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    • Suzanne Brooks, PsyD & NCSP
    • Molly Curcio, PsyD
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    • Kaeley Majewski, PsyD
    • Sherry Paden, PsyD
    • Ian Ljutich, MA, MSW
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    • Jenifer Nesin
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  • MMT Approach
  • Training
  • Our Posts
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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

Home Schooling Strategies-Mindful Parenting: Part 1 Embracing the Moment: Being with your child

3/8/2020

1 Comment

 
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Alexis Chirban, MA
​CCS-Psychology Intern
Doctoral Candidate-
William James College

View my profile on LinkedIn
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"I have often been asked: How can being mindful with a child be beneficial"        -Alexis               Chirban
Home Schooling Strategies

Mindful Parenting: Part 1
Embracing the Moment

Being with your child
Parents, 

Please apply the words that our Copernican Intern, Alexis Chirban, MA, wrote on the topic of mindfulness to being home and schooling your child. We were planning on posting this information before the current health crisis but more than ever feel that it is appropriate to help you support your child's transition to learning at home. Please check back in with us for additional posts by Alexis on how to apply these techniques over the next few weeks. 
                                                           Be healthy and be strong,
                                                                                                                         Dr. Perna


​Mindfullness Research: 
I have often been asked, “How can being mindful with a child be beneficial?”   

Research has shown mindfulness to be associated with:
  • Significant effects on improving parent-youth relationships by parents engaging with their youths in a more attuned, accepting and compassionate way (Coatsworth et al., 2015).
  • Lower levels of anxiety, worry, depression, rumination, mind-wandering and negative affect (Deng et al, 2019 & Geronimi et al., 2019).  
  • Improving executive functions of inhibition, working memory and shifting. 
    • Inhibition (inhibitory control) is the ability one has in managing behavior, attention, emotions and thoughts in response to both internal and external distractions at a given moment. 
    • Working memory is understood as the ability to store and manipulate information. 
    • Shifting is the ability to adapt to change and consider and appreciate a different viewpoint (Geronimi et al., 2019).  ​ ​
Mindfulness has received a large amount of press recently. If you gaze at magazine covers in your supermarket’s check-out isle you will notice articles that target mindful breathing, mindful coloring, and mindful eating. These writers seldom talk about what mindfulness actually means and how you can apply a mindful approach to your relationships with your children. Let’s give it whirl and see where we end up!

"Become aware of the moment"
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"Children typically  
are not judgmental"
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Mindfulness Defined: 
Simply put, mindfulness is about noticing and becoming aware of the present moment, in a non-judgmental way.   The hardest part of this process is avoiding the judgement.  We have built up so many layers of judgement in so many things that we do, we no longer notice that we are judging. Children typically do not judge; they experience life as it comes at them.  

Challenge:
Let’s try it. Right now... Take a moment to sit back. Notice what’s around you. What do you see? Hear? Smell? Touch? Taste? How do your surroundings feel to you? If you are saying, “Well I think…” Try to drop the “think” and simply finish the statement, “I feel….” whatever?

Kids are great at this first challenge. If you place food on their plate that they do not like, they will get a disgusted look on their face and comment, “Yuck, I hate it, take it off my plate.” Our tendency as parents is to become frustrated with them. Adults will attempt to discuss all of the thoughtful reasons why they should eat the food that is on their plate, such as:
  • “It is healthy for you”   
  • “You need energy for school” 
  • “You have to watch your weight”   
And as is typically the case, the foods that kids reject are commonly vegetables or whole grains. We judge their eating, based upon our thoughts of what is a “healthy diet.” They are simply enjoying the moment.  

"Reconnect
​to your childhood sensory experiences"
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"Mindful moments can spur on a dialogue with your child"
Use your Senses:
This is what your child is doing. 
One of the easiest ways to remind yourself what it is like to be a mindful child is to take a step back and become aware of all of your sensory input. From our earliest moments on earth, we have processed environmental experiences through our senses. To this day, we constantly scan our world, analyze it, and respond to it without our conscious awareness… even as you read the words in this article right now you are engaged in this process of sensory awareness.  

Reconnecting to our sensory experiences can help us reconnect to our environment. As a result, we can make these habitual and automatic ways of responding more available to our conscious level of being. When our automatic ways of responding become consciously known, we can then offer ourselves a chance to engage in a substantively different experience of being in the world, including our choice to be with our children in a qualitatively different way.  
​

Example: 
For example, maybe after you noticed your child’s rejection of a vegetable, you thought back to your own childhood. What did that vegetable taste like to you when you first tried it? Was it bitter? Was it fibrous? Did it smell funny? A momentary check-in offers an opportunity for you to consciously take in information about your own past sensory experiences and provides you with a new choice in how to respond to your child’s experience.

Rather than becoming frustrated with your child, you might comment to your child, “Oh I was just like you, I hated spinach when I was a kid. It tasted funny to me and I had a hard time chewing it. I can understand why you don’t like it.” This mindful moment might spur on a dialogue, perhaps a question like, “Then why do you want me to eat it?” 

The power of mindfulness is in the choice it gives you to either respond to your environment, including your child, unconsciously from habit, or engage with them and the world around you in a different way-a mindful way.  These are exactly the techniques that will allow you to help your child focus away from many of the stressful thoughts that are barraging them during this current health crisis. 
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Keep an eye out for future posts on specific applications of mindfulness activities for during the current health crisis. Be healthy and be strong. 

References:
Coatsworth, J. D., Duncan, L. G., Nix, R. L., Greenberg, M. T., Gayles, J. G., Bamberger, K. T., … Demi, M. A. (2015).  Integrating mindfulness with parent training: Effects of the mindfulness-enhanced strengthening families program. Developmental Psychology, 51(1), 26–35. doi: 10.1037/a0038212
 
Deng, Y., Zhang, B., Zheng, X., Liu, Y., Wang, X., & Zhou, C. (2019). The role of mindfulness and self-control in the relationship between mind-wandering and metacognition. Personality and Individual Differences, 141, 51–56. doi: 10.1016/j.paid.2018.12.020
 
Geronimi, E. M. C., Arellano, B., & Woodruff-Borden, J. (2019). Relating mindfulness and executive function in children. Clinical Child Psychology and Psychiatry, 135910451983373. doi: 10.1177/1359104519833737
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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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2 Caitlyn Chappell
3 Heather Corazzini
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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)



Your Adolescent's Eating Habits: From Soup to Nuts

1/20/2019

1 Comment

 
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Heather Corazzini, MA
Psychology Intern
Copernican Clinical Services

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
Borderline Personality Disorder
Education
Executive Function
Healthy Lifestyles
Learning Challenges
Nutrition
Social Media
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Your Child
Youth Violence

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"There isn’t   one single    reason eating disorders begin or are maintained"
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"For some kids certain food textures make them feel like someone is dragging their nails across a blackboard"
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“perfectionistic language” is a common trait shared
between parents and adolescents with disordered eating
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​Does your adolescent’s eating behavior, weight, or exercise ever appear abnormal to you? Do they seem preoccupied with their physical appearance? Have you considered asking them about it, but weren’t sure how to approach them? Not all eating patterns or behaviors would constitute an eating disorder diagnosis; however, disordered eating patterns and behaviors are real, require careful consideration, and can have serious health implications.
 
Trust Your Intuition:
Eating disorders are often disguised in ways that minimize their significance. At times they can be difficult to assess and are often overlooked by adults. If your intuition as a parent tells you something might be “off,” with your child’s eating, listen to it, and consult a professional for guidance. It’s okay to be unsure about what you have noticed.  Speaking with a mental health professional who has experience in this area can help you develop language that will allow you to express your intuitions to your child in a clear and supportive way. 
 
Eating Disorders can be Deadly: 
The prevalence of adolescent eating disorders has gained significant attention in the mental health field over the last decade. Some researchers have claimed anorexia nervosa has the highest mortality rate of all psychological disorders (NEDA, 2018). 
 
See: https://www.nationaleatingdisorders.org
for more information.
 
How does it Start?
Many parents ask, “How did this start? Why and when did my child become so obsessed with what they’re eating?”
            
Studies offer arguments for why and how eating disorders are developed and maintained. In 2016, a team of researchers examined risk factors they believed to predict onset of eating disorders in adolescent females.  According to their study, adolescent females were most at risk to develop eating disorders if they dieted, idealized thinness, had body dissatisfaction, and displayed unhealthy weight control behaviors (Stice et al., 2016).
 
Despite research supporting specific reasons for ED development and maintenance, it can be argued such reasons are multifactorial;there isn’t one single reason eating disorders begin or are maintained. Eating disorders may also function as a form of self-punishment, manifestation of anxiety, or addiction—with little to no emphasis on weight loss as a central goal.
 

Sensory Integration Issues:  
Not all eating disorders develop from preoccupation with fear of weight gain. Aversion to texture, fear of choking, fear of swallowing, etc., can also develop into ED (see Avoidant Restrictive Food Intake Disorder, DSM-5 criteria that are listed below). 
·       An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:     
  • Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
  • Significant nutritional deficiency.
  • Dependence on enteral feeding or oral nutritional supplements.
  • Marked interference with psychosocial functioning.
See:
https://www.nationaleatingdisorders.org/learn/by-eating-disorder/arfid
 
Many children who struggle with sensory integration disorders have difficulties with their eating, due to their reactivity to strong odors/tastes and certain textures of food. Their eating issues can often be compounded by the presence of muscular weaknesses in their mouth, tongue, and throat that impair their ability to swallow food.
 
One researcher stated…
“Often when kids display picky eating, especially those with food aversions/extreme picky eating, the touch, taste, or smell of a food is being processed in their brain as dis-pleasurable in some way.  And, by dis-pleasurable, I mean down-right uncomfortable.  Think of something that makes you shutter… nails on chalkboard or touching a slug?” (Grogan, 2018) 
 
See: https://yourkidstable.com/sensory-processing-and-picky-eating/
 
What about Boys?
According to the National Eating Disorders Association (NEDA), approximately 0.3 – 0.4% of young women and 0.1% of young men will suffer from anorexia nervosa. Despite the common assumption eating disorders are exclusive to women, NEDA claims 25% of individuals with anorexia nervosa are male. Additionally, NEDA claims disordered eating behaviors (binge-eating, purging, laxative abuse, fasting) are nearly equal across male/female genders. For example, many boys who wrestle in high school manage their calories and exercise level so they can “cut weight” before a wrestling match. Additionally, dehydration can cause poorer performance in these athletes and places them at risk for more serious health concerns. 

See: http://pediatrics.aappublications.org/content/140/3/e20171871

Regardless of the severity of source of the ED, the way you communicate about this with your child matters!
 
Researchers in 2011 conducted a study addressing the relationship between adolescent disordered eating and parent-child communication dynamics. The researchers concluded individuals’ thoughts of defectiveness, failure, and unrelenting standards from their parents contributed to their eating disorder. Findings suggest “perfectionistic language” is a common trait shared between parents and adolescents with disordered eating (Deas et al., 2011). “Perfectionistic language,” looks different within each family. 
 
Do NOT:
 
  • Make critical comments about your child’s physical appearance.
  • Encourage your child to “watch their weight,” or warn them of gaining weight.
  • Praise your child for appearing as if they lost weight.
  • Make negative comments about your own appearance/weight in front of your child.
            
Parents are encouraged to alter their communication style in ways that may discourage the onset or maintenance of an eating disorder. 

 
Do try to:
 
  • Praise your child based upon their achievements to enhance their self-esteem
  • Encourage healthy eating without rigidity; everything in moderation!
  • Work hard to make your child feel their weight/physical appearance is not everything. Instead, try to focus on their uniqueness in ways that will strengthen their mental health.
  • Consult with professionals about rising concerns, so you can feel equipped with positive and effective language to use with your child
 
Try not to forget:
It is your child, so it’s up to you.-Notice, listen, and speak up.


References:

Deas, S., Power, K., Collin, P., Yellowlees, A., & Grierson, D. (2011). The relationship between disordered eating, perceived parenting, and perfectionistic schemas. Cognitive Therapy And Research, 35(5), 414-424. 

Stice, E., Gau, J. M., Rohde, P., & Shaw, H. (2017). Risk factors that predict future onset of each DSM-5 eating disorder: Predictive specificity in high-risk adolescent females. Journal Of Abnormal Psychology, 126(1), 38–51. 


 
 
 
 
 
 
 
 
 
 
 
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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

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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

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David A. Perna, PhD
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"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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Note Taking & Students-Pen vs. Keyboard

2/22/2017

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David A. Perna, PhD
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Harvard Medical School
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Image From the New York Times

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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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WHAT’S ON YOUR CHILD’S PLATE?

1/9/2017

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Caitlyn Chappell, LICSW
​Licensed Clinical Social Worker
CCS Clinical Coordinator
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Your child's eating is important/
How to facilitate positive eating habits

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"Focus on healthy eating in your home... these healthy habits will follow your
child to other settings"

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The habits we develop early in life are likely to stick with us throughout our lifespan. This is why it’s important to teach our children right from wrong, daily life skills, appropriate ways to socialize, and a multitude of other skills to help encourage our children to develop healthy adult habits. One skill that tends to get overlooked in families is healthy nutrition habits. Often, when our children are younger, our main goal is to encourage them to eat anything, rather than focusing on the timing and quality of their meals. This is an injustice to our children in various ways. Not only are we neglecting to establish healthy eating patterns in terms of choosing and enjoying healthy foods, but we are also neglecting to teach our children appropriate structure and patterns regarding their eating. Parents can only control what is going on in their home not their neighbor’s homes, therefore, it’s important to model and set these patterns in a realistic way. The end goal is to allow children to generalize these patterns to additional settings without the help of their parents. 

Vocabulary is important...
help children understand which foods are healthy “go-to foods,”

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Introduction to Healthy Foods:
 
Let’s start with their introduction to healthy foods. It is important to remember that we develop the majority of our interests at a young age. This is why parents tend to introduce children to certain sports, activities and books during childhood. The same concept is applicable for food. If parents introduce fruits, vegetables, proteins and grains at a young age, these foods become “normal” and we develop a pattern of enjoyment and acceptance of these foods.
Younger children learn the majority of habits through watching others; this process is referred to as social learning. This means that children are constantly watching parents and other adults in order to develop a framework for how to live in the world around them. Therefore, if parents are modeling healthy eating habits, children are likely to follow suit.

Sometimes parents are unaware of how closely children scrutinize their eating habits as well as the food s that they eat. There are other options available to model healthy eating habits such as taking your children to the grocery store with you, exploring and learning about new and healthy foods and how to incorporate certain nutrients into your meals, and learning to cook to make meals fun and part of a creative process..

On the other hand, if parents choose to place sugar and various junk foods completely off limits, their children may learn to crave these foods and overindulge in them, i.e., binging on them. They become taboo. Sometimes the pendulum swings too far and extremes aren’t usually realistic to incorporate into everyday life. This is why the concept of balance is most important to healthy eating which is often the case in most other areas of life.
​
Vocabulary is important. Parents should help children understand which foods are healthy “go-to foods,” and those that are considered “snacks.” An active dialogue and ongoing information opportunities builds a child’s knowledge-base of healthy eating.  Micromanaging and controlling everything your child eats is simply not okay and is likely to prompt them to build up a sense of resentment and anger. Over time once they have learned realistic and balanced ways to incorporate all foods into their diets, they are less likely to overindulge when left alone. In essence they have incorporated your values around food, and in the end that is what most parents want their kids to do. 

"If we aren’t getting adequate nutrients we can feel lethargic, depressed, anxious or easily agitated"

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How Nutrition Affects Mental Health:
 
So, how does healthy nutrition affect our mental health? There are lots of ways nutrition affects our mental health, specifically relating to the way nutrition can affect our brain. Certain nutrients, or lack of nutrients, can either help or hinder the way our brain is working in terms of our energy and our mental capacity to focus.
 
  • Lack of fiber can decrease focus at school by reducing concentration
  • Sugar intake can cause drastic spikes and lows in energy and mood
  • Tryptophan can increase serotonin, promoting calmness and happiness
  • Lack of B vitamins (folic acid, B12) can increase depression and anxiety
  • Protein helps with increased alertness, energy and reaction time
  • Omega-3 fatty acids can help increase overall mood regulation
  • Caffeinated beverages suppress serotonin and cause dehydration, which can lead to depression and irritability, they also limit the ability to sleep causing increased stress and anxiety and susceptibility to illness as the immune system is suppressed.
 
Therefore, if we aren’t getting adequate nutrients we can feel lethargic, depressed, anxious or easily agitated. Alternatively, if we are getting the proper nutrients throughout the day we are likely to feel energized, motivated and calm. All of these symptoms can be amplified for the better or worse once they are combined with life’s many ups and downs.

"Eating routines and structure are important."

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Structure and Routine:

​The next important aspect of nutrition is structure and pattern. Life is hectic and for most parents it is difficult to have structured meals on a daily basis. Sometimes parents squeeze in a meal whenever people are home or in between activities.

​Developing unhealthy eating patterns teach children that eating is not a priority, nor does it require a lot of attention. Under such conditions children learn to avoid planning meals and eating them at set times during the day. As they mature, children can become adults who value nutrition and consistency and appreciate the impact of their nutritional choices on their energy levels and overall health.

"Role-model how to eat a meal at a reasonable pace."

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Nutrition Labels and Meal Pacing:

One area of detail that many parents forget is the simple process of modelling how to read nutrition labels in the grocery store. By doing so, we can teach our children how the many details associated with healthy nutrition are easily identified by a quick look. Research has shown that awareness of the overall number of calories in a given food portion can impact a child’s decision to eat it if he/she is aware of how much effort it would take to burn off those calories by walking, running, or biking.
​
Be sure to role-model how to eat a meal at a reasonable pace. Enjoy that first portion of food, relax and chat a bit while eating, and then ask yourself, “Am I still hungry?’ If the answer is yes, then it is okay to have another portion. Remember it takes our stomach about 20 minutes to tell our brain we are full. When we are eating too quickly, we don’t realize we are full until it is too late, therefore, causing overeating. One piece of advice to address this issue at meal time would be to have kids start eating their meal, then introduce a topic for discussion to slow down the eating process. Questions about the school day, a news event, or “high-lows” of the day are generally helpful. After a conversation you can ask your child if he she is still hungry? 

"Mindful eating  incorporates the five senses; smell, taste, sound, touch and sight."

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​The Mindful Meal:
 
Every parent has heard the term “Mindfulness,” but have often been confused about how to apply this concept to life-events.  A main component of anxiety reduction treatment is “mindfulness” work. This treatment modality speaks to the notion that as a society we are constantly multitasking and not fully immersing ourselves into what we are doing at any given moment, thus, overwhelming our minds and leading to anxiety and stress.
 
A portion of mindfulness work incorporates mindful eating.  As a family, it is important to strive for “The Mindful Meal”. This involves setting aside planned time and concentrating on just the action of eating our meals, without the distraction of any other tasks. Mindful eating also incorporates the five senses; smell, taste, sound, touch and sight. These can all be incorporated by using them as a framework for a discussion around the meal such as:

  • “How does the food taste?”
  • “How does the food feel in your body?”
  • “What about the food’s color do you find appealing?”
  • “How does the color add to the nutrition of what you are eating?
  •  “What colors are you noticing in this meal that contributes to certain nutrients?”
  • “How does this meal smell compared to others?,”
  • “What nutrients do you think are contributing to that smell?”
  • "Did you hear that food crackle when it was in the wok."
 
All of these concepts of mindful eating help train our minds and bodies to be present and calm. When your children and your family is more stress free, you are able to talk amongst yourselves about other things, thus facilitating healthy meals times and healthy discussion within the family. 

 
References:
 
http://www.abc.net.au/parenting/articles/nutrition_toolkit.htm
 
http://www.mentalhealth.org.uk/help-information/mental-health-a-z/d/diet/
 
http://www.nchpad.org/606/2558/Food~and~Your~Mood~~Nutrition~and~Mental~Health
 
http://www.livestrong.com/article/480254-how-long-does-it-take-your-brain-to-register-that-the-stomach-is-full/
 
http://life.gaiam.com/article/zen-your-diet
 
http://tribecanutrition.com/2013/05/healthy-snacks-around-the-clock-or-structured-meals/
 
http://www.everydayhealth.com/anxiety-pictures/anxiety-foods-that-help-foods-that-hurt-0118.aspx#10
 

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Executive Function Challenges and Anger

9/2/2016

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

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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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