Category: Mental Illness

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Chris Tuell Ed.D., LPCC-S, LICDC-CS
Clinical Director of Addiction Services Lindner Center of HOPE
Assistant Professor, Department of Psychiatry & Behavioral Neuroscience University of Cincinnati College of Medicine

In 1987, Francine Shapiro went for a walk. While on her walk, Francine was contemplating some very upsetting personal events that were occurring in her life at the time. But as she began to focus on this upsetting information, she noticed that her eyes began to flicker from side to side. More importantly, she noticed that the once upsetting information was no longer as upsetting. Shapiro felt that she had stumbled on some aspect of how the mind processes information. Eye Movement Desensitization and Reprocessing, better known as EMDR, was born.

For the past 30 years EMDR has become one of the most effective therapeutic approaches in the treatment of trauma. EMDR is not only approved by the American Psychiatric and Psychological Associations, but also by the United States Department of Defense and the Veterans Administration, as an effective therapy in the treatment of post traumatic stress disorder (PTSD). Dr. Shapiro believes that one of the major theories behind EMDR is the bilateral stimulation of both hemispheres of the brain. When we sleep at night, our brain continues to process information. This occurs during rapid eye movement sleep or better known as REM sleep.

The brain processes the events of the day, keeping what is important (e.g. family, work, school, friends), and purging what is unimportant (e.g., What I had for dinner last Tuesday). How many times have we have been faced with a tough decision and resorted to, “I’ll just sleep on it,” only to awake the next morning with a better idea of what to do? But when a traumatic event occurs, the processing of this information becomes disrupted. The brain becomes unable to process and clear the event or information, resulting in the trauma experience continuing to occur as if it is happening all over again. In this playing-out, the right hemisphere of the brain, the part of our brain that experiences emotions such as fear and anxiety, continues to be activated by the unresolved trauma. The patient experiences this activation through intrusive thoughts, flashbacks, and disturbing dreams, the basic elements of PTSD.

EMDR involves the bilateral stimulation of both hemispheres of the brain while targeting the upsetting aspects of the trauma. In therapy, the therapist recreates what happens naturally during REM sleep, with the movement of the eyes as they follow the therapist’s hand, stimulating both hemispheres of the brain. Over the years, additional bilateral stimulation methods have been found to be effective (i.e., tactile, audio). This targeting involves, not only activating the image of the event, but also identifying the negative thoughts, emotions and sensations experienced by the patient from the trauma. During the reprocessing of the trauma experience, the logical, rational part of the brain, the left hemisphere, is integrated with the right emotional hemisphere. This results in the patient having a more adaptive response to the trauma. The patient may still have memory of the event, but the emotional aspects of fear and anxiety have dissipated. During EMDR, the left hemisphere of the brain, the rational, logical part, is integrated with the emotional right hemisphere of the brain, resulting in the patient feeling and knowing that, “The trauma is no longer happening to me now; The trauma is in the past; I am safe now.”

EMDR is not a wonder cure nor is it a quick fix. EMDR involves hard work by the patient and it takes a good amount of clinical skills in order to implement. This is not about touching the person’s forehead and he or she is better. The patient and therapist have to be responsible and work at this process, but it does appear to go much more rapidly than traditional types of therapy. If a trauma can occur within a few moments, why do we automatically accept that it has to take years to undo it?

More than 20,000 practitioners have been trained to use EMDR since its discovery. The use of EMDR has been found to be beneficial in other areas of mental health besides, PTSD. Areas such as panic disorders, anxiety disorders, grief, pain, stress, addiction, and abuse, have shown to be responsive to this unique therapy. One aspect of EMDR that I have found to be valuable is the fact that it is unnecessary for me, as the clinician, to know all the details and specifics of a patient’s trauma in order for EMDR to be helpful. Many individuals who have experienced trauma stay clear of therapy for fear of reliving the memories and feelings. The EMDR protocol allows for such traumatic episodes to be addressed and reprocessed without describing the details of the trauma. As a practitioner, I have found EMDR to be a valuable therapeutic tool in assisting patients in moving past one’s past.

For more information about EMDR: https://www.emdria.org

 

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By Marcy Marklay, LPCC, Adolescent Therapist,
Lindner Center of HOPE

Technology has changed the way people bully each other. Cyberbullying via text messages and use of social media, as well as the more traditional forms of bullying,can occur in childhood, adolescence and into adulthood, even in college and in the workplace. Bullying is far from uncommon and needs to be addressed.

Reasons For Bullying
Bullying can occur due to someone being different. Elevating one’s social status can be a common motivating factor for bullying. Some bullies are motivated by obtaining power and control of others through fear. Some groups can gang up on someone, or another group, because of different beliefs, for example, being bullied for being lesbian, gay, bisexual, or transgender (LGBT).

How It Appears
Bullying can be subtle or overt, occur once or be persistent and chronic in nature. Bullies can use rumors or gossip and berate a victim and turn others against them in a deliberate attempt to sabotage their reputation. Chronic bullying takes a greater toll on the bullied individual, and can lead to mental, emotional, physical and social harm.

Addressing Bullying
Best practices in addressing bullying will include providing education about bullying as well as providing treatment interventions to those individuals affected or targeted by bullying. Education needs to include what to look for or ways to identify bullying, why bullying is harmful and unacceptable, and how to go about reporting it. It is generally a bully’s goal to disempower the victim. Teaching assertiveness skills are not the only interested in touring method to teach the target of bullying. More recently, utilizing bystander intervention has become increasingly helpful in combating bullying because it addresses the problem from a systems or group perspective. Bystander intervention involves enlisting the help of others in the school or community to assist in addressing and reducing the problem behaviors, by using a social norming campaign to teach students about appropriate behaviors. By adopting a community responsibility standard, bullying can be reduced in an environment where it is not acceptable. The number of individuals willing to confront bullying , whether cyberbullying , assault, threats, verbal abuse, or offensive behavior that can be humiliating, intimidating or threatening can be reduced more significantly in this way.

It is important to thoroughly listen to the victim of bullying’s story without quickly jumping to conclusions, and to explore possible options, such as what a treatment professional can provide, a victim can do for themselves, what a school or the police can do to help the victim. Narrative therapy is helpful in letting the victim tell their story. It can help them look at what is in and out of their control. It can externalize the negative experience of being bullied from the victim. In some cases a threat assessment is indicated to assess for the potential escalation of violence by the bully and retaliation from the person being bullied. Suicide prevention is also a concern, as some who are bullied may become suicidal and need crisis intervention. Victims can experience a wide range of symptoms due to being bullied, which are not limited to anxiety, depression, somatic complaints, falling grades, family stress, isolation. Victims often blame themselves. It is critical to focus on finding a sense of safety, addressing mental health concerns, and connecting the victim to a support system. Work on self-esteem and coping skills is helpful, and working to restore lost confidence is a goal. Victims may suffer from depression, anxiety, panic attacks, PTSD, acute stress disorder and even suicide. The victim’s primary relationships may suffer as a result of the bullying.

Help for victims
Helping those who have been bullied includes exploring ways to heal, examining realistic solutions to the problems, and prioritizing health. Encourage self-care and social support. Provide psychoeducation. Assist victims with finding resources. Keep a focus on the present and near future; focusing too much on the past does not give the goal-directed and strengths based approach these individuals need. Role playing and practicing and rehearsing coping skills in a safe space can be empowering. There is immense power in the act of listening to a victim of bullying. Parents are important in supporting the young person and can also benefit from internet and online safety training, and social media training along with their children. Many parents fear the internet and require their children avoid technology, which may help in the short term, but is not a realistic long term solution, as the internet is used for homework, employment and socialization. Teaching internet and online safety skills to both youth and parents is most effective. Parents then can become good role models for youth in using technology, enhance communication and develop a greater bond; this can result in personal empowerment for both youth and their parents.

Source
Cyberbullying: What Counselors Need to Know by Dr. Sheri Bauman; published in 2011

 

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Amanda Porter, MSN, APRN, PMHNP-BC

Psychiatric Nurse Practitioner, Lindner Center of HOPE Board-Certified in Internal Medicine, Psychiatry/Mental Health, and Addictions

 

The question of “What causes mental health disorders?” is the eternal question on the field of psychiatry. The most widely accepted theory as to the cause of depression thus far has been the neurotransmitter theory; however even with correct diagnosis and appropriate treatment “between 40% and 70% do no respond to treatment, or only partially, while roughly half of patients who do achieve full remission following txt for severe depressed mood relapse within 2 years even when continuing on antidepressants.” (Greenblatt & Brogan, 2016; Keitner & Mansfield, 2012). Even when we place patients on medications meant to boost their neurotransmitters, often remission of mood disorder symptoms is elusive. Therefore, it behooves us as clinicians to seek out complementary and integrative methods (CIM) for treating for mood disorders that can augment or sometimes replace traditional medical treatments.

One method of CIM includes Mindfulness and Meditation. Broadly, this is described as cultivation of awareness, relaxation, focused attention and stillness. This is a methodology pioneered by Jon Kabat-Zinn. Release of serotonin, GABA, dopamine and melatonin occurs during meditation (Newberg, 2010). Since 2009, roughly 10 studies have examined the efficacy of mindfulness practices with patients who were unresponsive to antidepressant therapy. Three-quarters of these studies showed statistically significant reduction in Ham-D scores (Jain, 2015). Mindfulness has been suggested to have the ability modulate the immune system itself as demonstrated in HIV-infected adults who show increased in circulation of CD4+ T lymphocyte counts (Cresswell, 2009).

Another method of CIM includes Spirituality/Prayer. Many of my patients experience depression surrounding some pretty heady questions such as “What is my purpose in life? What was I created for? What happens after I die?” Becoming involved in a faith community, and engaging in spiritual practices associated with that community increase a sense of belonging and self-worth in a person, which leads to overall improved mental health. “In a systematic review of 850 studies of religion and mental health, religion was associated with greater overall well-being in 79% of these studies, lower suicidality in 84%, lower depression 66% and lower anxiety in 51%.” (Koenig, 2001).  Also, it’s postulated that while a sense of well-being and purpose provides greater benefit in preventing depression, a positive relationship with God provides greater benefit after onset of depression.

Another method of CIM includes Yoga and Movement therapies. Yoga and other movement therapies such as Tai Chi or Qi Gong have been found to be helpful for depression, ADHD, anxiety and chronic pain and are especially helpful in vulnerable populations such as pregnancy, adolescents or the elderly. When combined with meditation, this is an incredibly effective therapy, and the beauty of Yoga practice is that even 15 minutes a day can be helpful, so it’s not time-consuming. Yoga practitioners downregulate their HPA axis and modulate their cortisol levels (Sieverdes, et al 2014). Yoga and Tai Chi also have excellent indication for sleep duration with less arousal time. The mechanisms that are involved in the effects of yoga on stress response include the following: positive affect, self-compassion, and inhibition of the posterior hypothalamus and salivary cortisol (Riley, 2015).

Another method of CIM includes Exercise. With depression, often the patient becomes isolated, withdrawn, with poor motivation. This leads to increase in sedentary behaviors. Therefore, it’s important to increase activity in the form of exercise. The higher the dose, the lower the risk of relapse rates in patients with MDD, with 10 days being sufficient to begin seeing an improvement in mood (Knubben, et al, 2007). Exercise increases rate of neurogenesis, production of BDNF, increases serotonin by increasing tryptophan, increases norepinephrine, increases phenylethylamine, decreased cortisol, increase endorphins, and increases dopamine (Greenblatt & Brogan, 2016). It’s hypothesized that exercise helps the brain deal more efficiently with stress by enhancing the body’s ability to respond to stress, and coordinating the sympathetic nervous system response (McWilliams, 2001).

Another method of CIM includes appropriate Nutrition. There is an ongoing discussion about the gut-brain connection and the impact that our nutritional choices have on our mental health. The typical Western Diet consist of high fructose foods or beverages, transaturated fats, with large amounts of carbohydrates in the form of bread products. Sugar and gluten are both incredibly inflammatory, and alter the microbiome of the gut. Factors like alcohol, antibiotic use, NSAIDS, cytokine production, and psychological stress increase also intestinal permeability (Greenblatt and Brogan, 2016). So our dietary choices do have great impact on our mental health. Gluten attacks an enzyme involved in the production of GABA (Kramer & Bressnan, 2016). Patients with schizophrenia and autism are at higher risk for intolerance to gluten, and respond very positively to gluten-free and casein-free diets. Higher dietary fiber content was associated with lower odds of depression; increased consumption of vegetables and nonjuice fruit was associated with lower odds for depression; added sugars, but not total sugars or total carbohydrates, to be strongly associated with depression incidence (Gangswisch, 2015). It’s important to remember that sugar is not the enemy here, but excess sugar is. As with most things in life, balance is key.

Further methods of CIM used to treat mood disorders include: Creative Arts including painting, drawing, music, dance, and writing/narrative medicine; Nature therapy; Pet therapy; Water therapy/Floating; Life coaching/Financial planning; Massage therapy; Acupuncture; Micronutrient therapy; Essential oils; Light therapy; Media fasts; Psychotherapy; and TMS/ECT.

At Lindner Center of HOPE, an Integrative Mental Health consult service incorporates the above treatment modalities, aimed at addressing mental health disorders as holistically as possible. The goal is to strive for recovery with the whole person in mind.

 

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By Danielle J. Johnson, MD, FAPA
Lindner Center of HOPE, Chief of Adult Psychiatry

May is Maternal Mental Health Awareness Month.  One in five women will develop a maternal mental health disorder.  They are also referred to as perinatal mood and anxiety disorders (PMADs) to emphasize that women experience more than postpartum depression during pregnancy and after birth.  Women who have symptoms of PMADs might not seek help because of guilt, shame, or embarrassment for feeling something different than the expected norms of motherhood.  Awareness and education are important to reduce stigma so mothers and babies get the help they need.

PMADs can occur during pregnancy or up to one year after giving birth. The most common PMAD is the “baby blues”, affecting up to 80% of new mothers.  Symptoms include sudden mood swings, loneliness, sadness, crying spells, loss of appetite, problems sleeping, irritability, restlessness, and anxiety.  These symptoms are a normal adjustment to changes in hormones and resolve without treatment in two to three weeks.

About 10% of women experience depression during pregnancy and about 15% during the first year postpartum.  Feeling sad, hopeless, helpless, or worthless; fatigue, difficulty sleeping or sleeping too much, appetite changes, difficulty concentrating, crying, loss of interest or pleasure; lack of interest in, difficulty bonding with, or excessive anxiety about the baby; feelings of being a bad mother, and fear of harming the baby or self are symptoms of peripartum depression.  Risk factors include poverty, being a teen mother, advanced maternal age; personal or family history of depression, anxiety, or postpartum depression; premenstrual dysphoric disorder, inadequate support, financial stress, relationship stress; complications in pregnancy, birth or breastfeeding; a history of abuse or trauma, a major recent life event, birth of multiples, babies in neonatal intensive care, infertility treatments, thyroid imbalance, and diabetes.

Anxiety can occur alone, or with depression, in 10% of new mothers.  Symptoms include constant worry, racing thoughts, inability to sit still, changes in sleep or appetite, feeling that something bad is going to happen; and physical symptoms like dizziness, hot flashes, and nausea.  Some mothers may also have panic attacks with shortness of breath, chest pain, dizziness, a feeling of losing control, and numbness and tingling.  Risk factors are a personal or family history of anxiety, previous perinatal depression or anxiety, and thyroid imbalance.

Post-traumatic stress disorder (PTSD) can occur in up to 6% of mothers following a traumatic childbirth.  Possible traumas are prolapsed cord, unplanned C-section, use of vacuum extractor or forceps to deliver the baby, baby going to NICU; and feelings of powerlessness, poor communication and/or lack of support and reassurance during the delivery.  Women who have experienced a previous sexual trauma are also at a higher risk for developing postpartum PTSD.  Intrusive re-experiencing of the traumatic event, flashbacks or nightmares; avoidance of stimuli associated with the event; increased arousal (irritability, difficulty sleeping, hypervigilance, exaggerated startle response); anxiety and panic attacks, and feeling a sense of unreality and detachment are symptoms of PTSD.

Obsessive-compulsive disorder (OCD) can occur in 3% to 5% of new mothers.  Obsessions are persistent, repetitive thoughts or mental images, often related to the baby. Obsessions can be so bizarre or disturbing that they can be mistaken as psychosis.  Compulsions are repetitive acts performed to reduce obsessions.   Mothers are distressed by the obsessions which can lead to a fear of being left alone with the baby or hypervigilance in protecting the baby.  Mothers with postpartum OCD know that their thoughts are out of the ordinary and are unlikely to ever act on them.

Postpartum psychosis is the most severe of the PMADs.  It is often associated with an episode of bipolar disorder. It is rare, occurring in 1 to 2 per 1000 women.  The onset is abrupt, within 48 to 72 hours and up to two weeks after delivery. This is a psychiatric emergency, requiring immediate treatment.  Mothers may experience hallucinations (hearing voices or seeing things) and/or delusions (believing things that aren’t true.)  If psychosis occurs as part of a bipolar manic episode, there might be additional symptoms such as irritability, hyperactivity, decreased need for or inability to sleep, paranoia and suspiciousness, rapid mood swings, difficulty communicating, and confusion or memory loss. Risk factors are a personal or family history of bipolar disorder or a psychotic disorder.  Most women with postpartum psychosis do not have violent delusions but there is an up to 5% rate of infanticide or suicide due to acting on delusions or having irrational judgement.

PMADs are the most common complication of pregnancy and childbirth.  They are treatable with psychotherapy and/or medication and early intervention provides relief for the mother and ensures the baby’s wellbeing.

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By Michael O’Hearn, MSW, LISW-S

The drum is one of the oldest musical instruments. An interesting paradox of medical and cognitive neuroscience is how a range of intra- and inter-personal stress mediation, self-regulation, and mind-body continuity interventions are accomplished through ancient
traditions of meditation (mental training) (Davidson & McEwen, 2012; Khalsa, Rudrauf, Davidson, & Tranel, 2015), and drumming (Bittman, Berk, Fleton, Westenguard, Pappas, & Ninehouser, 2001; Bittman, Berk, Shannon, Sharaf, Westenguard, Guegler, & Ruff, 20015; Bittman, Croft, Brinker, van Laar, Vernalis, & Elisworth, 2013).
This paper outlines a drumming technology that naturally integrates with Shamatha (Object) meditation (Ponlop, 2006). Drumming technology is a source of practically limitless transverse, bi-lateral, fine, and gross motor algorithms for individuals, couples, or groups. The targeted and individualized interventions (algorithms) serve as the object of Shamatha meditation. The psychoneuromuscular (PNM) practice not only conditions self-regulation, mind-body continuity, and stress mediation; the acquired abilities are eventually habituated in procedural or working memory (Sacks, 2007; Sapolsky, 2017) in
client systems.
The proposed drumming technology is central to a theoretical paper on music-based learning culture in former totalitarian undergraduate, graduate, and post-graduate education. It is expected to be published by Summer, 2018. Michael Radin, Ph.D., a classically trained pianist and Mathematics Professor at the Rochester Institute of Technology and Riga Technical University, and Liga Engele, Head of the Music Therapy
Center at Leipaja University, Latvia are lead and co-authors.

A Drumming Technology
The following is a description of drumming technology components and processes, some dyadic tables, and a low complexity algorithm. Table 1 and 1a outline phalange/hand, and foot sources for drumming algorithms:

 

 

 

 

 

 

 

Time Signatures. Time signatures are expressed as fractions; Table 2 illustrates a 4/4-time signature. The denominator represents the total number of beats per measure; the numerator represents the number of beats played per measure. Any source combinations can fit with practically any desired time signature.
Additional time signatures are not limited to 3/3, 3/4, 2/4, and 6/8.

Basic Rhythms. The following are basic rhythmic patterns ubiquitous in drumming and dance choreography. Again, any combination of  sources can fit these basic rhythms.

 

 

 

Accents. Downbeat and syncopation are two examples of various  accents to basic rhythms. Table 2 also illustrates the downbeat accent in 4/4 time.

 

 

Syncopated rhythms have accents that are not necessarily patterned or predictable; the accent often “anticipates,” or is played on the half-beat in Latin rhythms, Jazz, and progressive rock music. As syncopated  rhythms require additional effort and resources to capture and integrate, they are indicated to enhance integration in trauma recovery (van der Kolk, 2009; 2014) patients.

Medium. Drum kit, hand drum, finger drum, homemade drum, lap,  belly, table, or other are examples of medium – the instrument selected for a drumming algorithm.

Tuplet. Tuplet is the number of strokes attributed to each beat (the numerator) in any time signature; typically, single, double, or triple.

Tempo. A metronome is a meter that measures tempo in beats per minute/second (bpm/s), and provides an auditory “click track.” The  practitioner plays at a precise tempo, in sync or “on meter” with the  metronome. There are advantages to fast and slow tempo. Drumming  algorithms can emphasize one, the other, or include both.

Duration. Duration is the length of time of practice session, or the number of repetitions a drumming algorithm is played.

Examples of Dyadic Tables and a Drumming Algorithm.
The following are samples of fine and gross motor, transverse and bi-lateral dyadic tables for drumming algorithms. It is followed by an  illustration of a low complexity drummingalgorithm.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUMMARY
Meditative drumming is a psychoneuromuscular (PNM) intervention for individuals, couples, and groups that facilitates self-regulation, mind-body continuity, and stress reduction.
Individualized drumming algorithms are designed to engage one or a combination of: autonomic/vagal, cognitive, emotional, language,  visual-spatial, fine/gross motor, and memory along transverse and/or  bi-lateral pathways. Acquired abilities from meditative drumming algorithms are eventually habituated in procedural or working memory (Sacks, 2007; Sapolsky, 2017).

Its value for generating nonlinear efficacy in all settings (including all levels of care continuums), is matched only by its portability and cost efficiency.

REFERENCES
Davidson, R. & McEwen, B. (2012). Social influences on neural plasticity: Stress and interventions to promote well-being.
Nature Neuroscience, 689-695.
Khalsa, Rudrauf, Davidson, & Tranel. (2015). The effect of meditation on regulation of internal body states. Frontiers in Psychology, 1-15.
Bittman, B., Berk, L., Felten, D., Westenguard, J., Pappas, J., Ninehouser, M. (2001). Composite effects of group drumming music therapy on modulation of neuroendocrine-immune parameters in normal subjects, Alternative Therapies In Health and Medicine, Jan: 7(1), 38-47.
Bittman, B., Berk, L., Shannon, M., Sharaf, M., Westenguard, J.,
Guegler, K., Ruff, D. (2005). Recreational music-making
modulates the human stress response: a preliminary
individualized gene expression strategy, Medical Science
Monitor, 11, BR31-40.
Bittman, B., Croft, D., Brinker, J., van Laar, R., Vernalis, M., & Elisworth,
D. (2013 Recreational music-making alters gene expression pathways in patients with coronary artery disease, Medical Science Monitor,19, 139-147.
Ponlop, D. (2006). Mind beyond death. Ithaca, NY: Snowlion.
Sacks, O. (2007). Musicophilia. NY: Vintage.
Sapolsky, R. (2017). Behave: The biology of humans at our best and worst. NY: Penguin.
van der Kolk, B. (2009). Presentation of Trauma and Recovery, to the Milton H. Erikson Foundation Evolution of Psychotherapy Conference, Sacramento, CA.
van der Kolk, B. (2014). Trauma Recovery presentation to the 2014 International Trauma Conference, Boston, MA.

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By Jennifer L. Shoenfelt, MD
Board Certified Child, Adolescent, and Adult Psychiatrist, Lindner Center of HOPE
Assistant Professor, University of Cincinnati, College of Medicine, Department of Psychiatry and Behavioral Neuroscience
Assistant Professor, Wright State University, Boonshoft School of Medicine, Department of Psychiatry

There are several levels of psychiatric care for children and adolescents. These are separated by the acuity of the clinical scenario, past care, and the goals of treatment. The least restrictive type of care is the outpatient setting.  Higher levels of care include intensive outpatient, partial hospitalization, inpatient hospitalization, and residential treatment centers. Residential care exists in different settings or types of environments. Residential care is often considered when a child has “failed” other less restrictive interventions, such as having repeated inpatient stays in a short span of time. Residential care is also considered when the adolescent‘s family feels unable to assure the teen’s safety or the safety of other family members in any other environment. The following outlines advantages to pursuing or choosing residential treatment options.

  1. Residential treatment programs are longer in duration than most other levels of care. These programs range from 10-14 days for a diagnostic program to 3 months or longer for long term therapeutic interventions. In residential settings, the patient is away from home, living at the facility. Often, this means that the adolescent is a significant distance away from their family. They are removed from their daily stressors and the environment that is likely contributing to their current mental, physical and behavioral state.
  2. Residential treatment affords diagnostic clarification which includes in-depth testing, observational analysis, formalized testing, concentrated, in –depth, historical information gathering, and observation of family dynamics and social interaction. Professionals in multiple areas of expertise interact with the patient and then collectively formulate a differential diagnosis over time. Most programs are staffed with physicians, psychologists, social workers, teachers, chemical dependency counselors, nurses, family therapists, dieticians, and other specialty area professionals.
  3. Residential programs offer a vast array of therapies and approaches that are not commonly available in other treatment programs. Utilizing a combination of therapies or approaches may be what the adolescent needs to achieve success they could not find in other limited programming. For instance, a partial hospitalization program may be able to offer, dialectical behavioral therapy, group therapy, and recreational therapy among their regimen of daily activities. However, a residential program may be able to combine this with family systems therapy, cognitive behavioral therapy, acceptance and commitment therapy, eye movement desensitization and reprocessing, yoga, equine therapy, holistic approaches, martial arts, community service, academic planning and testing, etc. Of course, these do not come without a significant price.
  4. Residential programming allows the adolescent time to practice and strengthen skills they are learning. Many programs are based on the adolescent achieving certain levels of competency and progressing step-wise through a customized program that encourages improved self-esteem, acknowledgement of accomplishments, recognition of effort and gentle re-integration to their family dynamic.
  5. Educational planning if often another advantage to residential treatment. Adolescents can undergo detailed educational and neuropsychological testing. While in treatment, a plan can be devised and implemented to address any deficits or challenges the teen is facing. The educational team can make recommendations for placement and interventions for post discharge.
  6. Residential treatment comes in many different settings. There are programs focused on wilderness, arts, education, addictions and many others. While the teen is being treated in these novel environments, family members at home can be focusing on improving the home setting and engaging in their own specific therapies to prepare for re-integration of the child. This break for the family has its own healing effect and enables other family members to focus on their issues and concerns while their family member is away. Likewise, the adolescent may find new interests and strengths to build upon after discharge.
  7. Although residential treatment is costly and sometimes not covered by commercial insurance, in the long-term it can be cost effective by saving the family from multiple hospitalizations, partial hospitalization or expensive intensive outpatient care.
  8. Lastly, residential treatment is often more successful in addressing or treating co-occurring disorders. The comprehensive nature of residential and the duration of treatment allow the team to focus on all aspects of the clinical picture and to thoroughly attack each facet of the adolescent’s needs.

Overall, there are many advantages to residential care, though it is often the least used avenue in adolescent psychiatry. The drawbacks of cost and availability often preclude the neediest of adolescents from obtaining the comprehensive treatment benefits that could help them most.

 

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Integrative mental health (IMH) combines conventional biological psychiatry and psychological interventions with traditional and complementary alternative medicine (CAM) to provide holistic patient-centered care. Using non-hierarchical interdisciplinary teamwork, the patient and practitioner are able to explore psychological paradigms involving biological, cultural and spiritual dimensions of health and illness. Kindness, avoidance of harm and informed consent are core ethical principles of practice. As well as addressing immediate mental health problems, the patient is encouraged to become actively involved in their own prevention of mental illness and maintenance of mental health.

Mental health is a key determinant of wellness, and has been shown to be strongly influenced by lifestyle factors such as chronic stress, sedentary life style, poor nutrition, obesity, substance abuse, and social isolation. Use of complementary alternative medicine in mental health conditions has been driven by the high cost of conventional care, and the growing list of medication safety concerns reported by the FDA, but due caution must be used with all Interested in touring therapies, conventional or complementary.

The fundamental goal of an integrative approach to mental health is to find the most appropriate treatments (conventional and complementary) that safely and effectively address the symptoms
of the individual, while taking into account personal preferences, cultural beliefs and financial constraints, an approach endorsed by the American Psychiatric Association.

Integrative mental health is an evolving, whole-systems approach to wellness of mind, body, and spirit. It considers that symptoms are associated with multiple causes and that multiple approaches to assessment and treatment may be necessary so that each individual may attain an optimal state of health and well-being. Therefore, the integrative mental health professional is knowledgeable about complementary and alternative medicine and trained in the art of collaboration so that they can discuss patient care with medical doctors, as well. The goal is to understand as much as possible about the whole person and to be aware of what treatments are occurring simultaneously. Approximately half of the individuals diagnosed with mood or anxiety disorders are using a combination of therapies and conventional strategies to alleviate symptoms. For this reason, it is important for health care professionals to ask the right questions and to collaborate in seeking answers when treating individuals who come seeking help.

Today, these individuals may first seek counsel from a medical doctor, a psychotherapist, a chiropractor, an acupuncturist. Therefore, it is important that patients disclose all of their treatments to all of their health care professionals. Mental health professionals trained in integrative approaches frequently serve as the historians of each patient’s care, especially since they are the ones who spend the most time with each patient during the course of treatment.

Recent years have witnessed growing openness to nonconventional therapies among conventionally trained clinicians and researchers. At the same time people who utilize Western biomedicine as currently practiced are turning increasingly to integrating non-conventional therapies for the treatment of both medical and mental health problems. Approximately 72 million U.S. adults used a non-conventional treatment in representing about one in three adults. If prayer is included in this analysis almost two thirds of adults use non-conventional therapies. Anyone diagnosed with a psychiatric disorder is significantly more likely to use nonconventional therapies compared to the general population.

Integrative health care is based on the philosophy that health is influenced by a variety of interrelated factors such as life choices, environment, genetic makeup, intimate relationships, and the
meaning and purpose in life. As a model it is collaborative and multidisciplinary. It is open to and recognizes the importance of conventional medicine, complementary and alternative medicine, mental health care, and mind-body approaches (such as meditation, yoga, hypnotherapy, Reiki, and therapeutic massage). There is a respect for each individual’s journey and for the stories that make up the history of their lives. There is a belief that these individual journeys influence the biology that manifests in illness or in health. Integrative health care supports all of the important
aspects of life, including creativity, cultural expression and the celebration of community. To have “health” means that the whole person is in balance – physically, emotionally, psychologically, and spiritually. Is health really health without mental health?

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Jennifer L. Shoenfelt, MD
Board Certified Child, Adolescent, and Adult Psychiatrist, Lindner Center of HOPE
Assistant Professor, University of Cincinnati, College of Medicine, Department of Psychiatry and Behavioral Neuroscience Assistant Professor, Wright State University, Boonshoft School of Medicine, Department of Psychiatry

Depression is on the rise in American teens and young adults. Adolescent girls, in particular, seem to be the most vulnerable youth, according to recent research published online in the Journal of Pediatrics.  Data collected between 2005 and 2014, analyzed by the Johns Hopkins University School of Public Health, concluded that “the 12 month prevalence of major depressive episodes in adolescents increased from 8.7% in 2005 to 11.3% by 2014”.  This number rose from 4.5% to 5.7% in boys and 13.1% to 17.3% in girls. The reasons for this increase remain under discussion. However, cyber bullying has been hypothesized as one trigger, particularly for girls.

How does a parent know when and where to seek help? How can parents support their child or adolescent suffering from depression? Here are some general guidelines for getting started.

  1. Observe your child’s behavior for idiosyncrasies or changes. Children with depression may demonstrate low mood, irritability, anger, fear or anxiety, mood swings, disruptive or risk-taking behavior, disobedience/defiance/ illegal behavior, isolation, lack of self-care/hygiene, decreased interest in previously enjoyable activities, decreased energy, increased or decreased sleep, increased or decreased appetite, and changes in friendships or family relationships. Some children turn to drugs or alcohol. Others turn to the internet for support or socialization. School performance may deteriorate, or attendance may decrease due to physical complaints or blatant truancy. Some children engage in self-harming behaviors or talk of death and dying.
  2. Engage your child in daily conversation or other one- on -one activity to open lines of communication.  Gently ask questions about your child’s change in mood, daily life and issues or how he or she is getting along with others. Find novel ways, if necessary, for your child to communicate his or her feelings. This may include sharing a journal that you pass back and forth or quantifying your child’s mood with a “mood scale” (0= severe depression and suicidal thinking versus 5 = happy mood/doing well) or even sharing “emojis” reflecting how the child is feeling that day. If your child expresses suicidal thoughts, such as not wanting to live or wishing he or she were dead, talks about ending his or her life, or engages in writing suicide notes – please take them directly to the local emergency room for further psychiatric evaluation.
  3. Talk to your pediatrician or family doctor about your child’s mood or changes in behavior. Consult with your child’s teachers or school counselor. Talk to your minister, priest, or rabbi. Arrange timely assistance for your child, perhaps through your Employee Assistance Program or through your health insurance. These professionals can assist you in finding a qualified mental health professional to provide evaluation and counseling.
  4. Monitor and limit phone, computer and electronics time. Know with whom your child is communicating. Watch internet history, cellphone texting, and social media communications. Kids looking for support often look in the wrong places and meet the wrong people while there.
  5. Encourage a healthy and consistent sleep schedule.  Children and teens need about 8-10 hours of sleep per night. A regular pre-sleep routine that does not include electronics and enhances relaxation along with a scheduled bedtime and wake-up time are all tenets of a healthy sleep habit.
  6. Encourage healthy eating habits. Limit sodas, caffeine, sugar- laden foods and snacks. If your child is not eating regular meals or portions, encourage smaller, more frequent meals of healthy foods throughout the day. Observe aberrant behaviors at meals, such as restricting caloric intake, leaving the table immediately after eating to go to the restroom and diverting food by hiding it or throwing it away. Observe striking weight loss, excessive exercising, or obsessive concerns with body image that may indicate concern for an eating disorder.
  7. Be consistent and firm with limit setting. Some parents feel badly for their child with depression and feel they should relax limits or house rules to decrease perceived stress on the child with depression. They fear being too strict or harsh. Maintain the same or even slightly more stringent rules with your child to maintain structure and avoid singling out the child with depression. Treat all children in the family equally. Be aware of your child’s whereabouts and safety at all times.
  8. Safety- proof your home. Lock up all medications, even over- the -counter medications, and seemingly harmless remedies. Secure anything in the home that could be used as a weapon, particularly firearms. Remove firearms from the home entirely. Secure alcohol or remove it from the home entirely.
  9. Ensure that you are taking care of your own well-being and mental health. Depression can run in families. If you, as the parent, are struggling with your own mental health, it will be difficult to remain objective and supportive toward your child, who is also struggling. It may also make identifying your child’s depression more difficult or impossible. Resist the urge to tell your child that you know how they must feel or that you were once depressed or are currently depressed. Avoid trying to give advice or sharing how you have battled your own depression.

Practice listening attentively and reassuring your child that you will get them whatever help is needed for them to feel better and return to a healthy, happy life. Be sure to get help for yourself, such as therapy or medication or both. This will assist you in being the best possible support for your child and family.

Identifying child and adolescent depression and dealing with it can be overwhelming. The key is to reach out for assistance and allow others to provide their support and expertise, so that a team approach can be utilized to its fullest. Organizations such as the American Academy of Child and Adolescent Psychiatry, National Alliance on Mental Illness (NAMI) and the American Psychiatric Association are all excellent sources of information and support.

References:
Mojtabai R, Olfson M, Han B. National trends in the prevalence and treatment of depression in adolescents and young girls. Pediatrics. 2016; doi: 10. 1542/peds.2016-1878.
Glowinski AL, D’Amelio G. Depression is a deadly growing threat to our youth: time to rally. Pediatrics. 2016; doi:10.1542/peds.2016-2869.
American Academy of Child and Adolescent Psychiatry. Your Adolescent. 1999. 301-304.

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By: Chris Tuell Ed.D., LPCC-S, LICDC-CS
Clinical Director of Addiction Services Lindner Center of HOPE
Assistant Professor, Department of Psychiatry & Behavioral Neuroscience University of Cincinnati College of Medicine

Fifty years ago, I was six years old.  My family, like many families of the day, subscribed to Life magazine.  On the cover of the magazine for the week of September 16, 1966 was a picture of Sophia Loren.  The Hollywood starlet was portrayed wearing a black see-through lacy dress that covered all the necessary parts, and covered all the necessary standards for 1966.  But the picture left an image upon my brain that I can easily recall to this day.

Fifty years later, digital pornographic images are now easily accessible.  The Internet has made it possible for thousands of images and videos to be accessed within seconds.  The Internet has made it available for instant digital infidelity to occur.  Such images and encounters can easily be accessed on any smartphone, tablet, and computer.

So how concerned should we be as a society?  Do we accept this dark digital domain as a part of our technological culture?  How harmful can pornography and digital infidelity be?  Is it possible that sexual images and/or compulsive sexual behaviors reside within the same realm as problematic alcohol and drug use?  The answer is plain and simple.  It does.  Pornography and cybersex can become addictive.  In the long run, this behavior rewires the brain, and can lead to abusive and destroyed relationships for men and women.

Sixty-eight percent of young men and 18% of young women view pornography at least once a week, and those numbers are growing. A sexual addictive epidemic is on the rise, not only because of easier access, but also the lack of information people have had on the negative and harmful effects associated with this addictive behavior.

Many researchers and clinicians in the field of mental health no longer discriminate between behavioral addictions (i.e., pornography, sex, gambling) and chemical addictions (i.e., alcohol, drugs).  Simply stated: The brain doesn’t care.  The brain doesn’t care whether you pour it down your throat, place it in your nose, see it with your eyes, or do it with your hands.  Pornography and sex, along with other addictions, flood the brain with dopamine and make the recipient feel good.   They help you to escape, as you seek the behavior over and over again.  Over time, as more dopamine is released, the individual will begin to feel the effects of this neurochemical less and less. This leads one to search for more graphic images, increase high-risk sexual behaviors, escalating the addictive behavior in order to obtain the desired effect.

Researchers indicate that nearly 80% of individuals who have an alcohol or drug issue will also have a mental illness issue as well.  This is the rule rather than the exception.  So what is the relationship that pornography, cybersex, and other addictive behaviors have with mental illnesses like depression and anxiety?  This could be better understood by the CUBIS model, an acronym that represents five areas that I believe demonstrates this relationship between addiction and mental illness.

Chemical Imbalance 

Within the field of psychiatry a basic premise is that some individuals may have issues of mental illness as a result of a chemical imbalance. When an individual experiences challenges of depression and/or anxiety, for example, particular neurochemicals within the brain may not be producing at desired levels, resulting in symptoms of mental illness (e.g., depression, fear, anxiety, paranoia).  This is where medications can be helpful.  However, addictive behaviors like sex and pornography, as well as alcohol, drugs and gambling, can also serve to temporarily regulate this imbalance, resulting in the individual feeling better and distracting his or herself with undesirable and destructive behaviors.

Unresolved Issues

For many, issues of trauma, abuse, grief, loss and/or abandonment, can lead some individuals to seek out ways to escape and numb one’s self from the aforementioned mental health challenges.  Whenever these problems bubble up to the top, the individual doesn’t want to think about or feel the emotions associated with these particular issues.  Cybersex and pornography, like other addictive behaviors, serve a purpose in suppressing these thoughts or feelings and help the individual to escape, distract, or forget about mental health concerns.

Beliefs (that are distorted)

We all grow up with a belief system.  This system consists of the messages we receive from our parents, relatives, neighbors, and society in general.  It’s how we see the world, and how we see ourselves.  But what if some of these beliefs are untrue, irrational, or distorted?  What if one had the belief that the only way to be social is to have a drink, or the only way to relax is to smoke a joint?  These beliefs, of course, are untrue.  Anyone is able to relax and become social without substances.  But how do these distorted beliefs materialize with sexual acting-out behaviors?  Typically within healthy relationships, the initial element is one of friendship.  This is usually followed by trust, increased commitment, and closeness through intimacy (love), and then sex.  But for some, the way one develops friendship, establishes trust, makes commitment, is by being sexual.  Sex provides a way to meet his or her unmet needs.  One’s distorted and irrational beliefs may perpetuate this unhealthy cycle of addiction.

Inability to Cope

Think for a moment of someone who has been a best friend. A best friend is someone that you can always count on, and is always reliable, 24/7.  This is the same relationship that the addict has with pornography, sex, and other addictive behaviors.  Our digital world has made cybersex and pornography readily available 24/7.  It is accessible during good times and bad.  It always delivers what it promises to do when reality can be so unpredictable.  In addition, the area of the brain affected by addiction is the same area where meaningful relationships are developed.  One’s addiction becomes on par with his or her spouse, children, parents, and friends. Sometimes, unfortunately, it becomes number one.  For the addict with mental illness issues, in order to get well, I have to give up my best friend.

Stimulus-Response Relationship

When it comes to the brain and addiction, there are two main areas of the brain which play an important role with the other: the prefrontal cortex (PFC) and the midbrain.  The prefrontal cortex is the executive functioning part of the brain.  The PFC is where   decision-making, morality, and personality exist.  Everything about who one is as a person resides in the PFC.  The main role of the midbrain is to reinforce behaviors which are necessary for the organism to survive.  The midbrain does this by the release of certain neurochemicals, especially dopamine.  Dopamine provides pleasure. Behaviors that are necessary for survival are reinforced with dopamine.  If food and sex were not pleasurable, humankind would have expired thousands of years ago.

The midbrain reinforces behaviors necessary for our survival by the release of the pleasure chemical, dopamine.  But addictive behaviors also trigger dopamine.  Behaviors such as sex and pornography, as well as other addictions (drugs, alcohol, gambling) do this too.  When dopamine is released from the midbrain and begins to flood the PFC, there is a shutting down of the rational, logical, decision-making part of the brain.  The midbrain overrides the PFC which now no longer functions correctly. A hijacking of the brain’s reward system occurs.  When this happens, the memory neurochemical Glutamate is released and informs the midbrain:  “Don’t forget this!  Go out and get it!”

The brain now believes and remembers that addictive behaviors are essential for survival.  Logically, one knows that one does not need alcohol, drugs and other addictive behaviors to survive, but the brain does not realize this.  As a society, we have unfortunately responded and treated addiction as an issue of morality, a weakness, a lack of will power, a character flaw, an addictive personality, sociopathy, etc.  Our society has unfortunately responded to addiction with shame, guilt, blame, coercion, and incarceration for many years.  This old approach has and continues to be a failure.  Addiction starts earlier and deeper within the brain and hijacks its reward system by believing the addictive behavior is necessary for survival.

Treatment

What should the treatment be for these issues?  When it comes to pornography, gambling, alcohol, heroin, or in fact any addictive behavior, a strong correlation exists with mental illness.  Treatment approaches must include integration of the co-occurring disorders.  For years substance use disorders and mental illness have been treated separately from one another.  Unfortunately, this view continues in many treatment communities.  Research indicates that an effective treatment model of addiction must integrate with the individual’s mental illness issues.  If only the addiction is addressed and not the mental illness, both will get worse.  Likewise, if only mental illness is treated and not the addiction, both will get worse.

The CUBIS model provides a template for treatment:

  • Medication management:  For individuals who experience a chemical imbalance, medication management can be beneficial in assisting the individual in regulating issues of anxiety, mood, and depression.  The development of medication-assisted treatment for those in recovery has also proven to be therapeutically beneficial for individuals suffering from addiction.

 

  • Psychotherapy:  Therapy serves as a means to relieve symptoms, resolve problems in living and/or seek personal growth.  The utilization of psychotherapy can be helpful in assisting individuals with unresolved issues of trauma, abuse, grief, loss, abandonment, etc.

 

  • Cognitive-behavioral therapy:  Individuals experiencing issues of irrational, maladaptive, or distorted beliefs may benefit from cognitive-behavioral therapy.  This therapy approach focuses on issues of thoughts, perceptions, attitudes and actions in choosing healthier behaviors.

 

  • Skill development:  For individuals who need to find better ways of coping, developing skills to assist in the regulation of mood and anxiety can be helpful.  These skills may consist of various ways of coping including mindfulness, meditation, community support groups, exercise, dialectical behavior therapy, spirituality, etc.

 

  • Education:  Knowledge serves as a means of increasing understanding and awareness for individuals and family members in how addiction impacts the brain.  This level of education and awareness can hopefully reduce elements of shame, guilt and blame of the individual who suffers from addiction and mental illness.  Individuals suffering from addiction may lie, cheat and steal, but bad acts do not necessarily mean bad actors.

Final thoughts

For this clinician, a simple cover from a 1963 Life magazine has left an imprint.  It remains unclear what the long-term effect of exposure to pornography and digital images have upon the brain and especially on the developing brains of young people.  The Internet and the digital world have made many aspects of our lives more productive, informative, connected and creative.  However, in today’s world of social media, chat rooms, digital pornography, interactive webcams, instant messaging, “adult friend finder” apps and sexting, our digital world also provides more destructive means to escape from life stressors, depression, anxiety and all other forms of mental illness.  Individuals suffering from mental illness may be easily drawn into other means of regulating mood, thoughts, and behaviors by high-tech addictive behaviors.  No longer can humanity afford to turn a blind eye as men, women, and children are pulled into the seductive charms of the dark side of the digital world. There is nothing romantic about pornography. Instead, it promotes an unrealistic and unhealthy view of relationships and true intimacy.

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BY: Elizabeth Wassenaar, MS, MD, Lindner Center of HOPE, Staff Psychiatrist and Medical Director of Williams House

 

Life can be overwhelming and we all would like to take a day off every once in a while. Likely, as helping professionals, we don’t take mental health days as often as we could actually benefit from them.  This is one of the reasons why, when a child or adolescent refuses to go to school, we may be initially sympathetic.  Maybe a day or two off will help, we may think.  In too many cases, however, we see that a day or two off turns into something much more problematic as parents and professionals struggle to get a school avoider back to school.  Homework piles up, grades start to fall, and friends wonder what has happened to their classmate.  Parents try many different tactics to try to get their child back to school; bribing, negotiating, punishing, or even carrying a child through the school door.

Children want to not go to school for many reasonable causes: kids can be cruel; learning can be difficult; anxiety about performance can be overwhelming; health concerns can require special privileges that feel too identifying; and getting up early in the morning is harder for some more than others. Furthermore, mental illness can make school attendance difficult for many additional reasons.  There are good reasons to keep children home from school – physical illnesses can be contagious, some stages of mental illness are better treated with mental rest, and in some cases of bullying the safest way to deal with an unsafe situation is to remove the child.

Nevertheless, school refusal is avoidance, and anxiety loves avoidance. Nothing is more reinforcing that one cannot handle something than not doing it.  So, after one has checked on physical health and for other explanations, how can professionals support parents to keep their children in school or break the cycle of school avoidance and school refusal?

  1. Help parents identify the behaviors of avoidance and link that to anxiety.

Avoidance is a coping mechanism for dealing with anxiety, which can become maladaptive when avoidance becomes the only options. Avoidance can look a lot of different ways –tantrums, tearfulness, vague physical symptoms, negotiation (more on that later), chaos, and so on.  Parents may not be able to recognize all of the forms avoidance can take. Helping them objectify avoidance will help them strategize on how to deal with it.

  1. We have to truly believe that avoiding school will not make it better.

It can be tempting to collude with anxiety that the precipitant needs to be avoided for all the reasons laid out in this article and we need to be internally convinced that anxiety is not correctly assessing the situation. As difficult as school can be, school occupies a unique place in a child’s life.  It is the place of work, play, and love.  Learning and playing are the main jobs of childhood.  Playing looks both like playing at recess and like experimenting in relationships with both friendship and love. Identity is formed and reformed through our work, play, and love.  When a child is not in school for an extended length of time, they are abrupting their opportunity for this developmental process to proceed.

  1. Negotiation is another way of avoiding and is a dangerous game.

Many of my patients have used a variety of negotiating tactics with their parent: “Let me go in later and then I’ll go, I promise” or “Let me catch up on my work today and I’ll go in tomorrow”. Small avoidances add up to large avoidance and are not moving towards your goal.  Reverse the negotiation and set up conditions that will allow an out as long one starts the day at school.  Often, once anxiety has lost its argument that one cannot handle going to school, staying in school through the day is easier to manage.

  1. Encourage parents to work with the school

Parents and school are on the same side of this concern – both parties want the child to be successful in school. For parents, this may be the first time dealing with school refusal, but it is most certainly not the first time the school has dealt with school refusal.  Most schools have a variety of plans to help keep a child in school.  Have parents reach out to the school and let them know what is going on.

  1. Set small goals that lead to the victory

The ultimate goal of full school participation is an overwhelming prospect. Depending on how severe the school refusal is, reintroducing school can be an extended process of gradually introducing larger and larger challenges.  Perhaps, on the first day, one can only walk through the school doors.  Maybe a student will be able to be in the school building, but not in classes.  Parents can engage trusted friends to provide motivation and encouragement through social interaction and distraction while at school.

  1. School has many different forms

Many families choose alternative school arrangements including home schooling, virtual schooling, and others, for a variety of reasons and this article is not meant to convict choices that do not have a child in a classroom every day. There are many viable options for school that provide an environment that promote healthy development.  When a family is making a decision to change the way school is delivered, help them examine what factors are involved in their decision.  If they are making the decision from a place of believing that the anxiety that drives school avoidance cannot be defeated then, help them with all the ways described above.

School is a venerable and sometimes dreaded rite of passage. A great deal rides on academic and social success in school which increases anxiety and can lead to school refusal.  As a team, parents, professionals, and schools can help keep children and adolescents in school and accomplishing their goals.