Category: Cognition

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Staffing Shortage Underserves Long Term Care Residents

10Aging, Cognition, Dementia, Featured news, Health, Loneliness, Social Life February, 17

Source: Chris Marchant on flickr, Creative Commons

In the summer of 2014, I volunteered at a long-term care facility (LTC) in the Peel Region of Southern Ontario. Most of the residents who lived there were diagnosed with some form of cognitive impairment, primarily dementia. I saw first-hand the unfortunate reality of understaffing, and how it leads to deficits in patient care.

As the elderly population has grown, Ontario has seen a 22% increase in admission rates of LTC residents as of 2014. And the number of residents with cognitive impairments is especially high. According to the Ontario Long Term Care Association’s 2014 annual report, 62% of residents have Alzheimer’s disease or another form of dementia resulting from stroke, developmental disability, or traumatic brain injury.

Patients with cognitive impairments may have other mental health disorders as well. The Canadian Institute for Health Information (CIHI) indicates that 25.9% of residents in Ontario long-term care homes have shown symptoms of depression through 2013 and 2014.

In my time volunteering at the LTC, I noticed that residents often refrained from socializing because they were unable to take part in events due to memory deterioration, speech issues, and physical ailments such as paralysis or arthritis. Most residents required staff to transport them from one place to another and though they worked hard to support residents, there were simply not enough staff to supervise these daily activities.

Jane (name changed for anonymity), the Supervisor of Activation at an LTC in the Peel Region, spoke to the Trauma and Mental Health Report about this issue. Jane is responsible for organizing activities that motivate elderly residents to engage in social interaction and improve cognitive well-being.

Jane agreed that one of the biggest challenges for LTCs is staffing:

“Year by year, the case load of different residents is increasing, but with such little funding we do not have enough staff to support their needs. If residents aren’t participating in daily events and activities, their cognitive functioning is negatively impacted.”

A University of Ottawa study found that between the years 2000 and 2010, over 60% of residents with multiple cognitive deficits lacked stimulating therapeutic activities and social support. It showed that while residents received sufficient assistance with physical needs, such as feeding and changing, cognitive functioning continued to worsen in areas like memory and attention.

Jane also explained that despite research emphasizing the importance of activities that are engaging, staffing shortages make it difficult for these activities to be held in LTC homes:

“We need more activation staff for art therapy, music therapy and physiotherapy as these activities are beneficial to residents’ cognitive functioning. However, many activities are cancelled or postponed because of a lack of staff to facilitate the activities and monitor the residents. A few years ago, residents only needed one staff member or nurse for assistance, now they need two or more people. Sometimes, they’re left waiting for support.”

But perhaps the real issue here is funding. Adequate funds are necessary to increase the amount of staff within LTCs, so that residents can develop social relationships, participate in interactive activities, and improve their cognitive functioning and capabilities. Jane agrees:

“Funding hasn’t increased yet the resident conditions are changing and they require more care. The caseload is increasing, with little funding.”

Funding should also be allotted for appropriate staff training. LTC residents with cognitive impairments have a unique set of needs. According to the University of Ottawa study, residents require assistance in areas such as memory retention and engaging in regular social activities to help them interact and feel like recognized members of their community.

Making use of mental health first aid programs, such as the workshops offered atConestoga College and the Baycrest Health Sciences’ Geriatric Mental Health Serviceconference, can go a long way in improving the services staff provide.

As a past volunteer for an LTC home, I have seen the impact of limited support on residents’ lives. Greater funding and more staff to facilitate therapeutic activities are crucial to optimizing the care residents receive and to ensuring better cognitive functioning.

–Afifa Mahboob, Contributing Writer, The Trauma and Mental Health Report

–Chief Editor: Robert T. MullerThe Trauma and Mental Health Report

Copyright Robert T. Muller

This article was originally published on Psychology Today

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Book Review: The Marshmallow Test

00Behaviorism, Career, Child Development, Cognition, Emotion Regulation, Featured news, Self-Control June, 16

Source: Jørgen Schyberg on flickr

Walter Mischel, a psychologist best known for the Marshmallow Test, produced his first book at the age of 84.

The Marshmallow Test: Mastering Self-Control hit bookshelves in the fall of 2014, and became an instant media sensation. Part memoir and part scientific analysis of Mischel’s work on self-control, the book reviews research on the Marshmallow Test, which he first carried out at Stanford University, and which has since been replicated around the world.

The Marshmallow Test is a way of assessing children’s capacity for delaying gratification and resisting temptation. Children are placed in a room by themselves and given one marshmallow. An experimenter explains that if the child waits 15 minutes, they will receive a total of two marshmallows to eat. If they don’t wait, they’ll receive only one. After the experimenter leaves the room, the child is observed through a one-way mirror or recorded. The longer a child is able to wait, the greater the ability to delay gratification.

Many videos of children taking the Marshmallow Test have been posted to YouTube, often showing amusing coping strategies children use to maintain restraint. The Marshmallow Test has been so widely popularized that even the Wall Street Journal referred to it in assessing a proposed budget by U.S. president Barack Obama.

In his book, Mischel looks at the correlation between outcome on the test at age 5 or 6 with social skills and academic performance later in life. Results show that children who are able to wait longer for two marshmallows have better social skills and higher academic test scores. The book provides several explanations for this phenomenon, including the possibility that the Marshmallow Test accesses characteristics, such as delay of gratification, that are related to developing positive social skills and performing well academically later on.

For those seeking a step-by-step guide to improve self-control and achieve higher grades, this is not the right book. Mischel discusses theoretical concepts and summarizes research. Although he integrates many personal narratives to add a human touch, the book is not meant as a guide to self-improvement.

With critical and thorough analysis, Mischel instead explains how genetic, environmental, and social factors can impact self-control. He emphasizes that self-control is not predetermined or universal across all areas of an individual’s life. Someone who shows a great deal of control in academia may struggle to show that same level of control when overcoming problem drinking.

Making the content more personal, Mischel often incorporates his own challenges with overcoming a nicotine addiction and how his research was often affected by observations of his own children.

Empowerment is another important issue discussed throughout the book. In one section, Mischel refers to his time as a trainee in a clinical psychology doctoral program, recalling how he watched his mentor, George Kelly, work with an extremely anxious woman. The woman had asked Dr. Kelly, “Am I falling apart?” to which he replied, “Would you like to?”

Using this case, Mischel shifts the focus from the Marshmallow Test and how it might predict future action to how perceived self-control can impact demonstrated self-control. This is an idea that Mischel calls the ‘The Engine of Success.’

The idea is that there are essential resources nurturing and cultivating self-control. Mischel explains this theory through the case of George, a student completing his bachelor degree on a full scholarship at Yale University.

At the age of nine, George was enrolled in a KIPP school, which is an American charter school. Mischel explains how such schools attempt to integrate self-control, self-discipline, brain development, and delay of self-gratification into their curriculum. He emphasizes the need for more schools like this.

Although the original Marshmallow Test predicts a specific type of self-control in later life, Mischel stresses that self-control is fluid. Taking control of any area of your life, he suggests, starts with asking the very question George Kelly asked his client: Would you like to?

– Genevieve Hayden, Contributing Writer, The Trauma and Mental Health Report

– Chief Editor: Robert T. MullerThe Trauma and Mental Health Report

Copyright Robert T. Muller

This article was originally published on Psychology Today

Listening to voices

Can Some Lead A Better Life Listening to their Voices?

10Cognition, Cognitive Behavioral Therapy, Featured news, Psychopathy, Therapy, Trauma February, 16

Source: rumeysa babadostu on Flickr

Hearing voices is usually considered a sure sign of mental illness, but recent studies suggest that hearing voices is more common in the general population than previously thought. Though inconclusive, research estimates are that between 2 and 10% of people hear voices, with only 45% actually qualifying for a psychiatric diagnosis.

The notion that hearing voices can be non-pathological is still controversial.  Contemporary psychiatry views hallucinations (auditory or otherwise) as the result of abnormal brain function, representative of a more pervasive psychotic disorder.  Coming from a disordered brain, the content of voices are said to have no inherent meaning.  Treatments minimize or eliminate symptoms (usually through the use of medication) and provide coping strategies through cognitive behavioural therapy (CBT).

The ‘Hearing Voices Movement’ challenges the medical model.  Started in the early 1990s, the movement provides an alternative, non-pathological framework, claiming that hearing voices is fairly common in the general population and can exist outside of psychotic disorders.  They view voices as resulting from life events, (e.g., traumatic experiences), and that better coping comes from gaining insight into how the voices relate to unresolved trauma.

In a Dutch study published in 1989, Marius Romme, at the University of Limburg in Maastricht, and science journalist Sandra Escher found that out of 450 participants, about one third reported being able to cope well with their voices.  Of this group, people were more likely to have a positive interpretation of the voices, accepting them as part of their life instead of trying to fight or ignore them.   Although many of these participants still found some voices distressing, they were able to draw firmer boundaries and felt less powerless than the group that did not cope as well.

Building on the fundamentals revealed by their research, Romme and Escher were able to translate their findings into a therapeutic approach.  Known as the Maastricht approach, the aim is to foster curiosity about the content of the voices in order to gain insight, resolve underlying emotional problems due to past traumas, and eventually accept the voices as a part of the client’s life and self.

Voices can be positive, negative or banal –many voice hearers have some combination of the three.   In treatment, the client is asked to set aside a time to listen to the voices nonjudgmentally, as if they were talking to an actual person.  Along with the therapist, they try to unravel when the voices began and why.

In contrast, treatments like cognitive behavioural therapy (CBT) and similar methods aim to reduce the frequency, intensity and believability of hallucinations.  People receiving this type of therapy are encouraged to directly challenge the content of the voices, and cope by focusing on other things in their environment and use distraction to redirect their attention.

But when techniques like distraction and redirecting attention are used incorrectly, they result in people suppressing and fighting their symptoms, rather than learning to live with them.

Several studies show that individuals who try to suppress thoughts and hallucinations may increase their frequency and intensity, and exacerbate distress   (described in the work of Social Psychologist, Daniel Wegner of Trinity College).  Alternatively, the Maastricht approach encourages the client to eventually accept their voices without challenging their content or trying to fight them.

Some claim success for this kind of acceptance-based treatment, even in cases of psychosis.  In a study by clinical psychologists, Patricia Bach and Steven Hayes at the University of Nevada, Reno, 80 inpatients with schizophrenia were assigned to either continue their treatment as usual or engage in four sessions of acceptance and commitment therapy (ACT) in addition to usual treatment.

At the end, patients who attended the ACT sessions were three times less likely to be hospitalized again, and were more likely to question the voices’ control over them and evaluate the reality of the voices’ claims.  Bach and Hayes think the acceptance component allows people to be less distressed overall and view the voices as ‘just thoughts’ that don’t necessarily have meaning or power over them.

While ACT is a widely validated therapy, the Maastricht approach has less research to back up its claims.

The Maastricht approach is still considered peripheral in many circles, especially the idea of voices as an extension of human experience.   And critics of the treatment take issue with the implication that almost all auditory hallucinations are caused by traumatic experiences, overlooking or down-playing evidence regarding genetic and biological influences.  While it is true that many people who hear voices have experienced traumas in their lifetime, there is little evidence that trauma alone can directly cause auditory hallucinations.

And, some claim the Hearing Voices Movement ignores the needs of people with severe mental illnesses such as schizophrenia, which involves a host of other symptoms in addition to hearing voices.  Using the ‘hearing voices therapy’ only addresses one aspect of a multifaceted syndrome and may be harmful if the other symptoms worsen.

Still, when we look at the idea of hearing voices in a way that is not exclusively pathology-based, we open new possibilities, and we engage in what psychologist Andrew Moskowitz (University of Aarhus, Denmark) claims to be a necessary paradigm shift.  Indeed, it may be time for one.

– Jennifer Parlee, Contributing Writer, The Trauma and Mental Health Report

– Chief Editor: Robert T Muller, The Trauma and Mental Health Report

Copyright Robert T Muller 

This article was originally published on Psychology Today

Dysregulation: A New DSM Label for Childhood Rages

Dysregulation: A New DSM Label for Childhood Rages

00Anger, Child Development, Cognition, Featured news, Health, Parenting, Self-Control, Stress July, 15

Source: Mary Anne Enriquez/Flickr

With the many changes in the newest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), among the most significant has been the inclusion of Disruptive Mood Dysregulation Disorder (DMDD)—a direct response to the dramatic increase in the diagnosis of bipolar disorder in children and adolescents during the 1990s.

Diagnosing bipolar illness in children is considered elusive at best.  Characterized by extreme and distinct changes in mood, bipolar illness ranges from depressive symptoms to manic “highs.”  In younger populations, the shift between manic and depressive episodes is not so clear.

Children often experience abrupt mood swings, explosive and lengthy rages, impairment in judgment, impulsivity, and defiant behavior.  Such parent-reported symptoms became a popular basis for childhood bipolar disorder diagnoses.

In recent years, Ellen Leibenluft, a senior investigator at the National Institute of Mental Health and an associate professor at Georgetown University, developed the concept of “severe mood dysregulation” as distinct from bipolar disorder.  Her research highlights the difference between unusual intense rages, and the distinct mood swings in bipolar disorder.

Anchored in her research, the DSM-5 task force attempted to develop a new classification for a disorder that shared some characteristics with bipolar disorder but did not include the abrupt shifts in mood.  By doing so, the task force hopes the rate of diagnoses for bipolar disorder in children will decline.

The DSM-5 characterizes DMDD as severe recurrent temper outbursts that are “grossly out of proportion in intensity or duration” to the situation.  Temper outbursts occur at least 3 times per week and the mood between outbursts remains negative.  To separate DMDD from bipolar disorder, children must not experience manic symptoms such as feelings of grandiosity, and reduced need for sleep.

Differentiating between bipolar disorder symptoms and rages unrelated to mood swings may very well be a step in the right direction.

But some studies suggest that DMDD may not be all that distinct or useful as a diagnostic entity different from those already in use, such as oppositional defiant disorder or conduct disorder.  It may be that DMDD is not a condition of its own, but rather a primary symptom of a larger issue.  Irritability and rages may be an indication of a disorder already established in previous versions of the DSM.

Aside from diagnostic labels, taking social situations into account may lead to a sharper understanding of rages in children.

While the role of biology cannot be discounted in the development of mental disorders, childhood behavioral problems may be affected by social and economic circumstances. Financial hardships and other parental stresses have an effect on children’s mental well-being, and stress may be detrimental to the communication between the parent and child.

Along with biological conditions, the DSM task force should consider the impact of the child’s social experience.  Helena Hansen, assistant professor of psychiatry at the New York University School of Medicine, argues that the recent revisions in the DSM-5 have missed key social factors that trigger certain biological responses.  Her article, published in the journal Health Affair, emphasizes the importance of understanding how social and institutional circumstances influence the epidemiological distribution of disorders.

For example, differing temperaments can explain why some children appear to cope well with life stresses while others develop problem behaviors.  Lashing out in the form of rages and tantrums may be a natural response to intolerable anxiety and stress for some children.

As new terms for disorders are coined, such as DMDD, we need to ask if the development of another category is the best alternative.  Is substituting one label of childhood behavioral problems for another really our best option?

Due to the many possible causes for temper outbursts, giving the child a single label may not be all that helpful.  Instead, determining the core issues surrounding the rages may be more useful in providing the patient with an effective treatment plan.

Also, let’s keep in mind that mental disordersare simply constructs, not unique disease states.  They are developed to allow better understanding of a group of behavioral, emotional, and cognitive symptoms, and are regularly revised based on new research and changing cultural values.  While the DSM is useful for the purpose of understanding the challenges faced by patients, it should not be given “bible” status.

Along with mental health care providers, it is important for parents to get informed about DMDD, to ask questions, and to get involved in discussions when considering treatment options for their child.

– Khadija Bint Misbah, Contributing Writer, The Trauma and Mental Health Report

– Chief Editor: Robert T. Muller, The Trauma and Mental Health Report

Copyright Robert T. Muller

This article was originally published on Psychology Today

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Treatments Available to Long Term Abduction Victims

10Animal Behavior, Cognition, Depression, Dreaming, Family Dynamics, Featured news, Health, Parenting, Psychiatry, Psychoanalysis, Sleep, Stress, Therapy, Trauma April, 15

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Between 2002 and 2004, 16-year-old Amanda Berry, 21-year-old Michelle Knight, and 14-year-old Georgina DeJesus were abducted from the streets of Cleveland, Ohio. They were lured into the home of Ariel Castro where they spent the next 11 years in captivity.

Often kept in restraints and locked rooms, the women regularly had their lives threatened to deter any plans of escape.  They were given little food or the opportunity to bathe. Sexual abuse led to Knight being impregnated several times, only to be beaten and starved in order to force miscarriage.  It wasn’t until May 2013 that the women were finally rescued and Castro arrested.

Other cases popularized by the media include that of Elizabeth Smart, held captive for 9 months, and Jaycee Dugard who was held captive for 18 years. These victims are now free, but living with the emotional aftermath.

In a 2000 study by the Department of Neurological and Psychiatric Sciences at the University of Padova, interviews with kidnap victims showed common after-effects of abduction including vivid flashbacks of the events, nightmares, and feelings of depression, all common symptoms of Post-Traumatic Stress Disorder.  Hypervigilance was also reported, where individuals anticipated danger and frequently felt guarded, leading to trouble sleeping, eating, and social withdrawal due to difficulty trusting others.

Mental health professors David A. Alexander and Susan Klein, from the Aberdeen Centre for Trauma Research in the UK also add that some victims end up “shutting off’ their emotions or denying that they even experienced a traumatic event, which may stem from a desire to avoid anything that reminds them of their trauma.

How does someone this traumatized even begin to recover?  Clinicians who work with these victims help them find opportunities to make their own decisions, to slowly understand that they are no longer powerless.

Clinical psychologist Rebecca Bailey, therapist to Jaycee Dugard, is the author of, “Safe Kids, Smart Parents: What Parents Need to Know to Keep Their Children Safe.” In an interview with the Trauma and Mental Health Report, Bailey explained: “Number one is helping victims find their voice.  When you’ve been kidnapped, so much of your world is about having choices made for you…From day one you have to give them choices for everything, Do you want a glass of milk, or do you want a glass of water? Things like that.”

Another important aspect to recovery is the role of the family.  It is through a strong connection with the family that the victim can feel safe, comforted, and empowered.  Bailey mentions “tribal meetings” with families soon after rescue to reunify both parties and create a support system. Through these family systems, further recovery is possible.

Specific therapeutic approaches for victim recovery really depend on the individual.  In some cases Cognitive Behavioural Therapy can be used, in other cases experiential therapy or a more psychodynamic approach can be implemented.  Common techniques used in therapy with kidnapping victims are role-playing, therapeutic pets, music, or even walking through the wilderness in an attempt to trigger underlying feelings that must be dealt with.

Often, different therapies are combined to see which works best for the individual. Bailey reminds, however, that client interaction with the therapist also has a large impact on recovery.

Bailey: The most important thing is for the therapist to be mindful, authentic, and purposeful. Counterproductive would be having a therapist who says very little.  This could almost reinjure [the victim] because they need a certain amount of modelling as well.

Modelling how to have an authentic healthy relationship—after the abusive one they had with their abductor—is crucial to helping the victim integrate aspects of normal everyday life.

Still, even with proper therapy and a strong support system, the trauma of being abducted and held captive for years is unlikely to be erased.  In the case of the young women in Cleveland, along with many others, the journey to recovery has been a challenging one, but one that has been described as worth taking:

“I may have been through hell and back, but I am strong enough to walk through hell with a smile on my face and my head held high,” says Michelle Knight in a YouTube video addressed to the public.  “I will not let the situation define who I am.  I will define the situation.”

– Contributing Writer: Anjali Wisnarama, The Trauma and Mental Health Report

– Chief Editor: Robert T. Muller, The Trauma and Mental Health Report

Copyright Robert T. Muller

This article was originally published on Psychology Today

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Love Is War: Post Infidelity Stress Disorder

00Anger, Attention, Cognition, Dreaming, Empathy, Featured news, Health, Hormones, Infidelity, Memory, Post-Traumatic Stress Disorder, Relationships, Self-Esteem, Sex, Sleep, Stress, Trauma March, 15

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Blind-sided by the one you love, the one you married.

Learning about your spouse’s infidelity can be emotionally and physically devastating. The emotional damage is reflected in what some mental health professionals call Post-Infidelity Stress Disorder (PISD), for the stress and emotional turmoil experienced afterward.

Psychologist Dennis Ortman, author of Transcending Post-Infidelity Stress Disorder, describes the term as “not to suggest a new diagnostic category but to suggest a parallel with post-traumatic stress disorder, which has been well documented and researched.”

In Post-Traumatic Stress Disorder (PTSD), re-experiencing the trauma repeatedly is the first of three categories of symptoms described. The disorder is marked by flashbacks of war for veterans, nightmares of the accident for car wreck survivors, and painful memories of abuse for survivors of intra-familial trauma.

So too, in PISD husbands and wives will replay the painful realization of betrayal.  Even after the initial fall-out, people will have recurring thoughts of their partner with another.

Psychologist and certified sex therapist, Barry Bass, adds, “Like trauma victims, it is not unusual for betrayed spouses to replay in their minds previously assumed benign events,” those times when their spouse became defensive when asked a simple question, or the late nights at work, or the text messages from unnamed friends, all of these become viewed as possible deceitful acts.

The second category of symptoms for PTSD, avoidance and emotional numbing, is seen in PISD as well.  Rage or despair that comes after the initial shock of discovering the infidelity can be followed by a state of emotional hollowness.  Formerly pleasurable activities lose their appeal.  Those who were cheated on sometimes withdraw from friends and family and describe feelings of emptiness.

The last category of PTSD symptoms, hyper-vigilance and insomnia, can also arise for those dealing with infidelity.  Sleep patterns become erratic; and concentration becomes a challenge, affecting work performance and family life.

PISD can have physical consequences as well as emotional ones.  The stress of discovering infidelity can lead to what has been dubbed broken heart syndrome, also termed stress cardiomyopathy.  The American Heart Association describes symptoms such as sudden chest pain, leading to the sense that one is having a heart attack.  Physical or emotional stressors, such as a loved one passing or major surgery trigger a surge of stress hormones that temporarily affect the heart.  The condition typically reverses within a week.

Despite the stress, there is life after an affair.  Due to the symptomatic similarities, therapists are now beginning to use PTSD counseling techniques to help couples either stay together or move on.

Exposure and cognitive restructuring are techniques used when dealing with traumatic memories.  In exposure, spouses are asked to gradually imagine those heart-wrenching moments and to cope with them gradually, whereas cognitive restructuring substitutes irrational thoughts, feelings, and behaviours induced by the trauma, with adaptive ones.

Counselors use these “trauma focused” explorations with clients, sifting through the distressing memories and aversive feelings, to help build the client’s self-esteem and confidence in dealing with the betrayal or loss of the relationship.

Therapists are also working with their clients to help them understand the unique reasons that led to the infidelity.  Understanding why the affair occurred can help both people.

Along with help from family and friends, wounds can be bandaged and trust restored.  Infidelity trauma and the time and strength involved in recovery remind us that love, like war, can have its casualties.

– Contributing Writer: Justin Garzon, The Trauma and Mental Health Report

– Chief Editor: Robert T. Muller, The Trauma and Mental Health Report

Copyright Robert T. Muller

Photo Credit: Daquella Manera/Flickr

This article was originally published on Psychology Today

Brain Trauma, feature2

Coping With Traumatic Brain Injury

10Anxiety, Child Development, Cognition, Depression, Empathy, Environment, Featured news, Health, Memory, Neuroscience, Productivity, Sleep, Sport and Competition, Trauma February, 15

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Traumatic brain injuries (TBI) contribute to many deaths each year, and can lead to the development of secondary mental health problems.  The Centre for Disease Control has reported that approximately 1.7 million TBIs occur every year, and individuals with a TBI commonly suffer cognitive impairments and developmental delays.

The Trauma & Mental Health Report recently spoke with Tricia Williams, a clinical neuropsychologist at Holland Bloorview Kids Rehabilitation Hospital, who works with children who have different forms of TBI.  Williams explained how to improve child development and mental health for individuals coping with a TBI.

Q:  What are the most common injuries that lead to the development of a TBI?

A:  A TBI is caused when an external mechanical force, such as a blow to the head or a concussive force causes harm to the head or body.  Motor vehicle accidents are the leading cause of TBIs.

Other common injuries include falls (which are common in young children and infants), sport injuries, concussions, horseback riding, interpersonal violence (fighting, gun shots, physical hits to the head by person/object,) and war related injuries.

Q:  How is a TBI diagnosed?

A:  Professionals in emergency services diagnose a TBI in the acute state at the time of injury.  They assess the severity of the injury by checking eye responses, verbal responses, motor responses, and mobile ability.  CT scans are initially performed to rule out bleeding and swelling, and then an MRI may be performed as follow up.  Amnesia is another way to diagnose a TBI. The degree of memory loss prior to the event, and difficulty forming new memory can provide more information about the injury. The duration of loss of consciousness can also affect the severity of the injury, which may be ranked as either mild, moderate, or severe.

Q:  What is involved in rehabilitation following a TBI?

A:  In the acute state, the TBI is managed medically, including neurosurgical intervention.  Once stabilized at the hospital, children move on to rehabilitation.  An assessment of physical, functional, and speech abilities are conducted, and occupational therapists and speech and language pathologists then work with the children. Neuropsychological assessments are conducted after the acute state to help children transition back to school.  The children continue with follow-up visits to monitor the impact of the injury on developing cognitive skills.

Q:  As a clinical neuropsychologist, what is your role with patients who have a TBI?

A:  Children are seen as inpatients at the hospital after the injury, and are also seen as outpatients after they have transitioned home.  They can be followed for many years after the injury.  Typically, they are seen during transitional periods such as the transition from primary school to high school.  A thorough assessment of the child’s skills (IQ, memory and learning, language, processing speed, executive functioning, academic skills, visual and motor skills, socio-emotional status) are conducted and compared to previous testing to assess the child’s progress and developing difficulties.

Q:  What daily activities can become difficult for an individual with a TBI?

A:  Activities that can be difficult depend on the nature and severity of the injury, the stage of recovery, and how well they have been supported.  Common complaints across all injuries include:  keeping up with class, forgetfulness, difficulty paying attention, and becoming easily fatigued, overwhelmed, and frustrated.  Because these activities can be challenging, continued support from their physicians and neuropsychologists as well as family support is very important during the recovery process.

Q:  How can secondary mental health symptoms develop from a TBI?

A:  Depression is a common outcome, and can develop as a reaction to the injury or to neurochemical changes in the brain.  Anxiety is also a common reaction to the injury, because if the child is old enough to understand what has happened, they might expect it to happen again.  This is common for children who developed a TBI as a result of a sports injury.  Children can also be anxious about their academic achievement and about performing well in school.  It is important to make patients aware of potential secondary mental health symptoms. But, individuals with a TBI can also have a greater appreciation of life, as they see themselves as survivors.

Q:  What advice can you offer someone with TBI?

A:  Be patient with yourself and try to normalize your emotional variability.  It’s important to ask for and accept help, and to find the balance between accepting what has happened and moving on.  Individuals should keep in mind that while there are variable outcomes, full recovery is possible.  Finding a “new normal” for oneself without becoming centered on the injury is extremely important.

Q:  Do you have any further suggestions for coping with a TBI?

A:  Here is a list of helpful tips:

  • Take additional time on activities as needed
  • Manage fatigue (with exercise/relaxation, sleep)
  • Ask for repetition of key information and written outlines of key terminology
  • Repeat back what people tell you to ensure you are understanding
  • Use your phone or equivalent to make dictated notes and reminders with regularly scheduled playback times
  • Break down (or ask someone to help you break down) larger tasks into smaller manageable parts
  • Choose the time of day when you are most able to accomplish tasks that require more obvious mental effort and sustained attention
  • Recognize the signs that you are losing attention/productivity or becoming overwhelmed and take a break
  • Exercise can help relieve tension, improve sleep and attention
  • Seek out a quiet room to complete work or practice techniques as needed
  • Social support is extremely helpful

Traumatic brain injuries (TBI) contribute to many deaths each year, and can lead to the development of secondary mental health problems.  The Centre for Disease Controlhas reported that approximately 1.7 million TBIs occur every year, and individuals with a TBI commonly suffer cognitive impairments and developmental delays.

The Trauma & Mental Health Report recently spoke with Tricia Williams, a clinical neuropsychologist at Holland Bloorview Kids Rehabilitation Hospital, who works with children who have different forms of TBI.  Williams explained how to improve child development and mental health for individuals coping with a TBI.

Q:  What are the most common injuries that lead to the development of a TBI?

A:  A TBI is caused when an external mechanical force, such as a blow to the head or a concussive force causes harm to the head or body.  Motor vehicle accidents are the leading cause of TBIs.

Other common injuries include falls (which are common in young children and infants), sport injuries, concussions, horseback riding, interpersonal violence (fighting, gun shots, physical hits to the head by person/object), and war related injuries.

Q:  How is a TBI diagnosed?

A:  Professionals in emergency services diagnose a TBI in the acute state at the time of injury.  They assess the severity of the injury by checking eye responses, verbal responses, motor responses, and mobile ability.  CT scans are initially performed to rule out bleeding and swelling, and then an MRI may be performed as follow up.  Amnesia is another way to diagnose a TBI. The degree of memory loss prior to the event, and difficulty forming new memory can provide more information about the injury. The duration of loss of consciousness can also affect the severity of the injury, which may be ranked as either mild, moderate, or severe.

Q:  What is involved in rehabilitation following a TBI?

A:  In the acute state, the TBI is managed medically, including neurosurgical intervention.  Once stabilized at the hospital, children move on to rehabilitation.  An assessment of physical, functional, and speech abilities are conducted, and occupational therapists and speech and language pathologists then work with the children. Neuropsychological assessments are conducted after the acute state to help children transition back to school.  The children continue with follow-up visits to monitor the impact of the injury on developing cognitive skills.

Q:  As a clinical neuropsychologist, what is your role with patients who have a TBI?

A:  Children are seen as inpatients at the hospital after the injury, and are also seen as outpatients after they have transitioned home.  They can be followed for many years after the injury.  Typically, they are seen during transitional periods such as the transition from primary school to high school.  A thorough assessment of the child’s skills (IQ, memory and learning, language, processing speed, executive functioning, academic skills, visual and motor skills, socio-emotional status) are conducted and compared to previous testing to assess the child’s progress and developing difficulties.

Q:  What daily activities can become difficult for an individual with a TBI?

A:  Activities that can be difficult depend on the nature and severity of the injury, the stage of recovery, and how well they have been supported.  Common complaints across all injuries include:  keeping up with class, forgetfulness, difficulty paying attention, and becoming easily fatigued, overwhelmed, and frustrated.  Because these activities can be challenging, continued support from their physicians and neuropsychologists as well as family support is very important during the recovery process.

Q:  How can secondary mental health symptoms develop from a TBI?

A:  Depression is a common outcome, and can develop as a reaction to the injury or to neurochemical changes in the brain.  Anxiety is also a common reaction to the injury, because if the child is old enough to understand what has happened, they might expect it to happen again.  This is common for children who developed a TBI as a result of a sports injury.  Children can also be anxious about their academic achievement and about performing well in school.  It is important to make patients aware of potential secondary mental health symptoms. But, individuals with a TBI can also have a greater appreciation of life, as they see themselves as survivors.

Q:  What advice can you offer someone with TBI?

A:  Be patient with yourself and try to normalize your emotional variability.  It’s important to ask for and accept help, and to find the balance between accepting what has happened and moving on.  Individuals should keep in mind that while there are variable outcomes, full recovery is possible.  Finding a “new normal” for oneself without becoming centered on the injury is extremely important.

Q:  Do you have any further suggestions for coping with a TBI?

A:  Here is a list of helpful tips:

Take additional time on activities as needed
Manage fatigue (with exercise/relaxation, sleep)
Ask for repetition of key information and written outlines of key terminology
Repeat back what people tell you to ensure you are understanding
Use your phone or equivalent to make dictated notes and reminders with regularly scheduled playback times
Break down (or ask someone to help you break down) larger tasks into smaller manageable parts
Choose the time of day when you are most able to accomplish tasks that require more obvious mental effort and sustained attention
Recognize the signs that you are losing attention/productivity or becoming overwhelmed and take a break
Exercise can help relieve tension, improve sleep and attention
Seek out a quiet room to complete work or practice techniques as needed
Social support is extremely helpful

– Contributing Writer: Janany Jayanthikumar, The Trauma and Mental Health Report

– Chief Editor: Robert T. Muller, The Trauma and Mental Health Report

Copyright Robert T. Muller

Photo Credit: Shine In Your Crazy Diamond//Flickr 

This article was originally published on Psychology Today

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Book Review: Becoming Trauma Informed

00Addiction, Anxiety, Child Development, Cognition, Empathy, Environment, Featured news, Health, Leadership, Parenting, Psychopharmacology, Race and Ethnicity, Stress, Therapy, Trauma, Treatment December, 14

Red, and your heart starts to race. Red, and your palms sweat. Red, and the sounds around you blur together. Imagine becoming emotionally aroused or distressed at the sight of simple stimuli, like the colour red, without knowing why.

Because triggers like this can take the form of harmless, everyday stimuli, trauma survivors are often unaware of them and the distress they cause in their lives. And clinicians who practice without the benefit of a trauma-informed lens are less able to help clients make the connection.

To address this and other concerns, researchers Nancy Poole and Lorraine Greaves in conjunction with the Centre for Addiction and Mental Health (CAMH) in Toronto recently published Becoming Trauma Informed, a book focused on the need for service providers working in the substance abuse and mental health fields to practice using a trauma informed lens.

Becoming Trauma Informed provides insight into the experiences, effects, and complexity of treating individuals who have a history of trauma. Without a clear understanding of the effect traumatic experiences have on development, it is challenging for practitioners to make important connections in diagnosis and treatment.

The authors describe how someone who self-harms may be diagnosed with bipolar disorder, possibly insufficiently treated with only medication and behaviour management. But using a trauma informed lens, the practitioner would more likely identify the self-harming patient as using a coping mechanism common to trauma survivors, giving rise to trauma informed care.

Such care involves helping survivors recognize their emotions as reactions to trauma. And helping clients discover the connection between their traumatic experiences and their emotional reactions can reduce feelings of distress. 

Throughout the text, the authors describe an array of treatment options, pointing to ways they can be put into practice; for example, motivational interviewing to provide guidance during sensitive conversations, cognitive behavioural therapy for trauma and psychosis, and body centred interventions to allow clients to make connections between the mind and body, an approach that has become increasingly popular in recent years. 

Importantly, the authors emphasize that a single approach to trauma-informed care is unrealistic and insufficient. While all treatments should include sensitivity, compassion, and a trusting relationship between therapist and client, specific groups require unique approaches. 

The authors devote chapters to specific groups, including men, women, parents and children involved with child welfare, those with developmental disabilities, and refugees. They outline different approaches necessary for trauma informed care in various contexts, such as when working in outpatient treatment settings, in the treatment of families, and when working with women on inpatient units, where treatment requires sensitivity to both the individual’s lived experiences and environment

A unique and compelling feature of this book is the focus on reducing risk of re-traumatization, an often neglected topic. Responding to the need for trauma survivors to feel safe, the authors outline how trauma informed care minimizes the use of restraints and seclusion (practices that can be re-traumatizing), and they offer ways to reduce the risk of re-traumatization by placing trauma survivors in less threatening situations, where they are less likely to feel dominated. This may involve matching female clients to female therapists or support groups comprised of only females. 

The numerous case studies help illustrate specific scenarios, challenges, and outcomes of trauma informed care and highlight the growing recognition of the link between substance abuse, mental illness and traumatic experiences.

While the text is theoretically grounded, the authors convey information in a way that is accessible to wider audiences. It provides critical information for those working in the field by underscoring the relationship between past experiences and current functioning.

Becoming Trauma Informed delivers a deeply informative look into the field of trauma therapy.

– Contributing Writer: Janany Jayanthikumar, The Trauma and Mental Health Report

– Chief Editor: Robert T. Muller, The Trauma and Mental Health Report

Copyright Robert T. Muller

Photo Credit: https://www.flickr.com/photos/auntiep/4450279893/

This article was originally published on Psychology Today

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Fear of Ebola Leaves Orphaned Children Abandoned

00Anxiety, Child Development, Cognition, Deception, Diet, Fear, Featured news, Grief, Health, Parenting, Politics, Post-Traumatic Stress Disorder, Sleep, Stress, Teamwork, Trauma October, 14

13-year-old Jennette’s (name changed by UNICEF) grandmother died from Ebola. Shortly after attending the funeral, Jennette began to feel sick. When fever developed, she was taken to a local treatment center along with her mother and sister. All three family members tested positive for Ebola. Against all odds, they were successfully treated and released.

Jennette broke down in tears as she spoke about her experience as a victim of Ebola to Timothy La Rose, a Communication Specialist with UNICEF Guinea. Despite being healthy again, Jennette could not feel good about her recovery, now facing the stigma of being an ‘Ebola contact’.

“I cannot return home [to] my aunt who threatened me a lot when I was sick. So far she has never asked about my fate.”

The WHO (World Health Organization) estimates Ebola fatality rates between 25 and 90 percent. Passed on through contact with the bodily fluids of an infected person, symptoms are gruesome and can include internal and external bleeding. Currently, there are no approved vaccines, and the 2014 outbreaks in Guinea, Liberia, and Sierra Leone have created immense fear among those living in affected regions. Even in the United States, by October 2014 a handful of cases have quickly led to panic in some regions.

Jennette is only one of the many children facing the consequences of neglect due to the distrust surrounding Ebola survivors. UNICEF estimates that about 3,700 children have lost one or both parents to the current outbreak.

UNICEF’s regional director for West and Central Africa, Manuel Fontaine, said, “these children urgently need special attention and support; yet many of them feel unwanted and even abandoned.”

After surviving Ebola or losing a family member to the virus, these children are being shunned by surviving relatives due to fear of reinfection. “Orphans are usually taken in by a member of the extended family, but in some communities, the fear surrounding Ebola is becoming stronger than family ties,” Fontaine told CNN.

Orphans—some as young as two years old—are in the streets alone, lacking proper shelter, healthcare, and nutrition. Many of these children have undergone extreme trauma. Some have spent weeks in isolation wards without caregivers or proper mental healthcare. The New York Times reported a gut-wrenching scene:

In the next ward, a 4-year-old girl lay on the floor in urine, motionless, bleeding from her mouth, her eyes open. A corpse lay in the corner — a young woman, legs akimbo, who had died overnight. A small child stood on a cot watching as the team took the body away, stepping around a little boy lying immobile next to black buckets of vomit. They sprayed the body and the little girl on the floor with chlorine as they left.

Surviving children must also struggle with the grief of losing parents and siblings. “The hardest part of the job is telling parents their children have died or separating children from their parents,” Malcolm Hugo, a psychologist working in Sierra Leone, told the Guardian.

Many children are displaying symptoms of Post-Traumatic Stress Disorder, a condition that may develop after exposure to trauma. Intense grief, changes in eating and sleeping patterns, and extreme cognitive impairment are being reported in children who are most affected. Symptoms of depression and anxiety are also common.

The WHO reports that the most severely affected countries, Guinea, Sierra Leone, and Liberia lack resources to help those affected by the outbreak.

Many humanitarian aid agencies like Doctors Without Borders have sent physicians and healthcare workers to help in the treatment and containment of the disease. However, very little psychological or medical help is available for orphaned survivors. UNICEF has appealed for $200 million to provide emergency assistance to affected families but has only received a quarter of the amount so far.

Currently, the organization is looking at unique ways to provide emotional support. In Liberia, they are working with the government to train mental health and social workers. UNICEF will also be working with Ebola survivors who are now immune to the disease to provide support to children quarantined in health centres.

In a statement to Al Jazeera, Fontaine explained, “Ebola is turning a basic human reaction like comforting a sick child into a potential death sentence.” Further work needs to be done to abolish the harmful distrust surrounding Ebola survivors, and strengthen family and community support. Without this support, orphaned children face a harsh and unwarranted emotional toll, alone.

– Contributing Writer: Khadija Bint Misbah, The Trauma and Mental Health Report

– Chief Editor: Robert T. Muller, The Trauma and Mental Health Report

Copyright Robert T. Muller

This article was originally published on Psychology Today

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No Place to Be a Child

00Anxiety, Child Development, Cognition, Depression, Education, Empathy, Environment, Featured news, Grief, Health, Meditation, Resilience, Social Life, Stress, Therapy, Trauma, Treatment October, 14

“If we are to teach real peace in this world, and if we are to carry on a real war against war, we shall have to begin with the children” – Mahatma Gandhi

Over 18 million children are currently living in regions affected by war. While most humanitarian aid groups focus on meeting the basic physical needs of these children, in the midst of armed conflict, cognitive, social and emotional development is often inhibited and overshadowed by regional chaos.

Exposed to violent, traumatic and stressful situations that threaten their sense of stability and well-being, children have few places to simply be children, where they can play, learn and socialize safely. And few resources are in place to help them heal from the psychological burdens of war.

As the need for rehabilitative and restorative measures gains greater recognition by the international community, a growing number of child rights advocates, organizations and researchers are stepping forward to understand the implementation of psychologically therapeutic programs for war-affected children. The challenge is in figuring out what is needed, what is available and what will work across a variety of cultures, contexts and settings.

Seeking to bring psychological care on a tight budget, academics and policy advisors have emphasized evidence-based programs. Theresa Betancourt, professor and director of the research program on children and global adversity at Harvard’s school of public health, and her colleagues are evaluating the effectiveness of child trauma programs based in countries such as Uganda, Sierra Leone, Chechnya, Gaza, Sudan, Kosovo, Bosnia and Croatia.

Individual therapeutic interventions such as trauma focused therapy and narrative exposure therapy have shown promise among children affected by war and are approved by UNICEF as preferred techniques.

Group interventions have been used to accommodate the psycho-social needs of a greater number of children. These include Interpersonal group therapy for depression, creative play, mother-child psycho-education and support, and torture group psychotherapy with cognitive behavioural techniques.

Some other psycho-social initiatives have focused on the creation of Child Friendly Spaces (CFS’s) and Temporary Learning Centers (TLC’s) within refugee camp settings or local communities. These provide a child-centered environment for play, basic education and socialization; and they identify children in psychological distress.

But some concerns have been noted. The focus on trauma can lead to community stigmatization. In addition, these therapies are hard to carry out on a large scale due to the high costs of employing highly-trained professionals. Individualized services are rare and reserved for severely distressed children, usually demobilized child soldiers.

Problems arise when trying to apply western definitions and measures of distress that are not necessarily applicable to other cultures and contexts. And in understanding any given child’s psychological functioning, it is important to factor in ongoing stressful events and the social dynamics that a war-affected child must deal with on a daily basis.

There has been a movement away from a traditional western “clinical treatment” model toward a more inclusive, holistic framework of “psycho-social intervention,” termed to reflect the complex interplay between a child’s psychological and social development.

More effective group interventions for children have tended to be those that involve a school setting, address everyday stressors, utilize a form of trauma/grief-focused psychotherapy or use mind-body relaxation and coping techniques such as meditation, biofeedback and guided imagery.

Benefits include decreases in posttraumatic stress disorder, improved coping skills, and greater psychological relief and psycho-social adjustment.

Still, universal, comprehensive, culturally-sensitive psychological services for war-affected children remain a long way off. For more information on mobile psycho-social and education programs for war-affected children, please check out The Freedom to Thrive Foundation. Email FreedomToThriveFoundation@gmail.com to find out how you can get involved.

– Contributing Writer: Adriana Wilson, The Trauma and Mental Health Report

– Chief Editor: Robert T. Muller, The Trauma and Mental Health Report

Copyright Robert T. Muller

This article was originally published on Psychology Today