in therapy. However, this doesn’t mean that your therapist is just going to accept your point of view as verbatim and affirm everything you say and do.

As therapists, we are trained to recognize that there are always other sides of the story. We notice patterns and trends, clients’ behaviors, experiences and relationships. We can usually tell when there is missing information or things don’t seem to add up and will challenge clients to explore these blind spots and support them in that process of increasing insight and consciousness. While a therapist will most often empathize with a client’s emotional response to a situation, we also encourage clients to challenge their thinking, their belief systems, or look at things from other perspectives to help them learn, grow and move forward in their lives.

Myth 7: A therapist never takes sides.

Sometimes taking sides is necessary because it leads to progress. According to Terri Orbuch, Ph.D, a psychotherapist and author of Finding Love Again: Six Simple Steps to a New and Happy Relationship:

At times, a therapist might have to take a side, either to keep a couple moving along, to challenge a client, or because of a particular issue at hand. For example, let’s say a couple comes in for marital counseling. One of the partners refuses to change, and refuses to discuss any issue or even listen to the other partner. The partner that is refusing to discuss is very angry about being at the therapist’s office. At that time, a therapist might say to the angry partner: “Why are you here if you don’t want to discuss anything?” or “Do you think this lack of involvement is helping your marriage?” To me, this is siding with one partner [in order] to engage one partner or move the couple along. The therapist is taking a side to challenge the other partner.

Myth 8: If you don’t start feeling better right away, therapy isn’t working.

Many people think that therapy takes one or two sessions, said John Duffy, Ph.D, a clinical psychologist and author of the book The Available Parent: Radical Optimism for Raising Teens and Tweens.

“That’s about how long it takes to get the story down and establish a little sense of trust,” he said. “Then, therapy can begin.” Think of getting better as less like getting a shot at the doctor’s office and more like organizing a messy closet. According to Marter: I tell my clients that starting therapy is a little bit like cleaning out a messy closet. If you finally decide it is time to organize a closet that you’ve crammed with stuff over the years, you first need to start by pulling everything out. After all your stuff is spread around the room, it is normal to feel pretty overwhelmed and worry that you have made things worse or think it may have been better to just leave it alone.

The beginning of therapy can be overwhelming in a similar way, as you share old memories and experiences with your therapist, some of which may have been very difficult. It is common to feel a bit worse before you feel better, but if you stick with the process you can let go of some old stuff, rework some things and have your “closet” functioning better than ever. I always encourage clients to discuss their feelings about therapy directly with me so we can address any uncomfortable feelings and work through them together. The therapeutic journey of healing and growth doesn’t always feel good during the process but the feeling of having resolved difficult issues will make it all worthwhile in the end.

Myth 9: Change takes place during therapy.

Change actually takes place before and after the therapy session, Duffy said. “There are a-ha’s and revelations [in the session], to be sure, but for change to really happen and last, the majority of the work happens between sessions.” The goal of therapy is to apply these changes to your life, which, of course, is the hard part.

Myth 10: Seeing a therapist means you’re weak, damaged or really crazy.

There’s nothing weak or crazy about working on specific problems or trying to overcome intrusive symptoms. Therapy gives you the opportunity “to utilize all the tools at your disposal to maximize your satisfaction and effectiveness in life,” Duffy said. Sounds like a smart strategy, doesn’t it?

Myth 11: Once you start seeing a therapist, it’s best not to change therapists.

According to Orbuch, “If you are dissatisfied with the progress you’re making or you’re not comfortable with a therapist, you owe it to yourself to change who you’re seeing and find someone who is better suited to you.” How do you find a clinician you’re comfortable with?

Consider why you’re going to see a therapist in the first place, and research the best types of treatment approaches for those concerns, Duffy said. For instance, if anxiety is impairing your life, after doing some research, you’ll learn that cognitive behavioral therapy (CBT) is the most effective treatment. So you’d look for therapists who specialize in CBT. Also, consider if you’d prefer to work with a male or female therapist, Orbuch said. She suggested contacting two therapists and asking them questions before making an appointment. Ask about the therapist’s credentials, training and treatment approach (psychoanalytic? CBT?), she said. Then figure out if you’re comfortable with their responses, tone of voice, and anything else that’s important to you, she said.

May 9

Are People With Bipolar Disorder Dangerous?


By Madeline Vann, MPH
People with any mental illness are often labeled as potentially violent, even if they have no history of violence or any apparent violent tendencies. This stigma can be particularly strong when applied against people with bipolar disorder, which can be alarming and misunderstood by others.

The truth about the risk of violence among bipolar people is complicated. By some estimates, between 11 and 16 percent of people with bipolar disorder have had a violent episode. These typically occur during extreme moods or because of drug or alcohol use. But there are many people with bipolar disorder who are never violent. Knowing which bipolar symptoms of depression and mania to watch out for may help avoid dangerous situations.

“There has been a long-standing expectation that mentally ill individuals are more likely to perpetrate violent acts. However, large population studies suggest that mental illness alone does not increase the likelihood of violence,” says psychiatrist Michael Peterson, MD, PhD, an assistant professor in the department of psychiatry at the University of Wisconsin School of Medicine and Public Health in Madison.

Factors that Increase the Risk of Violence

While having bipolar disorder alone does not make violence more likely, there are situations which, when combined with bipolar disorder, can increase the risk of violence. These include:

Drug or alcohol abuse. Substance use is common among people with mental illness. Unfortunately, drugs and alcohol can make violent episodes more likely — and may also put people in situations where violence is the norm.
High emotional stress. Periods of great emotional stress or distress, such as losing a loved one or ending a relationship, may trigger mood swings that can increase the risk of violence.

The Danger of Self-Harm

In fact, people with bipolar disorder may be more of a threat to themselves than anyone else in their lives. Innocent bystanders may be worrying unnecessarily about their own safety when the reality is that bipolar disorder can lead to a lot more damage to the person living with it.

These risks include:

Suicide or attempted suicide. Rates of suicide are significantly higher among people with bipolar disorder than their peers. People with bipolar disorder are close to nine times more likely to commit suicide than their peers.
Drug or alcohol abuse. “People with bipolar [disorder] are also at higher risk of developing substance abuse or dependence,” explains Dr. Peterson, adding that bipolar patients are at higher risk of having manic or depressed episodes when they are abusing drugs or alcohol. Data suggest that 46 percent of people with bipolar disorder are dependent on alcohol and that 41 percent are dependent on other drugs.
Cutting. Occasionally, people with bipolar disorder cut or hurt themselves deliberately.
Non-physical damage. During manic periods, bipolar people may do a lot of “violence” to their own financial situation, relationships, and other elements of their lives as they act on impulse and pursue high risk behaviors.

If you have a loved one with bipolar disorder, Peterson says, “Be vigilant for signs of either depression or mania. Particularly during depressed or mixed episodes, when there are concurrent symptoms of both mania and depression, a real concern is suicidal thoughts and attempts.”

Peterson says signs of depression to watch out for include being more withdrawn or sad, or sleeping more than usual. Warning signs of mania include talking more, becoming more active, sleeping less, and becoming more outgoing and impulsive. Mania can lead to violence because of increased irritability and poor impulse control.

Peterson advises having “frank discussions” about these symptoms with the person who has bipolar disorder and then notifying her doctors or therapists, or even the police, if you continue to be concerned about your safety or the safety of the person with bipolar disorder. Effective medications are available that can help reduce the risk of violence and control the bipolar symptoms if urgent situations are identified in a timely way.

What can parents do to improve relations with teenagers?

Help your teenagers believe in themselves. They will only believe in themselves if you show them that you have confidence in them and faith that they will make the right decisions.
Recognize the efforts of your teenagers. Reassure them that they have the qualities you want for them.

And if conflict with your teenager does arise:

Focus on the behaviour, not the person.
Think ahead to what you will say and how you will say it.
Keep your messages clear and concise.
Stick to one issue at a time.
Do not argue with the way your teen sees things. Instead, state your own beliefs and opinions
Do not talk down to your teenager. There’s nothing more irritating than a condescending tone
Do not lecture or preach. This only provokes hostility. Besides, the average teenager goes “deaf” after hearing about five sentences.
Do not set limits or consequences you cannot enforce.

May 8

Learning Disabilities Affect Family Life


If you have a child with a learning disability, you are probably learning that your child learns and reacts differently at home as well as in school. You will likely have to adapt your parenting strategies to your child’s neurology. If you have a diagnosis, then it is likely that you also have a neuropsychological testing report. These reports and the IEP (individual education plan) include recommendations for instruction. Good test reports will also have recommendations for home. You can look at these recommendations and adapt them for home use. Here are a few that I run into in families I work with.

Slow Processing Speed

Your child is bright enough to do the work, but she thinks things through slowly. Think of having a computer with an old CPU. Often the IEP will recommend that a teacher provide “wait time” after asking a question. Parents need to do the same. If you patiently wait for your child’s response after a question, you can include her in family dinnertime conversations that she might otherwise be left out of. Processing speed can especially be a problem in tense situations. For instance, suppose you are asking about a missed homework assignment. Give her a minute to remember and give her response, instead of filling in for her.

Nonverbal Learning Disability

This is a disability that affects children’s ability to read social cues and to understand metaphor and sarcasm . They can be very sensitive to tone of voice, and their own modulation of tone of voice is poor. However, they can be taught these skills over time. It helps to understand that if your child responds angrily to a request, it might be because he thought you were angry. It is important to keep your voice neutral. Joking with this child is a tricky business. You will need to explain teasing because he won’t pick up from your tone of voice that you actually mean the opposite of what you are saying. Adding, “Just kidding,” can be essential.

Poor Working Memory

This is a problem that affects a person’s ability to keep a few ideas in mind in order to manipulate them or use them for problem solving. This could come up if you give your child complicated instructions. For instance you might say, “When you go upstairs to start your homework, check on the hamster food, and if we don’t have enough for the week, tell me so I can buy more.” This is a lot to keep in mind — go do homework; check on hamster food; and then what? You can have more success, and your child will feel more successful, if you break down the requests. Start with “Go check to see whether we have enough hamster food for a week, and tell me what you learn.” Then say, “Ok, now start your homework.” Adjustments like these avoid misunderstandings that frustrate everyone.

Executive Function Deficits

This seems to be the diagnosis dejour in my caseload. If executive function is a problem for your child, you are probably already well aware of it. Your child loses and misplaces things related to school and everything else in life. It’s really frustrating for all. But scolding and shaming her for being disorganized doesn’t teach her strategies. I find it helpful to give kids like this lists for different situations. For instance, before going out the door in the morning, she could check off backpack, lunch bag, instrument for band, gym shoes. For going to soccer practice: cleats, socks, shin guards, ball. The same list applies for leaving soccer. Some kids are visual learners, and for them, a picture or drawing of themselves labeled with all the right equipment would be more useful.

These are just a few of the ways that learning difficulties affect home life. Learning about how your child thinks and learning strategies for managing life with a person with this brain will save you and your child a great deal of aggravation. Using accommodations at home can actually teach your child coping strategies for life. I know young adults who have learned to make their own lists so that they don’t travel without essentials.

My website, has a number of resources listed that can be helpful for parents in learning what they need to know about living with learning disabilities.

May 8

Best Ways to Support Someone with Depression


By Margarita Tartakovsky, M.S.
If your loved one is struggling with depression, you may feel confused, frustrated and distraught yourself. Maybe you feel like you’re walking on eggshells because you’re afraid of upsetting them even more. Maybe you’re at such a loss that you’ve adopted the silent approach. Or maybe you keep giving your loved one advice, which they just aren’t taking. Depression is an insidious, isolating disorder, which can sabotage relationships. And this can make not knowing how to help all the more confusing. But your support is significant. And you can learn the various ways to best support your loved one. Below, Deborah Serani, PsyD, a psychologist who’s struggled with depression herself, shares nine valuable strategies.

1. Be there.

According to Serani, the best thing you can do for someone with depression is to be there. “When I was struggling with my own depression, the most healing moments came when someone I loved simply sat with me while I cried, or wordlessly held my hand, or spoke warmly to me with statements like ‘You’re so important to me.’ ‘Tell me what I can do to help you.’ ‘We’re going to find a way to help you to feel better.’”

2. Try a small gesture.

If you’re uncomfortable with emotional expression, you can show support in other ways, said Serani, who’s also author of the excellent book Living with Depression. She suggested everything from sending a card or a text to cooking a meal to leaving a voicemail. “These gestures provide a loving connection [and] they’re also a beacon of light that helps guide your loved one when the darkness lifts.”

3. Don’t judge or criticize.

What you say can have a powerful impact on your loved one. According to Serani, avoid saying statements such as: “You just need to see things as half full, not half empty” or “I think this is really all just in your head. If you got up out of bed and moved around, you’d see things better.” These words imply “that your loved one has a choice in how they feel – and has chosen, by free will, to be depressed,” Serani said. They’re not only insensitive but can isolate your loved one even more, she added.

4. Avoid the tough-love approach.

Many individuals think that being tough on their loved one will undo their depression or inspire positive behavioral changes, Serani said. For instance, some people might intentionally be impatient with their loved one, push their boundaries, use silence, be callous or even give an ultimatum (e.g., “You better snap out of it or I’m going to leave”), Serani said. But consider that this is as useless, hurtful and harmful as ignoring, pushing away or not helping someone who has cancer.

5. Don’t minimize their pain.

Statements such as“You’re just too thin-skinned” or “Why do you let every little thing bother you?” shame a person with depression, Serani said. It invalidates what they’re experiencing and completely glosses over the fact that they’re struggling with a difficult disorder – not some weakness or personality flaw.

6. Avoid offering advice.

It probably seems natural to share advice with your loved one. Whenever someone we care about is having a tough time, we yearn to fix their heartache. But Serani cautioned that “While it may be true that the depressed person needs guidance, saying that will make them feel insulted or even more inadequate and detach further.” What helps instead, Serani said, is to ask, “What can we do to help you feel better?” This gives your love one the opportunity to ask for help. “When a person asks for help they are more inclined to be guided and take direction without feeling insulted,” she said.

7. Avoid making comparisons.

Unless you’ve experienced a depressive episode yourself, saying that you know how a person with depression feels is not helpful, Serani said. While your intention is probably to help your loved one feel less alone in their despair, this can cut short your conversation and minimize their experience.

8. Learn as much as you can about depression.

You can avoid the above missteps and misunderstandings simply by educating yourself about depression. Once you can understand depression’s symptoms, course and consequences, you can better support your loved one, Serani said.

For instance, some people assume that if a person with depression has a good day, they’re cured. According to Serani, “Depression is not a static illness. There is an ebb and flow to symptoms that many non-depressed people misunderstand.” As she explained, an adult who’s feeling hopeless may still laugh at a joke, and a child who’s in despair may still attend class, get good grades and even seem cheerful. “The truth is that depressive symptoms are lingering elsewhere, hidden or not easy to see, so it’s important to know that depression has a far and often imperceptible range,” Serani said.

9. Be patient.

Serani believes that patience is a pivotal part of supporting your loved one. “When you’re patient with your loved one, you’re letting them know that it doesn’t matter how long this is going to take, or how involved the treatments are going to be, or the difficulties that accompany the passage from symptom onset to recovery, because you will be there,” she said.

And this patience has a powerful result. “With such patience, comes hope,” she said. And when you have depression, hope can be hard to come by. Sometimes supporting someone with depression may feel like you’re walking a tight rope. What do I say? What do I not say? What do I do? What do I not do? But remember that just by being there and asking how you can help can be an incredible gift.

by Amy Morin, LCSW Marrying someone whose first spouse passed away is much different than marrying someone who has simply been divorced. It’s important to be aware of your spouse’s needs when entering into a marriage with a widow or widower. Unlike when there’s been a divorce, the first marriage didn’t end because it didn’t work out. Therefore, there are some extra things to take into consideration.

Accept Your Spouse’s Past

Don’t pretend your spouse’s first marriage didn’t exist. You’ll need to embrace your spouse’s previous life. In fact, many people who marry a widow say they feel like their marriage includes the first spouse in some way.

In a divorce, the ex-spouse takes their possessions. When someone is widowed, their first spouse’s belongings are still around. It’s important to recognize that years after someone is widowed, their first spouse’s belongings may still be present.

Recognize the sentimental value in these item. Try to refrain from demanding that they be removed or thrown out. Instead, communicate with your spouse about your needs. For example, if your husband insists of keeping his late wife’s dinner plates and you want to use your own, discuss your options. Perhaps saving the former set for a special occasion or using both sets might be a good compromise. Don’t insist he throw them out or get rid of everything.

Educate Yourself About Grief

Your spouse will grieve even after getting remarried. This isn’t a reflection of not having enough love for you. Instead, it is important to recognize that grief is a process. It is normal to experience grief after the loss of a loved one, even when falling in love with someone else. It is possible to grieve one person and love another simultaneously.

Learn as much as you can about stages of grief and what to expect. Read books about grief. Do some online research. Consider seeing a counselor for yourself if you have questions or concerns.

It is important to know what to expect. For example, although holidays may be a joyous occasion, it may also be hard for your spouse at times. There are also going to be days that you may not be familiar with, such as birthdays, anniversaries, and the anniversary of the death, that may initiate a lot of grief for your spouse. Be patient and ask what you can do to be helpful. Sometimes a spouse may want extra support and at other times, may want extra space.

Give Your Spouse Permission to Talk about Grief

It is important that your spouse be allowed to talk about the grief process and the loss of their first spouse. Your spouse may not feel comfortable bringing this up, so by asking questions sometimes you may be giving your spouse permission to begin talking about it. It may be difficult to hear at times, but know that it can be very helpful to your spouse.

Be Patient with Extended Family

If your spouse has children, they may struggle to accept you. It likely has nothing to do with you. It just may be a difficult part of their grief process.

Be aware that extended family members may struggle to accept you as well. This is especially true of your spouse’s former in-laws. They may have a hard time seeing their son or daughter-in-law in a new marriage.

Fight the Urge to Compete

Remember, that it isn’t a competition. Try not to compare yourself to your spouse’s first husband or wife. Know that you may have to endure hearing stories about how “Jan was the best cook” or “Bill was so funny.” Don’t be offended when you hear these stories. Instead, recognize that it is a good sign that people feel comfortable talking about it and it can be part of the healing process.

It is important to recognize how you may have some similarities but will likely have plenty of differences. It’s unlikely that your spouse was looking for a “clone” of their first spouse. Instead, consider it a compliment that your spouse had such love the first time around that it was worth doing all over again! Know that it’s likely the love and the type of relationship is going to be different and it would be like comparing apples and oranges.

Create New Memories

Don’t be afraid to create new memories with your spouse. If your spouse always vacationed in Europe with his first wife, suggest going to Hawaii instead. Don’t feel pressure to fall into the same old habits. Instead, encourage your spouse to try new things and begin some new adventures together. Create new traditions at holidays and make lots of new memories together.

Communicate About Your Feelings

Be willing to speak up when your feelings are hurt. Discuss how to negotiate certain things that may be bothersome. For example, if you don’t like it when your husband refers to you as his “second wife” or when he often talks about “my first wife” see if you can come up with a plan. Sometimes there are creative yet simple solutions that can solve these problems. If the two of you struggle to talk about these things, consider seeking help from a counselor. A marriage counselor can help you learn how to work together on developing solutions for your marriage.

May 8

Why Are We so Obsessed With Improving IQ?


by Jonathan Wai, Ph.D.
David Hambrick’s recent New York Times opinion piece—“I.Q. Points for Sale, Cheap”—warns that we should be skeptical of the recent studies that claim to show that intelligence can be improved through training. The title itself suggests that these IQ points can be bought cheaply simply because these gains are likely hollow. The truth is that at this point the scientific community as a whole just isn’t sure whether genuine intelligence can be increased through training.

However, some psychologists believe they have found a way to increase intelligence that only requires hours of training. Here is a summary of that famous 2008 study led by Susanne Jaeggi and Martin Buschkuehl:

“In the Jaeggi study, the researchers began by having participants complete a test of reasoning to measure their “fluid” intelligence—the ability to draw connections between things, solve novel problems and adapt to new situations. Then some of the participants received up to eight hours of training in a difficult cognitive task that required paying careful attention to two streams of information (a version of this task is now marketed by Lumosity); others were assigned to a control group and received no such training. Then all of the participants took a different version of the reasoning test. The results were startling. The authors reported that the trained participants showed a larger gain in the reasoning test than the control group did, and despite the relatively brief period of training, this gain was large enough that it would be expected to substantially improve performance in everyday life.”

The desire to improve intelligence is not new. There have been many large scale attempts in the past which have been unsuccessful. Hence the skepticism of many researchers, including Zach Shipstead, Thomas Redick, and Randall Engle who published a thorough critique of the working memory training literature (which included discussion of the study summarized above).

Perhaps we can find ways to improve intelligence one day. However, maybe brain training isn’t the only way to approach the issue.

As Richard Haier pointed out in my article Could Brain Imaging Replace The SAT?: “The goal of our research is not to replace the SAT with brain imaging. The goal is to understand what it is about brain characteristics that make some people smarter than others. As we learn about brain/intelligence relationships and mechanisms, we might be able to manipulate the brain to substantially increase intelligence using neurochemicals or other means.”

You can go on the web today and find numerous online IQ tests that claim to tell you just how smart you are and many sites even claim that their brain training games will increase your intelligence. If you are really serious, you can find a licensed psychologist to give you an individually administered IQ test. And it turns out that if you’ve taken the SAT or ACT, you can even translate these scores into IQ scores.

However, I think that the reason the desire to improve intelligence has always been popular is because as a society we really care about smarts. The recent article in The New York Times “Can You Make Yourself Smarter?” along with Hambrick’s latest opinion piece shows that trying to make ourselves smarter has become something of a societal obsession. And the key is that we want to get smarter without having to put in much effort. That is why short term training studies are so alluring. However, why are we so obsessed with improving IQ or intelligence? Shouldn’t we be more focused on helping each person use their intelligence to accomplish whatever they are capable of and in the process allow them to develop their skills and abilities more naturally?

Arthur Jensen, when he was asked whether there was any value in knowing your IQ wisely shared the following:

“I’ve never bothered to find out my own IQ, because I don’t know what I could do with it if I knew it. It has been much more useful to me to determine, in relation to my specific goals, what specific things I knew or could do and what things I didn’t know or couldn’t do, and then set about working to learn the necessary things. That done, you go on the same way to the next step, whatever it may be. Your acquisition of knowledge and skills gradually cumulates to some level of mastery in the things of importance for the realization of your ambitions. The notion of some neutral, norm-referenced level of intellectual capacity or potential never crosses one’s mind in the whole process. This doesn’t mean that I could do anything, but I can do what I try to do, with some effort, and I don’t believe that knowing my IQ would ever have been of any use to me in the process of trying to achieve any of my goals. Even if I did happen to know my IQ, I certainly wouldn’t let that knowledge limit what I would try to do.”

So knowing your IQ doesn’t really matter. And don’t be fooled into thinking that online brain training games will increase your intelligence in any meaningful way that will help you pursue your goals. Rather, find something that you want to master and put in the hard work to realize your ambitions. Who knows? Maybe in the process you might even make yourself smarter.

© 2012 by Jonathan Wai

May 8

Sleep Disorders Linked to ADHD


By Beth W. Orenstein A growing number of sleep studies suggest a link between sleep disorders and attention deficit hyperactivity disorder (ADHD) in children. “It’s unclear, however, which comes first, the sleep problems or the ADHD,” explains Lisa Liberatore, MD, co-medical director of REM Sleep Disorders Center in New York City.

If your child has ADHD and has trouble sleeping, talk to your doctor. Studies show that behavioral interventions can help. “The best thing we can do for our children with or without ADHD is to make sure they are getting enough sleep,” says Amy Korn-Reavis, a registered respiratory therapist and polysomnography technician and coordinator of the Polysomnography Program at Valencia Community College in Florida. “They should have a fixed bedtime and have a 20- to 40-minute sleep routine prior to that bedtime to help them to go to sleep. The less sleep deprived they are, the better they will be able to focus and manage their ADHD symptoms.

Sleep Disorder No. 1: Sleep Apnea

Sleep apnea is a sleep disorder that occurs when the muscles in your upper airways relax and collapse and you momentarily but repeatedly stop breathing through the night, says David White, MD, a clinical professor of sleep medicine at Harvard Medical School. While sleep apnea in adults is often related to obesity, sleep apnea in children can be caused by allergies or having small airways. “Also, kids are starting to get obese, which could be why we’re seeing more sleep apnea in children,” Dr. White says. An ADHD child with sleep apnea can and should be treated by a sleep specialist.

Sleep Disorder No. 2: Snoring

One study of 5 to 7-year-olds found that snoring is more common in children with mild ADHD symptoms than in children with significant ADHD symptoms or with no symptoms. “We used to tell parents that snoring is nothing to be alarmed about and the child will outgrow it,” says Dr. Liberatore, who is also board certified in otolaryngology-head and neck surgery and facial plastic surgery in practice at Lexington E.N.T. in New York City. “But now we know snoring is abnormal. Snoring is a red flag that the child is not getting good-quality, deep sleep.” If children don’t have quality sleep, their performance and their attitude are going to suffer. If your ADHD child is snoring, see a sleep doctor or an ear, nose, and throat specialist — recent studies show removing a child’s tonsils or adenoids can help.

Sleep Disorder No. 3: Restless Leg Syndrome

With the sleep disorder restless leg syndrome (RLS), the legs involuntarily jerk in very regular intervals while you sleep — every 20 to 40 seconds or so. RLS is only a concern if it’s disturbing your child’s sleep, White says, because when children don’t get a good night’s sleep, they’re tired during the day and sleepiness can manifest itself as ADHD. RLS may be related to an iron deficiency and is easily treatable with medication, White adds. It can also be a side effect of ADHD medications.

Sleep Disorder No. 4: Bed Wetting

Children with ADHD wet their beds more often than children without the disorder. However, there is no evidence that one causes the other and no research to explain why it is more common in children with ADHD. “It may have something to do with the disruption of sleep caused by other issues that keep the body from secreting anti-diuretic hormones,” says Korn-Reavis. These are hormones that reduce urine output while you’re asleep.

Sleep Disorder No. 5: Sensory Processing Deficits

Sensory processing deficits (SPD) are not specific to ADHD, but children with ADHD can have SPD, says Kenny Handelman, MD, author of Attention Difference Disorder and a psychiatrist at Oakville Trafalgar Hospital-Halton Healthcare services in Ontario, Canada. Children with SPD, also known as sensory integration or SI, can’t organize their sensory responses appropriately and may be disturbed by the tag in their pajamas or loud noises outside their window, creating a sleep disorder and preventing restorative sleep. If your child has signs of SPD, talk to your doctor.

Sleep Disorder No. 6: Nightmares

Nightmares, another type of sleep disorder, usually occur during slow-wave sleep, which lasts for longer periods in young people. “Although the child may not be aware he is having nightmares, his parents usually are,” says Korn-Reavis. “Nightmares are usually brought on by anxiety and worry, which are very common in children with ADHD.” It may help ease symptoms of ADHD if children get into a regular sleep routine, have a favorite toy or stuffed animal in their bed, use a nightlight, and sleep with the bedroom door open.

Sleep Disorder No. 7: Initiation Insomnia

Children with ADHD may be taking stimulants to help them focus. Stimulants can cause sleep issues, White says. It’s important that children on medication for their symptoms of ADHD take them on a schedule so that the drugs are out of their system by the time they go to bed. Talk to your child’s doctor about what else could be causing your child to have trouble falling asleep — it doesn’t necessarily have to be ADHD, and it’s often treatable once you know the cause.

May 8

Dealing with Extramarital Attraction


BY DENISE J. CHARLES There is nothing like the headiness of a new romance to convince us that the passion and desire we feel are for keeps. We love how we feel in the early stages of our relationships: not being able to take our eyes off of our spouse, waiting longingly for that phone call or just finding deep contentment in each other’s presence. In a new marriage, sex will tend to carry an extra sizzle and can often be the high point which energizes the entire relationship.

These memories and experiences are great and important because they provide a reference point for our marriage journey. Because our memory of “falling in love” is often heady and based on the effects of physical attraction, we hold this aspect of our marriage dear and understandably expect that these exclusive feelings will last a lifetime. In most marriages, they probably will to some degree. This reality is, however, not enough to guard us from “falling into attraction” with someone else. Maintaining an attraction to our spouse is no guarantee that we may not find ourselves physically or emotionally drawn to someone else.

My counseling experience has led me to believe that because we are unprepared to deal with the eventuality of extramarital attractions, we are clueless as to how to handle them when they do come along. Because we buy into the notion of exclusive enduring romantic feelings with the one we love, we do not set out to strategically put systems in place to guard our marriage from the threat of extramarital attractions. Since we trust the commitment made to our spouse, we can respond with naiveté; unknowingly we can begin to expose ourselves and our relationship to the threat of an outside influence.

If we are going to strengthen our marriages and guard them against the threat, which external attractions can pose, I think we must first understand how they happen and then devise practical strategies for coping with them when they do occur.

Adjust Our Notion of “The One”
While I do believe in the idea of a “soul-mate” or in the suitability of one person over others based on life-scripts or personalities, I think our notion of “the one” can be sometimes flawed. There are, in fact, probably several “ones” that we could have chosen to commit to. As a consequence, we should not be glibly unaware of our potential vulnerability to someone else. Notions of finding “the one” can sometimes fuel the belief that the universe is somehow cooperating to guide us to our destiny. Where this becomes problematic is where we abdicate or minimize our personal responsibility because we believe that our relationship is somewhat special and magically shielded from the threat of temptation. We may childishly think that infidelity could never happen to us. If, however, destiny has brought a couple together, be very sure that it is a conscious, decisive commitment and action that will keep them together… not magic. Our basis for marriage therefore needs to be one of conscious choice.

Know What Attracts Us
It has been said that many women become attracted to their counselors or clergy because they find in them a man who will listen and give them his undivided attention, something they long to have with their spouses. Men on the other hand are sometimes drawn to sexually assertive women or to quietly supportive women. In both instances, our vulnerability to attraction can be based on an unmet need in our marriage. Knowing what our basic needs are and then vocalizing them to our spouses brings us into a greater level of awareness and responsibility. While this is not an automatic guarantee that we will not act on a perceived deficit in our relationship, it calls us to a higher degree of personal accountability and functioning. That being said, understanding that there will be others who we may just find physically attractive is critical for our own marriage survival. If we prepare ourselves, then we are not easily surprised and we can hopefully exercise greater control over our responses.

Dethrone Our Spouse
Yes, it is critical that we believe in, affirm and validate our partner. Complimenting, applauding and supporting the man or woman we married, is important. It is, however, also necessary that we ditch the idea that our spouse will meet our every need. Embracing our partner’s foibles, flaws, limitations and even idiosyncrasies is critical to embracing their humanity. We must not set ourselves up for disappointment by expecting a perfect marriage or spouse, this makes it easier to perceive that the grass is greener on the other side. When we focus on what we bring to the relationship as opposed to what we can simply get from our spouse, then we are less likely to succumb to extramarital attraction as a response to our unmet needs or as a consequence of an imperfect partner.

Establish Boundaries
While physical attraction can be almost instant and a chemical response to raw, instinctive, sexual energy; emotional attraction is a more complicated issue. Recognizing someone else’s physical beauty, physique or basic attractiveness can be harmless at one level. Dwelling on their attributes, seeking them out with our eyes or deliberately trying to get their attention is indicative of our lack of discipline and can prove problematic to our ability to cope with the attraction. It is critical that we establish as couples, the physical and emotional boundaries that will govern our relationship with those of the opposite sex—especially those to whom we feel attracted. This will include things like no dining alone with the attracter; no intimate discussions on marital matters or even of personal/private issues; and definitely no physical familiarity like hugging or kissing. Maintaining physical and emotional distance is paramount to preserving our marriage’s sexual integrity.

Disempower the Attraction
Keeping our attraction private is perhaps the most lethal thing we could do to our marriage. Privacy provides the breeding ground for fantasizing and for thoughts of “what if.” Being upfront with our spouse about how we feel has the potential to strip the attraction of its power since it is now exposed. We may fool ourselves into thinking that as long as there’s no actual sex involved, then the attraction is harmless and need not be uncovered; this is a mistake. Hiding the attraction to protect our partner, especially if it is ongoing, is actually a cowardly response to protect ourselves. Of course other unresolved issues in the relationship may influence how we choose to respond. In a lackluster marriage, focusing our thoughts on someone new may actually be sexually stimulating or emotionally exhilarating and we may enjoy these emotions. This is, however, of no help to the relationship as it can become a substitute for confronting the real challenges the marriage is facing.

Practice Being Present
In marriage, our sex life is seen as the barometer which reveals the state of our relationship. Paying special attention to areas that pose a direct threat to it is therefore critical if we hope to have a successful marriage. While there are no perfect marriages, being emotionally and sexually present is essential for staving off the effects of extramarital attractions, which are inevitable. Being present means having an ongoing awareness of our own and of our spouse’s needs. It means recognizing that those needs will likely change with age, added responsibility and with the growing complexities of life. Being present in our relationship also means living our marriages with intention; not expecting an automatic or childish fairytale ending, but recognizing that our marriage will reflect the effort we put in on all fronts.

“Denise J Charles” is an educator, counselor, relationship-coach, published author and blogger. She holds a Masters Degree in Education and is a qualified trainer-of-trainers. Denise is Executive Director of “Better Blends Relationship Institute,” a counseling and training entity founded by herself and her husband Gabriel. Denise’s blog on sex can be found “here”. Denise’s new book is “How To Have Mind-Blowing Sex Without Losing Your Brain.”

May 8

Depression in middle age linked to dementia


People who have symptoms of depression in middle age may be at increased risk of dementia decades later, a new study suggests.

Using medical records, researchers tracked more than 13,000 people in a large northern California health plan from roughly their 40s and 50s into their 80s. Compared to people who had never been depressed, those who experienced symptoms of depression in middle age — but not later in life — were about 20% more likely to go on to develop dementia.

Those who received a depression diagnosis later in life only were at even greater risk. That group had about a 70% increased risk of dementia compared to their depression-free peers, according to the study, which was published this week in the Archives of General Psychiatry.

Full story of depression and dementia at CNN

May 7

Does Post-Traumatic Stress Disorder Require Trauma?


By Scott O. Lilienfeld and Hal Arkowitz
Stress is an inevitable part of our life. Yet whether our daily hassles include the incessant gripes of a nasty boss or another hectoring letter from the Internal Revenue Service, we usually find some way of contending with them. In rare instances, though, terrifying events can overwhelm our coping capacities, leaving us psychologically paralyzed. In such cases, we may be at risk for post-traumatic stress disorder (PTSD).

PTSD is an anxiety disorder marked by flashbacks, nightmares and other symptoms that impair everyday functioning. The disorder is widespread. At least in the U.S., it is thought to affect about 8 percent of individuals at some point during their lifetime.

Although PTSD is one of the best known of all psychological disorders, it is also one of the most controversial. The intense psychological pain, even agony, experienced by sufferers is undeniably real. Yet the conditions under which PTSD occurs—in particular, the centrality of trauma as a trigger—have come increasingly into question. Mental health professionals have traditionally considered PTSD a typical, at times even ubiquitous, response to trauma. They have also regarded the disorder as distinct from other forms of anxiety spawned by life’s slings and arrows. Still, recent data fuel doubts about both assumptions.

Shell Shock
PTSD did not formally enter psychiatry’s diagnostic bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM), until 1980. Yet accounts of syndromes that mirror PTSD date back to Sumeria and ancient Greece, including a mention in Homer’s Iliad. In the American Civil War, veterans suffered from “soldier’s heart”; in World War I, it was called “shell shock,” and in World War II, the term used was “combat fatigue.” In the 1970s some soldiers returning from the war in Southeast Asia received informal diagnoses of “post-Vietnam syndrome,” which also bore a striking resemblance to the DSM’s description of PTSD.

According to the DSM, PTSD occurs in the wake of “trauma”—defined by the manual as an extremely frightening event in which a person experiences or witnesses “actual or threatened death or serious injury, or a threat to the physical integrity of self or others.” (Less violent experiences such as serious relationship or financial problems do not count.) The most frequent triggers of PTSD thus include wartime combat, rape, murder, car accidents, fires, and natural disasters such as tornadoes, floods and earthquakes.

PTSD is now officially characterized by three sets of symptoms. These include reliving the event through intrusive memories and dreams; emotional avoidance such as steering clear of reminders of the trauma and detaching emotional­ly from others; and hyperarousal that causes sufferers to startle easily, sleep poorly and be on alert for potential threats. These problems must last for a month or more for someone to qualify for the PTSD label.

Immune to Trauma?
After the terrorist attacks of September 11, 2001, many mental health experts confidently predicted an epidemic of PTSD, especially in the most severely affected locations: New York City and Washington, D.C. The true state of affairs was much more nuanced, however. It is certainly true that many Americans experienced at least a few post-traumatic symptoms following the attacks, but most of the afflicted recovered rapidly. In a 2002 study psychologist Roxane Cohen Silver of the University of California, Irvine, and her colleagues showed that about 12 percent of Americans suffered significant post-traumatic stress between nine and 23 days after the attacks. Six months later this number had declined to about 6 percent, suggesting that time often heals the psychic wounds.

Work by epidemiologist Sandro Galea of the New York Academy of Medicine and his colleagues, also published in 2002, revealed that five to eight weeks after 9/11, 7.5 percent of New Yorkers met the diagnostic criteria for PTSD; among those who lived south of Canal Street—that is, close to the World Trade Center—the rates were 20 percent. Consistent with other data, these findings suggest that physical proximity is often a potent predictor of stress responses. Yet they also indicate that only a minority develops significant post-traumatic pathology in the aftermath of devastating stressors. Indeed, the overall picture following the 9/11 attacks was one of psychological resilience, not breakdown.
More broadly, research that psychologist George A. Bonanno of Columbia University and his colleagues reviewed in 2011 suggests that only about 5 to 10 percent of people typically develop PTSD after experiencing traumatic life events. And although the rates rise when stressors are severe or prolonged, they hardly ever exceed 30 percent. The rare exceptions may occur with repeated trauma. In another 2011 study psychologist Stevan Hobfoll of Rush Medical College and his colleagues reported that of 763 Palestinians living in areas rife with political violence, more than 70 percent exhibited moderate PTSD symptoms and about 26 percent had severe symptoms.

The finding that PTSD is not an inevitable sequela to trauma has spurred investigators to pursue factors that forecast relative immunity to the condition. Across studies, higher income and education, strong social ties and male gender tend to confer heightened resilience, although these predictors are far from perfect. People who usually experience very little anxiety, guilt, anger, alienation and other unpleasant emotions—that is, who have low “negative emotionality”—are also less likely to suffer from PTSD following trauma. Thus, in ways that researchers do not yet understand, individual characteristics must combine with trauma to produce this illness.

Emotional Triggers
Not only is trauma insufficient to trigger PTSD symptoms, it is also not necessary. Although by definition clinicians cannot diagnose PTSD in the absence of trauma, recent work suggests that the disorder’s telltale symptom pattern can emerge from stressors that do not involve bodily peril. In 2008 psychologist Gerald M. Rosen of the University of Washington and one of us (Lilienfeld) reviewed data demonstrating that significant PTSD symptoms can follow emotional upheavals resulting from divorce, significant employment difficulties or loss of a close friendship. In a 2005 study of 454 undergraduates, psychologist Sari Gold of Temple University and her colleagues revealed that students who had experienced nontraumatic stressors, such as serious illness in a loved one, divorce of their parents, relationship problems or imprisonment of someone close to them, reported even higher rates of PTSD symptoms than did students who had lived through bona fide trauma. Taken together, these findings call into question the long-standing belief that these symptoms are tied only to physical threat.

In light of these and other data, some authors have suggested that the PTSD diagnosis be extended to include anxiety reactions to events that are stressful but not terrifying. Yet such a change could lead to what Harvard University psychologist Richard J. McNally calls “criterion creep”—expanding the boundaries of the diagnosis beyond recognition. This and other controversies aside, recent results raise the possibility that PTSD is a less distinctive affliction than originally thought and that its symptoms may arise in response to a plethora of intense stressors that are part and parcel of the human condition.

May 7

The Reality of Time for children


By Cheryl McCarthy
Now, before you allow this to become a test of your patience, know this… Kids are impatient because “now” is all they know.

You see, without a lot life experience and nascent memory skills, little ones have no real sense of the concept of “past.” Without understanding “past” there is no understanding of the more complex concept of “future.” Without “future,” there is no understanding of waiting. And it’s the waiting part that takes patience.

For young children time isn’t real because it’s not tangible. They can’t see it, hear it, taste it, smell it, or touch it. For instance, ask any two year old what she did yesterday and chances are you’ll get a blank stare. Ask her if she went to the circus yesterday, and she’ll tell you all about it. She remembers the circus. She simply doesn’t understand that it happened yesterday.

For time-strapped parents, it’s hard to imagine the very thing that rules every minute of your day can be so illusive – so NOT-real – to your child. So let’s talk about how time comes into focus for little ones…

Monday, May 23, 2011
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“Are we there yet?,” the backseat asks.

Uh oh.

“In a little while,” you answer, hoping against hope that this will satisfy her. But like every parent, you already know what’s coming… the fidgeting, the fussing, the fooling around, and the falling apart.

You have just entered The Impatient Zone.

Now, before you allow this to become a test of your patience, know this…

Kids are impatient because “now” is all they know.

You see, without a lot life experience and nascent memory skills, little ones have no real sense of the concept of “past.” Without understanding “past” there is no understanding of the more complex concept of “future.” Without “future,” there is no understanding of waiting. And it’s the waiting part that takes patience.

For young children time isn’t real because it’s not tangible. They can’t see it, hear it, taste it, smell it, or touch it. For instance, ask any two year old what she did yesterday and chances are you’ll get a blank stare. Ask her if she went to the circus yesterday, and she’ll tell you all about it. She remembers the circus. She simply doesn’t understand that it happened yesterday.

For time-strapped parents, it’s hard to imagine the very thing that rules every minute of your day can be so illusive – so NOT-real – to your child. So let’s talk about how time comes into focus for little ones…

MAKING IT REAL. Kids learn about time by moving through it. At first it may be noticing the difference between day and night — light and dark. Next, she may begin to associate time with routine, everyday things. For instance, breakfast, lunch, and dinner are regular, time-based events that make time tangible for her.

LEARNING SEQUENCE. Next comes the idea of the passage of time when she begins to grasp “before” and “after.” Putting on your socks before you put on your shoes is the very beginning of sequencing, which will later unlock abstract concepts such as “past” and “future.”

TIME MEASUREMENT. Actual increments of time — seconds, minutes, hours, days, weeks, etc. — are far more sophisticated concepts that will come to her with experience and language acquisition… dare I say it… over time.

TELLING TIME. And finally, the ability to read the clock will emerge as she begins to recognize and understand numbers and number sequencing, and relating those numbers to the time-based events in her life.
Like so many things in a young child’s life, time concepts unfold naturally through everyday experiences and the words she hears from you. So choosing your words about time is important. After all, what does “in a minute” mean to a little one who doesn’t yet understand how long a minute actually is.

Here are some of the time-based words we use casually in everyday conversation. Try to imagine what these actually mean to your child…

Soon • as soon as • shortly • almost • just about • not long • later • in a second • in a moment • in a minute • in five minutes • in a while • just a minute • not now • until • not until • before • during • while • after • yesterday • today • tomorrow • next week • next month • last week • last month • since • once • never.

Is there any wonder they get impatient?

To help your child get an understanding of time, she has to get a “feel” for it. And one of the things you can do to help that process is to make sure you’re saying what you mean. Use time language that is specific, contextual, and descriptive. A few examples…

Choose a specific time then set an egg timer, explaining that when it rings, it will be time to play.

If you can’t be specific, put time in context, such as, “I’ll play later, after dinner.”

When you’re not sure your child will understand an abstract time concept, describe it, such as, “After we wake up in the morning, it will be tomorrow and then I’ll play with you.”

Now, I can’t promise you that precision language will keep you out of The Impatient Zone entirely. But a little clarity and lot of patience and understanding on your part may make those trips through “The Zone” easier to navigate.

And one last note. When you say you’ll be there “in a minute,” be there in a minute. If you show up 10 minutes later, you run the risk of confusing her. She may begin to sense that one minute is 10 times longer than it actually is.

But even more, when you show up when you say you will, you’re teaching her the importance of keeping your word.
And on that subject, every minute counts.

SET UP. If you don’t have one, I strongly suggest going out and buying an egg timer. Setting the timer and hearing it ring is great sensory reinforcement of time concepts. Alternatively, many smart phones have timer apps already installed, or you could find a few short, one-minute songs your child loves, using them as the timer for these games.

TO PLAY. Set the timer for one minute (or whatever time increment you believe your child can manage), then go have fun! Use the following list as your starting point, then make up your own Minute Moves! But be sure not to make these games competitive. The idea here is to have your child understand what time feels like by playing and moving through time. Enjoy!

How far can you run in a minute?
How much sand can you scoop in your bucket in a minute?
How many times can your roll over in a minute?
How many blocks can you stack in a minute?
Can you hang from the monkeybars for a minute?
Can you wiggle your toes for a minute?
Can you bounce a ball for a minute?
Can you stay still for a minute?
Can you brush your teeth for a minute?
How many kisses can you give mommy in a minute?

May 6

Borderline Personality Disorder?


By Diana Rodriguez
When someone has anxiety, depression, or another form of mental health condition, symptoms are usually present day in and day out for weeks, months, or years.

People with borderline personality disorder (BPD), however, may have strong emotional episodes that last only hours at a time, flaring up time and again. And this serious psychiatric disorder is one that requires serious treatment. Why? It can destroy relationships, careers, and even someone’s life if it’s not identified and brought under control.

Unstable Relationships
One of the major symptoms of borderline personality disorder is having volatile and unstable relationships, even with close family and friends. People with borderline personality disorder can quickly swing from having intense respect and love for someone to suddenly becoming very angry and hating that loved one. Any separation or change in an expected schedule can trigger an extreme reaction and feelings of rejection in someone with borderline personality.

Unwarranted Anger
Situations that are obviously out of another person’s control or are truly insignificant can inflame the temper of a person with borderline personality disorder. One of the common borderline personality disorder symptoms is intense anger that is out of proportion to the given situation — for instance, if a parent or significant other has a work commitment that takes him away for a short time, someone with BPD may blow up in anger and hostility out of a sense of rejection and isolation.

Impulsive Spending and Other Risky Behaviors
Spending money carelessly and in excessive amounts is a risky and impulsive behavior that is characteristic of someone having an episode of borderline personality, but that’s not the only way people with BPD act out. Other destructive patterns seen with borderline personality disorder are unsafe sex, eating binges, gambling sprees, or risky driving. These are thought to be related to a poor self-image of the person with BPD.

Abusing Drugs or Alcohol
Substance abuse problems and alcohol dependency are other destructive behaviors often seen in people with borderline personality disorder. It’s common for those with borderline personality to turn to illicit drugs or to abusing alcohol during episodes of borderline personality to attempt to find escape or relief. All these issues must be treated in order to help better control borderline personality disorder symptoms.

Hurting Oneself
Borderline personality disorder symptoms can be extremely intense, and people with BPD often have issues with body image and self-esteem. It’s not uncommon for people with BPD to try to hurt themselves in some way. Destructive behaviors could include causing physical harm, such as cutting themselves. They may have suicidal thoughts or actions; these require immediate medical attention.

Feeling Empty Inside
When someone he loves is physically gone — even just for a day or only a few hours — the sense of isolation felt by the person with borderline personality disorder often leads to an intense feeling of emptiness and the inability to cope with the absence. Borderline personality disorder symptoms may include a loss of self-worth, and a loved one’s being away — no matter how innocent the reason for it — can trigger feelings of being abandoned and emptiness.

Being Afraid of Being Alone
Lashing out in anger, a hallmark of BPD, often stems from one basic yet intense and overriding fear — the fear of being alone. People with borderline personality disorder often go into a panic or rage when they feel that they are being abandoned or are left alone, whether that abandonment is real or imagined. Being so afraid of being alone can cause serious problems in relationships.

By DeeAnna Merz Nagel
I have spent time lately training therapists and writing about a therapist’s boundaries online. And so now I am curious from the other perspective, what people think about connecting with their therapist online via social media sites like Facebook, MySpace or other similar social networks?

I guess it might help for those of you who are not in the counseling profession, to talk first about our code of ethics- what we as therapists, counselors, psychologists, social workers and psychotherapists must carry out to remain ethical. Regardless of the discipline, we all have a code of ethics that we are expected to follow, and with a few differences in intent and wording, there are some ethical tenents that remain universal. Two of these tenents are with regard to confidentiality and dual relationships.

While most ethical codes have not yet addressed social media in their codes, some of us in the field have interpreted the existing codes as applied to social networking as follows:

Friending a client on Facebook or MySpace could potentially breach confidentiality. While the client may agree or even initiate the connection, others who are friends of the therapist and/or the client may “connect the dots” and assume or confirm that the person is indeed a client of the therapist.

Friending a client on Facebook or MySpace could be interpreted as a dual relationship. As a therapist I do not socialize with my clients. I don’t meet my clients for coffee and I don’t go to their home for dinner. Inviting a client to my Facebook page is like inviting a client into my living room.

May 6

Questions Doctors Ask When Screening for Depression


By Chris Iliades, MD Not everyone experiences the same warning signs of depression. Some people may endure sadness, hopelessness, feelings of guilt; others may lose interest in their favorite activities, have trouble thinking clearly, or face fatigue and changes in their sleeping or eating patterns. That’s why diagnosing depression isn’t always easy — and why doctors have developed a number of screening tools to help determine if you are at risk.

“Diagnosing depression requires a complete history and physical exam,” says Richard Shadick, PhD, associate adjunct professor of psychology and director of the counseling center at Pace University in New York City. Doctors must also rule out medical problems such as thyroid disease and consider coexisting emotional health issues like anxiety disorder, post traumatic stress, and substance abuse.

What goes into a depression screening? “There are many types of depression scales and depression screens,” explains Shadick. “The questions asked look for common symptoms as well as how much these symptoms might be affecting a person’s ability to function and maintain relationships.”

Which Depression Screening Will Your Doctor Use?

Two of the most commonly used standardized screening tools for depression are the Hamilton Depression Rating Scale (HAMD) and the Montgomery-Asberg Depression Rating Scale (MADRS). These depression screenings may also include questions that are specifically designed to screen the elderly or children.

Some doctors also rely on the Beck Depression Inventory and the nine-item Patient Health Questionnaire (PHQ-9). “These various screens may include questions about motivation, fatigue, sleep patterns, suicidality, or hopelessness. They may also ask about frequency and duration,” adds Shadick. “In most cases, a depression symptom must be present most days of the week for at least two weeks to be significant.”

The Type of Questions Your Doctor Will Ask

Here are some typical questions from a few of the more common depression screening scales:

From PHQ-9: “In the past two weeks, how often have you felt down, depressed, or hopeless?” Your possible answers include: Not at all, several days, more than half the days, or nearly every day. Feeling down for more than half the days or nearly every day over the past two weeks suggests depression.
From the HAMD: “Have you had any thoughts of suicide?” Answers to this question allow mental health professionals to rate the severity of depression. The person being screened can answer as follows: Never, some thoughts of death, some thoughts of suicide, or some attempt at suicide.From the MADRS: “How is your sleep?” Answers include: Sleeping as usual, slight difficulty, sleep reduced by at least two hours, or getting less than three hours of sleep at night. Greater sleep disturbance signals a greater risk for depression.
From the Beck Depression Inventory: “How is your energy?” Declines in energy level are a common sign of depression — the more significant your lack of energy, the higher your depression risk rating. Possible answers to this question include: As much energy as ever, less energy than before, not enough to do much, or not enough to do anything.
From the Geriatric Depression Scale: “Do you prefer to stay at home rather than going out and doing new things?” This question asks for a yes or no answer and recognizes that isolation and withdrawal are common signs of depression — especially in the elderly.
True depression isn’t the same as occasional periods of feeling down. The questions mental health professionals ask when screening for depression try to determine how many symptoms of depression you have, how long you have had them, and how much they interfere with your ability to live life normally.

If you answer yes to some of these warning signs of depression, and your symptoms have been present for more than two weeks, you could be depressed. But don’t forget: Screening for depression is just the first step to helping you get better. Depression treatments work — so answer the questions as honestly as you can, and don’t be afraid to ask for help.

May 5

Sleep disorders can cause hyperactivity


The bottom line is that doctors have to look at the big picture and not have tunnel vision. The same is true for Attention Deficit Hyperactivity Disorder ADHD). Just because your child is hyperactive or has difficulty with their schoolwork does not mean they have ADHD.

Even if your child truly has ADHD, they may also have other disorders that contribute to, exacerbate or mimic ADHD. Specific learning differences may exist such as dyslexia, visual or auditory perceptive disorders and a host of other learning disabilities may be present. Hyperactivity may be a reflection of boredom, anxiety or other psychiatric or neurologic disorders. The American Psychiatric Association estimates the incidence of ADHD in school-aged children at 3 to 7 percent. Many, if not most, of these children are placed on stimulant medications.

Many of these children’s symptoms of ADHD improve on these medications, but a signifi- cant proportion of these children not only does not improve with stimulants, but suffer from side effects or show little or no improvement at all. On top of that, these medications are often not covered by insurance and they can be very expensive. There is another saying in medicine that we teach our medical students, interns and residents early in their careers: “If you hear the sound of hoof beats, think horses, not zebras.” In other words, they should think of something common before thinking of an exotic or uncommon diagnosis.

Unfortunately, as a sleep disorders specialist, I see far too often a child that has been labeled with a diagnosis of ADHD without their pediatrician or family physician having also considered two common sleep disorders as possible causes or contributing factors to their symptoms of ADHD. The two common sleep disorders that I refer to are obstructive sleep apnea (OSA) and restless limb syndrome (RLS).

In last month’s Acorn, I wrote about OSA in adults. In the pediatric population, the prevalence of OSA has been estimated at 2 to 3 percent of otherwise normal children. Unlike adults, whose primary symptom is excessive daytime sleepiness, sleepiness is a rather uncommon complaint in children with OSA. Think about what happens to children who do not sleep well at night, the main consequence of OSA. They are cranky and irritable. They don’t pay attention. They act out. They won’t sit still, and they frequently perform poorly in school. These are many of the same symptoms that occur in children with ADHD.

RLS is a disorder in part manifest by an irresistible urge to move the legs. The National Institutes of Health estimate that one million school-aged children in the U.S. have RLS, with onethird having moderate to severe symptoms. In addition, 80 to 90 percent of patients with RLS also have Periodic Limb Movements during Sleep (PLMS), a disorder that disrupts sleep, often without the patient themselves knowing it.

Just like the sleep disruption occurring in OSA, the sleep disturbance associated with PLMS causes daytime symptoms mimicking the inattentiveness, difficulty with concentration, poor school performance, behavioral difficulties and hyperactivity of ADHD. To further support the overlap between RLS and ADHD, a deficiency in central nervous system iron has been found in both disorders. Treating patients with iron supplements has been found to improve symptoms of both RLS and ADHD.

The point of this article is not to debunk a diagnosis of ADHD, a real disorder affecting a signifi cant number of children every year. But two common sleep disorders are often confused with ADHD and should be considered in any diagnosis of ADHD. There is a great deal of overlap in the symptoms of ADHD, OSA and RLS. Furthermore, all of these diagnoses can coexist in the same child, and frequently do.

Treating only ADHD without considering the possibility of coexisting OSA and/or RLS is a prescription for failure and denies your child the greatest opportunity to succeed in school and life.

What should you do if you or a loved one has been diagnosed with ADHD? See your doctor and ask about the possibility of coexisting OSA or RLS. Ask your doctor for a referral to a board certified sleep specialist at an accredited sleep disorders center.

Dr. Ronald Popper is medical director of the Southern California Pulmonary and Sleep Disorders Medical Center. He is board certified in sleep medicine by both the American Board of Sleep Medicine and the American Board of Medical Specialties. For more information, visit

May 5

Blood Test Close To Help Spotting Depression


By Randy Dotinga, HealthDay News FRIDAY, Feb. 3, 2012 (HealthDay News) — Depression can be a tough condition to diagnose accurately, but new research suggests that someday a blood test might help.

It’s not clear how much the test might cost, and it needs more stringent validation before it will be ready to be used in medical offices. Still, “it appears that these results are promising, after decades of research into finding a biological test for depression,” said study author Dr. George Papakostas, an associate professor of psychiatry at Harvard Medical School.

The study was funded by the Ridge Diagnostics Co. and appeared in a recent issue of the journal Molecular Psychiatry. It may seem like depression is an easy condition to diagnose and doesn’t need a test to verify that it exists, but Papakostas said there are several ways that a blood-based depression test might be helpful.

For one, he said, a test could help doctors who aren’t as experienced in psychiatric disorders. Also, he said, a test may provide assistance to doctors who aren’t sure about the proper diagnosis of a patient: “This could be of help to them, in terms of guiding them in one way or another,” he said.

Yet another use for a test would be to verify that a patient has depression, and therefore help him or her accept the diagnosis. “The majority of patients diagnosed with depression have no problem accepting the need for treatment,” Papakostas said. However, “there is a minority of patients who feel that validation of an underlying process is helpful,” he added. In their study, Papakostas and his team gave a blood test to 36 patients with depression and 43 people who weren’t depressed. The test looked for levels of nine different “biomarkers” in the blood that are associated with depression. These biomarkers are linked to inflammatory processes, the development and maintenance of brain cells, and interactions between brain structures associated with the stress response and other functions.

The researchers found that the test correctly identified patients with depression 91 percent of the time; the rest of the time it gave a false-negative diagnosis (it failed to spot the depression). The test correctly identified patients who weren’t depressed about 81 percent of the time, giving false-positives the rest of the time.

The next step is to try to confirm these findings through further research, Papakostas said. He didn’t know how much the test might eventually cost, but he said it won’t be as high as thousands of dollars and should be more akin to routine blood tests.

The test appears to detect inflammation in the brain, which has been linked to depression, Papakostas said. “That really doesn’t surprise researchers. Chronic inflammation has been tied to a number of other illnesses in the kidneys, lungs and heart,” he noted.One outside expert said such a test would be welcome.

Dr. Michelle Riba, a professor of psychiatry at the University of Michigan who’s familiar with the findings, said a blood test for depression could be helpful in several ways. For one, it would be useful to identify people, especially children and adolescents, who are prone to depression and try to prevent it, she said. Also, she said, a test could help give physicians insight into how depression treatments are working over time.

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