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    • Sherry Paden, PsyD
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Are Your Patients Vaping 58 Joints/Day?

11/1/2020

5 Comments

 
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​David A. Perna, PhD
Licensed Psychologist
Lecturer in Psychology
Department of Psychiatry
Harvard Medical School

View my profile on LinkedIn

The Clinical Assessment of Vaping Exposure

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For: Parents/Therapists/College Counselors

My close friend and professional colleague, David Smelson, PhD, UMASS Medical Center, and his co-researchers from Children's Hospital, Harvard Medical  School in Boston, offer an excellent article/quick read to help clarify terminology and evaluation of vaping both cannabis and nicotine. Please be sure to read their article. I have listed the reference below. 

I was impressed with the following two usage/statistical points that I had not picked up on in my clinical work with patients in our group practice or in speaking with students in our College Transition Program: 

"The amount of THC that some users vape can be dramatic, reaching up 50 mg THC inhaled in a single session, with a total consumption of up to 700 mg per day; in comparison, a typical ‘‘joint’’ of marijuana delivers approximately 12 mg inhaled THC" (Boyer, et al, 2020, p. 4).

That means that a teen/college student using a vape can inhale the equivalent of 58 joints per day. That's right, according to this article, by doing the math, that is what you come up with-think about that. That is why I am seeing so many patients suffering from the impact of severe cannabis intoxication, referred to as Cannabinoid Hyperemesis Syndrome (CHS).

At low levels of use, cannabis causes increased appetite and stimulates eating, which brings about the commonly known term as the "munchies" following use. That is why it was first medically used to help people who struggled with cancer. These medical patients who were being given chemotherapy to treat their illness commonly experienced gastrointestinal distress. Small doses of cannabis allowed them to eat so they would be able to maintain their weight while they proceeded through treatment. However, at the opposite end of the continuum,  in extremely high doses, cannabis  will commonly cause:


  • Severe nausea
  • Vomiting or Cyclical Vomiting (Repeated bouts of vomiting) 
  • Abdominal pain

I have never witnessed patients struggle with the negative effects of such high doses of cannabis until the onset of the vaping boom in the Boston area. I have now had several patients who have struggled with the above-mentioned issues. I have also had several students in our College Transition Program who have decided to stop using cannabis completely since they felt that vaping the higher amounts started to  make them feel increasingly anxious and on edge. 

​The second point that was made in Dr. Smelson's article on vaping  that I found was quite helpful was as follows: 

"...over 60% of adolescents do not understand that JUUL devices are nicotine delivery devices." (Boyer, et al, 2020, p. 2).

I found this fact to be quite amazing. I never focus on educating kids/teens on the reality that vaping devices deliver either 
nicotine or cannabis. I assumed that all kids were completely aware of this fact. They know that cigarettes contain nicotine. Why would they inhale the vaping vapor? This issue will allow me to explore their awareness of this fact more closely in our initial sessions when vaping is discussed as a standard part of our intake evaluation  process or when vaping is specifically presented as a treatment concern by parents.

Thanks again to Dr. Smelson and his colleagues for such a powerful, information-packed,  yet concise article. 

​Resources for Parents:
  • Vaping Toolkit
  • Vaping and Marijuana: What You Need to Know
  • Talk with Your Teen About E-Cigarettes: A Tip Sheet for Parents

Resources for Professionals:
  • Cannabinoid Hyperemesis Syndrome 
  • Cannabinoid Hyperemesis: A Case Series of 98 Patients

​
APA Citation For This Article:
Boyer, Edward, MD, PhD, Levy, Sharon, MD, MPH, Smelson, David, Vargas, Sara, et al. (2020). The Clinical Assessment of Vaping Exposure. Journal of Addiction Medicine, Advance on-line publication. Retrieved from http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=ovftw&NEWS=N&AN=01271255-900000000-99270. https://doi.org/10.1097/ADM.0000000000000634

Additional References:
Galli, J. A., Sawaya, R. A., & Friedenberg, F. K. (2011). Cannabinoid hyperemesis syndrome. Current drug abuse reviews, 4(4),
241–249. https://doi.org/10.2174/1874473711104040241





5 Comments

Copernican Clinical Services: Coronavirus-COVID-19 Plan of Action

3/9/2020

1 Comment

 
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David A. Perna, PhD
Licensed Psychologist
Lecturer in Psychology
Department of Psychiatry
Harvard Medical School

View my profile on LinkedIn

"We will be here to support you as these events unfold"
"The overriding goal of this letter is to promote hygiene and not to increase anxiety"
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CDC: "Face-masks should be worn by health professionals who have direct contact with patients" 
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"The CDC has asked that people attempt to “socially distance” themselves from others to help decrease transmission."
"We are supportive of all of our Asian and Asian-American 
​colleagues, patients, and their families who are dealing with this issue. 
."

Copernican Clinical Services:
Coronavirus-COVID-19
​Plan of Action


To Our Patients
​and Their Families,

 
In my role as the president of Copernican Clinical Services, I wanted to help clarify how my staff and I are responding as a behavioral health company to the Coronavirus concerns that have recently arisen throughout the world and more recently in our home state. 
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On the whole, we will continue to provide timely and targeted support for all of our patients and their families in any way possible to help decrease anxiety or other mental health concerns related to this public health event. We will be here to support you as these events unfold. Please be aware that only an extremely small segment of the US population will have a serious impact from the virus. Many of our patients are considered to be at very low risk for a serious impact.
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Feel free to contact me directly if you have any questions about how your specific treater or any of our staff can help you through these challenging times. Our procedures are based upon Massachusetts public health procedures and federal guidelines that are distributed via the Centers for Disease Control. The overriding goal of this letter is to promote hygiene and not to increase anxiety. You can refer to the links listed at the end of this post for additional information.
 
Practical health behaviors that we have implemented to minimize transmission:
  • We have purchased touchless Purell dispensers that are placed at the entrances to both of our facilities. Please use these dispensers when you arrive for a session and when you leave a session. We hope to be able to purchase more supplies over time.
  • We have installed touchless paper towel dispensers in all of our bathrooms.
  • We have placed spray bottles of disinfectant in each bathroom which you may use as you see fit to maintain a hygienic environment for you and/or your child.
  • We ask that you accompany younger children to the bathroom to be sure that they are using proper hygiene to minimize any transmission concerns.
  • Please consider washing your hands before and after you use the bathroom. Washing beforehand will decrease the likelihood of self-infection as you use the bathroom.
  • Please let your clinician know immediately if we are out of any items such as paper towels, Purell, or disinfectant.
  • Please let your clinician open and close the door to their office before and after your session.
  • Face-masks: The CDC has clarified that face masks should be worn at all times.
 
Informing us of Risk Factors:
  • If you think that you have been exposed to someone who has had the Coronavirus, we ask that you seek medical attention and ask that you to contact your clinician via phone/email, rather than in person, and develop a plan with your clinician to address your health and mental health issues.
  • If you think that you or your child has been exposed, then we do not want you to present in person at our facility. This request is in line with CDC guidelines to minimize transmission in health-related facilities.
  • If you or your child has been exposed, please note, we will continue to support you without question via phone/telehealth sessions, whether these sessions are covered by your insurance or not (details are provided below).  Our goal is to help minimize exposure within our communities.
 
At the onset of each session:
  • Session Check-ins: CDC guidelines have been set for health providers to take an active role in asking about patient risks for recent exposure. Your clinician will ask you at the onset of each session if there are any recent concerns surrounding your health and/or the health of your family that have increased your risk of exposure to or transmission of the virus. They will also check-in with you on your anxiety level related to this event with regard to your physical and/or mental health.
 
  • Work/Financial Concerns: We also understand that many patients are concerned about their ability to address financial stress related to their job, business, or to recent swings in the global financial markets. Please feel free to speak with your clinician about these issues, while they are unable to provide you with financial counseling, they can help you manage these stressors and put together a plan to help decrease your anxieties about your finances. We believe that these work/financial issues will tax the energy of our adult patients even more so than the health implications of this crisis and as such are prepared to have a conversation with you on this topic.
Isolation Stress:
  • Social Distancing:
    • The CDC has asked that people attempt to “socially distance” themselves from others to help decrease transmission. These measures are temporary and will fade as the health scare passes. Examples of social distancing would include:
      • Staying 6-feet away from others if possible
      • Avoiding larger gatherings if possible
      • Avoiding common social formalities such as handshakes/kisses/hugs during the crisis.
    • ​Racial/Ethnic Profiling: Please be aware that the CDC has been clear that this virus impacts everyone. Asian-Americans are at no higher risk than anyone else in the US. However, Americans who have travelled to high-risk regions are a major concern. The first high risk patients in Newton consisted of students from Newton who had studied in Italy for a week. Almost all of the other cases in Massachusetts were connected to high level executives who attended a global staff meeting at the Biogen Corporation.  We are supportive of all of our Asian and Asian-American colleagues, patients, and their families who are dealing with this issue. 
  • Self-Quarantines:
    • If you are informed by your physician to “self-quarantine,” you and your family will have minimal contact with others during this 14-day period. We understand that this intense level of home-based interaction may stress your family. We encourage you to speak with your clinician about ways to make this experience an opportunity to bond with your family in a healthy way. Your clinician can check in by phone or via a telehealth interaction on an as-needed basis during a self-quarantine. Please inform them of your needs directly. Under such circumstances, we would ask that you provide your clinician with a letter from your health provider to clarify that you are ready to return to face-to-face interactions in our facility.
 
  • Emergency/Urgent Contact: You can call our emergency phone line, (617)-244-2447, to reach your clinician if you do not feel that you receive a timely response via phone/email. Please be aware that our clinicians may be managing a variety of urgent/emergency calls during this period of time. We will definitely work together as a team to help support you.
 
Grief Support:
  • If you lose a family member, friend, or loved-one as a result of a Coronavirus-related health issue, we will provide you with emotional support and any other support possible to help you through your grief. We can also advise you on how to talk with your children about these events in a developmentally appropriate manner.  
 
What if your clinician becomes ill?
  • If your clinician becomes ill, we will expect them to simply follow their doctor’s medical advice. If that advice includes time off from work due to feeling ill, caring for a family member who is ill, being subjected to a self-quarantine, or any other disruption in their ability to meet with their patients, then they will provide you with a plan to address your specific treatment plan moving forward.
  • All of our information systems are cloud-based so your clinician can fully function with relevant clinical information relating to your case from any location where they find themselves, including their homes.
  • We have been clear in our most recent staff meeting that all Copernican Clinicians should make decisions that are in the best interests of their health and the overall health of their patients.
  • Cross Coverage: If needed, we can provide cross coverage with other staff members from our practice if your clinician is unavailable.
  • Telehealth Solutions: If your clinician is unable to be present for sessions in person, or if you are unable to be present for sessions due to health concerns, and are able to engage in an online telehealth session, then you can arrange a time to meet with your clinician virtually. Your clinician will email you a link that will allow you to meet with them virtually via a HIPAA protected telehealth interface. The interface is extremely simple to use.
  • Helping Others: If you have a friend or extended family member who becomes anxious about this public health event, please feel free to offer our supports if you deem it appropriate. Once again, if they are fearful of coming into our office, we can schedule a telehealth meeting with them remotely.  
 
I thank you for taking the time to review our concerns and response to this global health event. As is always the case, the support that we provide to each other and the manner by which we work together during these trying moments will help us define who we are in these times of uncertainty. My staff and I all look forward to passing the most critical test during these times, the test of our compassion for others during times of need. Be well and remain as healthy as possible.
 
 
Sincerely,
 
         Dr. Perna

          David A. Perna, PhD
          President, Copernican Clinical Services
          Lecturer in Psychology, Department of Psychiatry
          Harvard Medical School
 
Helpful Links:
 
How to prepare for Coronavirus in your:
  • Home:
    • https://www.cdc.gov/coronavirus/2019-ncov/community/home/index.html
  • K-12 school settings:
    • https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/index.html
  • College settings:
    • https://www.cdc.gov/coronavirus/2019-ncov/community/colleges-universities.html
  • Faith-based organization/community events:
    • https://www.cdc.gov/coronavirus/2019-ncov/community/organizations/index.html
 
 
American Psychological Association Podcast on Coronavirus and anxiety:
  • https://www.apa.org/research/action/speaking-of-psychology/coronavirus-anxiety
 
Bloomberg-How Quarantines Have Impacted Mental Health in China:
  • https://www.bloomberg.com/opinion/articles/2020-02-27/coronavirus-quarantine-raises-mental-health-concerns-for-china
 
Psychiatric Times Article-Coronavirus and its Impact on Global Mental Health:
  • https://www.psychiatrictimes.com/psychiatrists-beware-impact-coronavirus-pandemics-mental-health
 


1 Comment

Asian Mental Health Concentration Launch-Thanh Phan

2/19/2020

 

Thanh Phan, MA, our Psychology Intern from William James College,  helps launch the Asian Mental Health Concentration


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David A. Perna, PhD
Licensed Psychologist
Lecturer in Psychology
Department of Psychiatry
Harvard Medical School

View my profile on LinkedIn

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Thanh is so committed to her family and her family's traditions
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The Launch of the Asian Mental Health Concentration at William James featured Lion Dancers from the Boston Chinese Freemasons Athletic Club.
Dr. Vuky is an incredible mentor to Thanh and so many other students at William James
​
-Dr. Perna

​Asian 
​
Mental Health

Concentration Launch


Diversity
​Matters​

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Dr. Perna congratulating Thanh Phan on the launch of the Asian Mental Health Concentration at William James College

Thanh Phan, MA, our Psychology Intern, had asked me if Copernican Clinical Services (CCS) would help sponsor the launch of William James College's Asian Mental Health Concentration (AMHC). I told her that we would all be thrilled to do so. 

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CCS Staff Member, Jenifer Nesin, helps Quanzhou (Jack) Zhao, a Chinese calligraphy artist, display his beautifully crafted artwork at the launch celebration

CCS staff members-Caitlyn Chappell, LICSW, Jenifer Nesin, and Thanh's co-intern Alexis Chirban, MA, and I were present for the launch that celebrated the Lunar New Year at William James in conjunction with a large crowd of William James students, faculty, and extremely energetic supporters (Including Thanh's family).


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Faculty, students, and family members were enthusiastically engaged in the launch and the Lunar New Year celebration

Acculturation: 
Thanh is a thoughtful, hard working, sensitive trainee who has brought so much to our training program this past year. She is not only fluent in Vietnamese but is proficient in Mandarin.  She impressed us from the start. 

Thanh exudes a sense of purpose and meaning in all of her clinical activities as she is rooted in her experience of being a person who has moved through the acculturation process and is able to speak her truth in relating to so many other immigrants who are currently experiencing their own personal transition. Her dedication to her family's cultural heritage, her parents and younger brother, as well as the diverse needs of the various family's that she interacts with at CCS is evident in all of her systems work.

Thanh is a first-generation Vietnamese immigrant who was born in Vietnam. Her understanding of the diverse mental health needs of Boston's Asian immigrants and their unique experiences in Boston  allowed us to quickly identify her as a top candidate for our training program. Her multi-faceted background has provided staff members and trainees with a perspective of American culture and American mental health practices that is extremely rare to come by. As a result, she is sensitive to the needs of the many clients who are simply not well-treated by our various state and federal support programs. 

When Thanh interviewed with us she shared a story about how she accompanied a  previous client and her family to a local emergency room during a psychiatric crisis. She knew that she would be needed to help translate for the overwhelmed family. She simply rolled up her sleeves, jumped in, and did what was needed. True Grit! That's why we offered her a training slot and we have not been disappointed.


Mentoring: Thanh has been mentored by Dr. Catherine Vuky, PhD,  the Director of the Asian Mental Health Concentration at William James who is also a staff psychologist at The South Cove Community Health Center in Boston. Dr. Vuky and Thanh make a great duo. It is easy to see why Thanh has such a sense of hope for the future of the AMHC. That future burns so brightly in the eyes of Dr. Vuky every day and is only matched by her warm smile and sense of commitment to her work. I am glad to see that they both have so much energy. The road ahead is long-so the company you keep makes all the difference. ​

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Catherine Vuky, PhD

Please click on the following Links for more information:​​

South Cove Community Health Center: Boston, MA

William Jame College's Asian Mental Health Concentration Information Page: (Click here)

William James College's Blog Post regarding the launch of the Asian Mental Health Concentration: (Click here)



Anger Research: Staff at the Yale Child Study Center Provide a Helpful Summary Article

1/19/2019

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David A. Perna, PhD
Licensed Psychologist
Lecturer in Psychiatry
Harvard Medical School

View my profile on LinkedIn
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Categories

All
1 David A. Perna
2 Caitlyn Chappell
3 Heather Corazzini
Adolescent Psychology
Anger Management
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Your Child
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"Anger Follows a Developmental
Trajectory"

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"We use the CBT framework for our anger
management
​groups "

​Dr. Perna

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Staff at the Yale Child Study Center have provided a helpful summary Article on how to differentiate between anger, irritability, and aggression. I think that it is one of the better summary articles that I have come across in the last year. While it covers a variety of topics that have been discussed in the past, it does so with a sense of clarity that fellow authors seem to lack. 

Here are a list of the points that I think were helpful:
  • Anger follows a Developmental Trajectory
  • Oppositional Defiant Disorder has three symptoms:
    • Angry/irritable mood
    • Argumentativeness/defiant behavior 
    • Vindictiveness
  • ODD has two primary trajectories, one that predicts future mood lability and one that predicts conduct disorder. 
  • Parent Management Training (PMT): Focuses on the antecedents to aggression as well as the consequences. The goal is to break the link between the two by focusing on the parent impact on the child.
  • Cognitive Behavioral Therapy (CBT) : Focuses on the interaction between cognitions, feelings, and behaviors. 

Sukhodolsky offers his version of treatment which has proven to be clinically effective in a research environment. It is a sophisticated treatment model that is thoughtful and has withstood randomized treatment trials. However, like many of these manual-based, highly structured research protocols one can easily ask, "What is the clinical relevance of this research, when one applies it to a typical outpatient treatment environment?"

I do think that reading this type of research can be helpful in guiding clinicians to adopt "best practices" that help with anger management treatment. However, out-patient treatment of anger is complicated and at times sequentially confusing for both the patient and the inexperienced clinician. 


I do find it surprising that Sukhodolsky comments that CBT is generally implemented on a one-on-one basis. He seems to miss the fact that many models of anger management are based on group models that rely on CBT frameworks. We use the CBT framework for our anger management groups. 

Overall I give the article two thumbs up. Kudos to the staff at Yale!

​Dr. Perna




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MIT/Dyslexia/New Research: Reading Challenges are More Pervasive than Previously Thought

11/22/2018

1 Comment

 
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David A. Perna, PhD
​Licensed Psychologist
Lecturer in Psychiatry
Harvard Medical School

View my profile on LinkedIn
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Categories

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1 David A. Perna
2 Caitlyn Chappell
3 Heather Corazzini
Adolescent Psychology
Anger Management
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Executive Function
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Nutrition
Social Media
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Your Child
Youth Violence

"Dyslexia affects many brain regions, not just those involved with language."

 
Gabrieli-2016

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MIT Researcher John Gabrieli published fascinating findings in the journal Neuron as part of his research and the research of his team (See Reference below) into the roots of dyslexia. His research revealed that dyslexia impacts many different systems within the brain which in turn impact the ability of the dyslexic child to adapt to his/her environment. 

Gabrieli also noted:
  • That there were other systems impacted in the dyslexic brain that had nothing to do with language development and aquisition.
  • He specifically noted a decrease in "Neural Adaptation." He defined this as the brain's ability to adapt to repeated information.
  • He also posited that the brain has many neural systems to work-around challenges in areas of brain funtion that are evolutionarily older. He indicated that the brain had not developed these compensatory systems in reading to date since reading is a much newer brain function. 

I found this article fits my clinical impressions of the complex nature of many child and adolescent patients who struggle with dyslexia. It also highlights the numerous systems that we need to address in our treatment in an applied clinical setting with this population. In our work, we commonly address the degree to which these patients struggle with anger outbursts, poor frustration tolerance, and impulsivity, all of which bring them to our door for treatment. In treating such a complex population, our treatment interventions are equally complex, including familial support, school support, self-esteem support, referral for specialized testing (Such as Central Auditory Processing Evaluations), and individual/family therapy that are all intertwined to address each patients specific learning/mental health concerns. 
​
It is beyond the scope of this review to reveal the complexity of this MIT team's work in this area. A thorough reading of the article that is listed below is recommended. 

Perrachione et al., 2016, Neuron 92, 1383–1397 December 21, 2016

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1 Comment

Note Taking & Students-Pen vs. Keyboard

2/22/2017

3 Comments

 
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David A. Perna, PhD
Licensed Psychologist
Lecturer in Psychiatry
Harvard Medical School
View my profile on LinkedIn
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Image From the New York Times

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1 David A. Perna
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Here is the 2014 New York Times article that many educators have asked me to forward to them. It focuses on the differences in note taking with a pen vs. keyboarding on a computer.  It talks about:
  • How handwritten notes increase retention of academic material
  • The proliferation of high-quality college notes on Note-Taking Apps
  • How college students  are selling notes for cash
  • Academic studies on notetaking such as Dr. Mueller’s work out of Princeton University  

​Please feel free to look at Dr. Mueller and Oppenheimer's academic article:
 
Mueller, P., & Oppenheimer D. M. (2014). The Pen Is Mightier Than the Keyboard: Advantages of Longhand Over Laptop Note Taking. Psychological Science, Vol. 25(6) 1159–1168
mueller-pam-notetaking_atricle-2016.pdf
File Size: 844 kb
File Type: pdf
Download File

Here is the link to the original New York Times article that was written by reporter Laura Papano:
 
Take Notes From the Pros (2014, October 31) The New York Times, Retrieved From http://nytimes.com

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Executive Function Challenges and Anger

9/2/2016

1 Comment

 
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David A. Perna, PhD
​Licensed Psychologist
Lecturer in Psychology
Department of Psychiatry
Harvard Medical School

View my profile on LinkedIn
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"Executive functions are viewed to be primary learning challenges that impact functioning across a variety of learning contexts." 

Many children with anger issues suffer from executive function deficits. These deficits impact their ability to make effective academic progress in school in addition to impacting their functioning in a variety of other social-learning contexts. Executive functions are viewed to be primary learning challenges that impact functioning across a variety of learning contexts. Unlike a specific learning disability, such as dyslexia, which is viewed to impact a specific learning category, such as reading, an executive function deficit generally, impacts multiple categories of learning.

For example, an attention deficit disorder would impact an individual’s ability to make progress in many learning categories, whether they are academic or social. The inability to pay attention in class can impact the ability to learn history as well as the ability to drive a car safely. Organizational deficits are pervasive as well. For example, the inability to organize one’s assignment pad would impact school performance, while it could also impact the ability to socialize with friends (calling friends to get together too late on a friday night rather than earlier in the week).

"Cognitive flexibility allows kids to adjust to the curve balls that life throws at them."

Common Executive Function Deficits
Associated with Anger Management Disorders:


1. Causal Linking Challenges:
The inability to understand that one event causes the other. An example would be a patient who thinks that his probation officer is causing him to have a limited social life, forgetting the fact that the probation officer was assigned to work with him because he had made the poor choice of assaulting another person. In this situation the patient loses track of his own behavior as the primary reason why he has lost many age-appropriate freedoms. Within school it might include the lack of understanding that completing homework will increase one’s understanding of the class material and subsequent performance on tests.

2. Organizational Deficits: 
Difficulties with the ability to keep track of details that allow the patient to successfully negotiate a myriad of social interactions and learning opportunities. An adolescent might be upset that she has misplaced her homework assignment and cannot complete her homework. However, within her social interactions she might become angry at a parents when she misplaces a slip of paper that contained a phone number that she felt was essential to her social life.

3. Sequencing Challenges:
Difficulties with the ability to keep track of sequences of events that are needed to facilitate a positive outcome in a learning situation. The inability to follow a given sequence to solve a math problem will generally result in the wrong answer. In a job situation, an adolescent might sanitize the counters of a fast-food establishment and then place a package with raw chicken onto the cleaned counter in front of his boss just prior to being terminated. A hard-working kid would have lost a job over the likelihood that his sequencing challenge could result in someone going to the hospital.

4. Time Management Issues:
Difficulties with allocating time to complete/attend events and activities that are of meaning to the patient or other people in his/her environment.  An example would include having an adolescent plan on completing a major project for school on a weekend when relatives were visiting from out of town resulting in a huge family fight. Within the social realm it might include being bombarded by complaints from peers as a result of being late for a movie. 

5. Transition Issues:
Difficulties with the ability to transition between two activities. Examples of these difficulties range from obvious difficult transitions, such as ending summer and starting school in September to less clear transitions, such as the movement from a sleeping state to a waking state each morning. The resulting morning tirades can be overwhelming for parents. Within a middle school environment the process by which kids constantly move from class to class could prompt a student with this challenge to feel unsettled throughout the school day. As soon as he feels settled in class the bell rings and he has to head off to the next one. As the day progresses the sense of stress increases to the point where an explosion can occur in the last period of the day.

6. Cognitive Flexibility:
The ability to learn new ways of coping with ever-changing stressors in a fluid manner. This issue is many times referred to as the ability to be prepared for all of the “Curve balls” that life throws one’s way. A child who was taught one way of solving a math problem using long division in 5th grade becomes enraged when her 6th grade teacher introduces a new method. Or in social settings it might represent the ability to quickly respond to the fickle interests of a peer group who wanted to go to the mall on Friday night when plans were made earlier that day during school lunch, to the movies when plans were made at 6PM Friday night, and out for food at 9PM when all the peers at the theater realized that the popular kids were having dinner at a nearby Shake Shack. For the average teen popularity always tops planning, however, for the teen with cognitive flexibility issues the plan is written in stone. This skill challenge is closely tied to transitioning challenges and challenges in understanding other people’s perspectives (theory of mind).

7. Memory:
The ability to remember information in a manner that allows it to be readily available for quick and efficient access. For example, a child might erupt at the thought that he had to get his hair cut when in fact both parents informed him of the hair cut days earlier. In school it might include the embarrassment of walking into class on a Monday morning and being handed a test by the teacher after forgetting to study over the weekend.


8. Generalization:
​The ability to generalize from one situation to the other. For example, a student is told not to write on his desk at school, which he agrees not to do, but is then caught writing on a table in the cafeteria. In such a situation the child may be incredibly frustrated that the teacher did not clarify this issue to a greater extent and may become highly focused on the fact that he has not written on his desk since the teacher asked him to stop. The connection between the two situations is simply not apparent to the student, while the teacher may start to feel that the student is playing him/her. In reality the student is simply clueless to the connection between the two contexts. 




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Anger and The Monster Within Us

3/17/2016

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David A. Perna, PhD 
Licensed Psychologist
Lecturer in Psychiatry
Harvard Medical School

View my profile on LinkedIn
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“And if thou gaze long into an abyss, the abyss will also gaze into thee”
​-Nietzsche

For those who are interested in working with angry patients the journey is fascinating. However, from a countertransference perspective one needs to be cautious and should follow the advice that Nietzsche offers in Beyond Good and Evil:

“He who fights with monsters should be careful lest he thereby become a monster”

“And if thou gaze long into an abyss, the abyss will also gaze into thee”
​

Let me be clear, the monster is not the patient, it is the anger and rage that he or she harbors. In his comments Nietzsche is referring to the extent that one can become tainted and reactive when interacting with such challenging behaviors over time. It is often all to easy to focus on the client’s overreactions and extreme rages and lose sight of the clinician's own clinical shortcomings and tendencies to be blind to his/her own hurtful behavior and countertransference blindspots.

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Arc de Triomphe interior,
​statue- “La Marseillaise”
Credit: David A. Perna (2014)
In working with angry patients one is constantly challenged to address one’s own temper and tendency to lash out in a sadistic/hurtful manner. Boundaries that seem to be so clear when one is in training under clinical supervision can at times become blurred later in a clinician's career during an intense treatment experience. The risk is the likelihood that the clinician can start to treat the patient with the same sense of  venom and distrust that the patient experiences in his/her daily interactions. This is the slippery slope that prompts one to lose clinical perspective as the abyss grabs a hold and pulls the clinician downward..

One of Marsha Linehan's greatest contributions to the field of contemporary  psychology has been her ability humanize the the treatment of patients diagnosed with Borderline Personality Disorder. This population has always been identified by treaters and members of the general population as angry and furious. Prior treatment approaches encouraged sadistic reactions to borderline patients who struggled with mood regulation skill challenges, rage, and a long history of interpersonal instability with significant others.

Linehan's "Eastern Philosophical" approach to treatment posited that the therapist was at fault if the patient did not progress, thereby prompting the therapist to think of ways to change his/her approach rather than simply rebuking the patient as being lazy or slothful. This humanistic approach ushered in a much healthier era in treating Borderline patients by helping them develop skills in an incremental manner that is at times slow, and yet with time-steady and incrementally effective.

So in following
Nietzsche's lead, the clinician should always question him/herself when the interaction with the patient becomes intense. Anger and rage focused back towards the patient and family should always be considered as unhealthy and connected to the pull of the abyss. There have been so many clinicians who have rationalized these hurtful approaches as appropriate and needed in light of the patients acting out, but the truth is that they represent an unhealthy countertransference response to a vulnerable group of patients.

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Today's Social Media: Windows into a Violent World

6/5/2015

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David A. Perna, PhD
Licensed Psychologist
Lecturer in Psychiatry
Harvard Medical School 

View my profile on LinkedIn
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"Parents Should Use Their Values to Guide Their Parenting"

Parents, educators and fellow clinicians have asked me the same question:
"What impact does violent social media have upon my child/student/patient?"
​

I recently had the opportunity to address this topic along with my colleague Liz Barcewicz, PsyD. We were asked by Court Booth, Director of Community Education in Concord-Carlise (He is also a LinkedIn Member), to speak about the impact of violent social media on our youth. We had the added pleasure of presenting at Concord-Carlisle's new high-tech high school. The school was only seven days old when we walked into the new multi-media center. 
Our primary talking points were as follows:
  • Engagement Rather Than Containment: The Internet is here to stay. Parents must learn how to engage their children in discussions about all forms of cyber-media rather than simply focusing on containing/limiting their access.
  • Values: Parents should use their values as a frame of reference or “pathway” that will help guide their kids as they confront these issues. Although it is not readily apparent, kids feel safer when such values are clearly articulated by their parents. Values serve as a filter that can be used to understand and process the wide breadth of information that is available on the Internet. Parents were surprised to learn that research into family values shows that many kids gradually adopt their parent’s values as they mature (Knafo, 2004). 

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"Help younger children by placing upsetting news stories into a larger context"

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​“Note your child’s temperament and adjust media exposure to suit his/her needs”

​
  • Passive vs. Interactive Media: Parents were informed that prior research on the topic of passive media does not readily apply to the internet/social media, given that the latter involves interaction, choice, and active decision-making.
  • Who Can They Trust? We reviewed how much of the recent research on interactive media use is plagued by poor definitions of cyber behavior (Patton, 2014) and in many ways is riddled with researcher bias (Ferguson, 2013).
  • Developmental Approach: Parents were informed about how to discuss these issues with younger children versus adolescents.​
  • Younger Children: Younger children require more supervision/monitoring and need more help in being able to identify their feelings. At times they also need help in distancing themselves from imagery/thoughts that are disturbing. Dr. Barcewicz discussed how to use Mindfulness Techniques, such as comforting images (thoughts of leaves floating down a river or clouds floating through the sky) to help kids clear their thoughts. She also mentioned how helping children shift to different activities, particularly physically engaging activities can have a positive impact on mood (Siegal & Bryson, 2011). One of the most comprehensive summaries of how terror/violent media impacts younger children was summarized on the National Association of School Psychologist’s website in 2002, following the World Trade Center terrorist attacks. Both Dr. Barcewicz and I found it to be the most comprehensive listing of information on this topic and we highly recommend it to parents and professionals (http://www.nasponline.org/resources/crisis_safety/children_war_general.aspx)

  • Older Children: Older children need to feel that their parents listen to them and respect their opinions. Dr. Barcewicz talked about the biological underpinnings of adolescent brains and their need for high stimulation/ excitement. She cited recent research and a helpful book on the topic, "Brainstorm," by Daniel Siegel (Siegel, 2014).
  • Talking to Adolescents: I covered how parents could discuss the recent series of civil rights violations and civil unrest that has arisen in many US cities with their adolescents. I emphasized how to connect emotion with thought by talking with adolescents about a recent NY Times article that discussed the relationship between “Missing Black Men” in US cities and the subsequent likelihood of racial unrest (Wolfer, 2015). Parents found this example helpful since it provided them with a practical way  to connect their values with their child’s media experience.


​
“Teach your kids how to take responsibility for their down-time and boredom”

​
  • Boredom Management: At the end of the presentation, I reviewed how adolescents need to learn how to manage “down-time” when they are not exposed to social media. We also talked about how parents can guide them in  structuring their own time in order to decrease boredom. Parents learned that they need to encourage their kids to take responsibility for their boredom rather than asking others to manage it for them.

References:

  • ​Alia-Klein, N. et al. (2014). Reactions to media violence: It’s in the brain of the beholder. Viewing Media Violence, 9, 1-10.
  • Becker-Blease, K.A., Finkelhor, D., & Turner, H. (2008). Media exposure predicts children’s reactions to crime and terrorism. Journal of Trauma and Dissociation, 9, 225-248.
  • Brown, K.D. & Hamilton-Giachritsis, C. (2005). The influence of violent media on children and adolescents: A public health approach. www.thelancet.com, 365, 702-710.
  • Ferguson, C.J. (2013). Violent video games and the supreme court. American Psychologist, 68, 57-74.
  • Ito, M. et al., Living and learning with new media: Summary of findings from the digital youth project. (2009). Cambridge, MA: MIT Press.
  • Knafo, A., & Schwartz, S. (2004). Identity formation and parent-child value congruence in adolescence. British Journal of Developmental Psychology, 22, 439-458.
  • O’Keeffe, G.S., Clarke-Pearson, K., & Council on Communications and Media (2011). Clinical report-The impact of social media on children, adolescents, and families. American Academy of Pediatrics, 127, 800-804.
  • National Association of School Psychologists (2002),Children and Fear of War and Terrorism. Retrieved from http://www.nasponline.org/resources/crisis_safety/children_war_general.aspx.
  • Patton, D.U. et al. (2014). Social media as a vector for youth violence: A review of the literature. Computers in Human Behavior, 25, 548-553.
  • Siegel, D. & Bryson, T. (2011). The whole-brain child: 12 revolutionary strategies to nurture your child’s developing brain. New York: Delacorte Press.
  • Siegel, D. (2014). Brainstorm. Brunswick: Scribe Publications.
  • Wolfers, J., Leonhardt, D., Quealy, K., (2015, April 20). 1.5 Million Missing Black Men. The New York Times Retrieved from http://www.nytimes.com/interactive/2015/04/20/upshot/missing-black-men.html?abt=0002&abg=1.

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