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

​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. 

 
 
 
 
 
 
 
 
 
 
 

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

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

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. 

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. 

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.

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.

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? 

​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.