TODAY I HAD THE HONOR OF DELIVERING THE ARGOSY UNIVERSITY, HAWAII COMMENCEMENT SPEECH!

Check it out for a different kind of inspiration that includes Post Malone, Gandhi, AND Michael Jackson quotes!

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Good afternoon Argosy graduates and faculty, family and friends. I am honored to be here on this momentous occasion. And thank you for that kind introduction, President Guerrero.

We’re all gathered here today to celebrate these outstanding Argosy graduates. Congratulations to you all in the various areas of study!

You know, as I was writing this speech, I kept hearing the Post Malone song Congratulations in my mind’s ear. Some of you know the lyrics. Worked so hard, forgot how to vacation…look we made it. And yes, graduates, you made it!

Argosy has nurtured you with an excellent education, immersed you in diversity, and provided you a safe community. In return, you’ve made the university proud. And let’s not forget all the mothers, fathers, sisters, brothers, grandparents, uncles, aunts, spouses, kids, and friends, who’ve supported you on your journey to this moment. This is a great moment. Relish it like the wonderful meal I hope you are treated to tonight.

You’ve worked hard to get to this point. And there will be more hard work in your future. There will be bills to pay, maybe mouths to feed, or other circumstances that require hard work and money. But I’m not going to talk about hard work.

I’m going to talk about you. Well, your life. More specifically the journey of your life. For it’s your journey, with all its varying stretches of smooth roads, potholes, and epic cracks, that tells you who you are. It is the journey that unlocks your true potential.

But graduates, beware on your journeys! Because society, whether it’s on television, in magazines, on social media streams, in the honeyed words of some well meaning people you know, or in the lingering mist of the fear of missing out, society tells you that success and achievement define you. That you are most worthy if you have a great career, or wealth, or a fancy car, or a perfect body. “Success makes you great,” society whispers while sucking you dry of your soul.

Don’t take the bait, graduates, because there is danger lurking in the shadows of this type of success. This type of success, you see, is a drug and society is the dealer. Society it brazen. It stands out in the open as it slips you free samples of success. One or two hits might be all it takes to get you hooked. Then you might crave the intoxication. Too much and you might overdose with privilege and entitlement. I am special. I deserve this. Privilege and entitlement can be taken to the extreme and people who purport to serve others can end up serving only themselves.

Just turn on the news. It’s full of examples of these success junkies. They lie, cheat, steal, evade taxes. Whatever it takes. Some of these people lead our nation. Many of them take what they want, the way they want it, when they want it—women, votes, campaign funds, etc.

Most of us don’t engage in this kind of extreme behavior to achieve our success. Still, it’s easy to get swept away in mainstream society’s success messages and lose sight of who you really are and what you really stand for. It can happen to anyone. It can cross all political, racial, and religious lines. In all sorts of professions. On all sorts of scales from the White House to more humble homes.

I hear about it all the time in my office when smart, hard working people tell me their stories. Many of these good people have tons of higher education but that doesn’t make them immune to seduction by success goals. Many of them end up ignoring their life journeys and they make poor decisions in the moment that hurt either themselves or others.

There was this attorney who wanted to succeed in advancing his career to partner and earn the biggest bucks to support his family and send his kids to private school. But he became blind to his marital struggles and ignored his children. He and his wife fought all the time and their kids began acting out to the point where one was kicked out of the very private school he was working so hard to pay for.

Then there was this physician who was driven by the goal to be voted by her colleagues onto Honolulu Magazine’s Top Doctors list. She spent her time networking and made the list. But she didn’t spend enough time with her patients and some of them ended up hospitalized for things that could’ve been easily treated in her office.

And for some of the teens I see, there’s that success goal of straight A’s and a prestigious college. They study, study, study without sleeping or eating enough. Their parents allow it because hey, their kids are studying in their rooms, not out shooting up heroin under dark bridges. Some of these teens develop depression, anxiety, eating disorders. They hate themselves. They hurt themselves. They hurt their peers by withdrawing without explanation. But they get straight A’s and great SAT scores.

In all these cases, were the end goals of success worth it? One thing’s for sure, their day-to-day journeys were painful and harmful.

And then there’s me. I know all too well the downsides of focusing on success. But how could I not focus on it? It was, is, the American dream after all and my parents were immigrants from Gujarat, India on a quest for this dream in the land of endless opportunity. From the outside they achieved the sweet American dream of success. Their child was born and raised in the stars and stripes and they owned two businesses and a house. I had more opportunities than they did, the most important being access to great education. My parents worked hard. I worked hard. I graduated valedictorian of Molokai High, went to Stanford for my B.A., got my M.D. at U.H. then did residency and became a child & adolescent psychiatrist. Bam! My parents couldn’t have been more proud of their “successful” doctor daughter.

But that was all a paper-thin guise. Under the veil of good intentions, the American dream didn’t erase the toxic stains of my parents’ very different and difficult upbringings. In fact the American dream turned out to be my mother’s personal nightmare. Our seemingly happy family was a lie. Their arranged marriage was a pernicious sham where my father treated everyone else better than he treated my mother yet she just took it because she couldn’t forget the lesson her own father had taught her—that husband is god. What made it worse was that she had no voice. I watched and learned the underlying message their actions taught me—Shut up, smile, look pretty, and do as you’re told. My stifled voice only found release in the safety of the classroom. No where else. The boundaries at home were blurred and, without going into the icky details that my father vehemently denies, my mother and I were ultimately reduced to nothing more than objects for him, while he was out “saving the world” with his activist goals.

To survive in that traumatic environment my developing brain became hardwired with anxiety, I’d over-think everything to avoid rocking our family’s already leaky boat. My thoughts became negative and sometimes turned into depression, suicidal urges, and poor decisions.

And the “successful” physician who helped youth and adults all day in the office ended up making some terrible personal decisions that hurt herself and the people she loved the most.

Graduates, success in and of itself isn’t worth it if you end up hurting yourself or others along the way. It seems obvious. Especially when most of us, including me, never intend to hurt anyone while aiming for success. But it can and does happen.

Don’t get me wrong, I’m not saying forget your dreams. I’m saying what matters is the journey. The journey defines us. Not the end goal. The journey is about right here, right now and that’s where the magic is.

Before I really understood this, I was future tripping and past living. I was anywhere but right here, right now. I was future tripping hard on my goal of being a physician so that my self-worth was completely attached to achieving that goal. But at the same time I was past living by recreating my family relationships with everyone else in life. My distant relationship with my mother and her inability to be assertive to protect herself or me turned into difficulties in forming female friendships and my own voicelessness. And the role I had as my father’s object, I continued with other older men.

And it’s not uncommon to future trip or past live. Most people don’t realize they’re doing it. My therapeutic work with patients often focuses on identifying and changing these patterns. I challenge you to take some time one of these days to think about it. Are you future tripping or past living? Are you letting fear of not achieving or fear of some horrible future drive your actions? Are you repeating old patterns that are not serving you well?

Dare to fix these things so that you can stride nobly on your journey.

I wish I’d figured that out sooner. Before I blew up my life. So I was in this deep, dark pit of shame, anxiety, and depression. I didn’t know how to get out. One day I picked up a pen and pad and wrote what was in my head. That was the start of being in the moment for me. I wrote and wrote and wrote. It happened to be rap and spoken word poetry that flowed onto the pad I think because I had the good fortune of growing up during the golden age of hip hop. I rhymed about issues important to me and my patients in the moment—the detrimental effects of patriarchy, misogyny, abuse, the beauty myth. I wrote about empowerment, voice, feminism, courage, friendship, and love. Whatever was going on in the moment. I performed my pieces. The confidence and power of my delivery formed new connections in my brain and quieted the anxious pathways. I was letting go of my painful past by speaking up and realizing that my worth was not based on achievement or attention from men. That helped me set boundaries. I wasn’t living in the past or trying to control the future anymore. I was in the moment. I was right here, right now. I was becoming the real me. And it felt so good.

I ended up with a binder full of rap and poetry. At some point I was flipping through the pages and I found that if I put them in a certain order it turned into a young woman’s story! My story plus that of some young women I’d treated. The story got published as a young adult novel. I was, am, humbled and inspired. But what’s most humbling and inspiring is when I receive emails that express gratitude from young women and teens who’ve been sexually abused or grown up in dysfunctional families, I cry tears of relief and hope. I’ve realized that I can live the words of one of my heroes, Mohandas K. Gandhi: “Be the change that you wish to see in the world.”

Be the change that you wish to see in the world. Eleven powerful words that beseech you to be on a noble journey so that you will be part of a positive ripple effect. Eleven words that don’t care what your career is, how much money you make, how much recognition you have. Eleven words that don’t care if you’ve achieved. Eleven words that don’t judge you. Eleven words that are a cool, gentle breeze caressing your face on a hot, humid day whispering, “The journey is the great equalizer.”

Live for the journey and watch the beautiful ripple effect in the lake of your life. Your noble journey will change the world. So, graduates, congratulations on this step. Now, how will you continue your journey from this day forward?

Let me end with one more story. When I was in elementary school, I lip synced and danced to Billie Jean at a talent show—curly hair, jacket, sequined glove, moonwalk, and all. It was cool but I wish I’d understood the deeper meaning of the words I was lip syncing, especially the line: Be careful of what you do because the lie becomes the truth. That line was like a personal gift I didn’t, couldn’t, unwrap until I was an adult. I’ll leave you with another set of Michael’s lyrics—a gift to you that I encourage you to unwrap and use now. I'm starting with the man in the mirror. I'm asking him to change his ways. And no message could have been any clearer. If you want to make the world a better place, take a look at yourself, and then make a change. Thank you and congratulations!


Personal Boundaries

Think of personal boundaries as the barriers we set with others to demarcate which of their behaviors towards us are permissible and which are not. Personal boundaries can encompass the following categories: intellectual, physical, emotional, social, and spiritual. My patients who have difficulty knowing and setting their personal boundaries usually lack self-worth or adequate role models from whom to learn these skills. Some lack both.

I lacked both. Growing up, my father crossed boundaries with me and my mother couldn’t maintain any for herself or me. This became my blueprint for life. I was an object that existed first to please my father and later to please others. I did not see any inherent value in myself. It set me up to live and repeat the torturous cycle of poor self-worth, inability to set boundaries, bad decisions, poor self-worth, and on and on.

Fortunately, this is no longer the case for me. These days, my self-worth is strong. I know my boundaries. I set my boundaries. No exceptions. My decisions are better. I can take care of myself and others.

It took much pain and practice to get to this point. And now that I’m here, I want nothing more than to help my patients on their journeys towards healthy self-worth and boundaries.

It takes time, I tell my patients. Generally, we start by identifying family patterns that may have contributed to their ongoing struggles. Then we see how they might be repeating these patterns in their current lives. Next we figure out what their boundaries should be and how they might begin to set them. Setting the boundaries requires assertiveness (being able to verbalize their true thoughts, feelings, wishes, and decisions) and the ability to tolerate the negative feelings that initially accompany not doing what they think other people want. We discuss how they can practice these skills in the here and now of their lives.

There are times when my patients can grasp the theories we discuss, but have a difficult time stopping their own cycles of poor self-worth, inability to set boundaries, and bad decisions. In these cases, involving their families or significant others can be helpful. Sometimes the patients end up repeating their cycles in their therapeutic relationship with me, and on some of those occasions I may have to set strong boundaries with them to role model appropriate behavior. And in order to avoid enabling the cycles that keep them stuck, I might even have to stop treating them. During our final session, I remind them that they are worthy and that it is imperative that they work on knowing and setting limits with others so that they can nurture their own self-worth and sustain and nurture their most important relationships.


Hawaii's Lack of Psychiatrists

Check out this informative article in Honolulu Civil Beat- Hawaii’s Mental Health Care Crisis: The lack of psychiatrists is a particular problem for people who rely on the state’s public health insurance for low-income residents.

https://www.civilbeat.org/2018/09/hawaiis-mental-health-care-crisis/

I am grateful to have my thoughts included.

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Thank you, San Jose Public Library!

I am a HUGE fan of BTS, so this blog post from San Jose Public Library made my day! Click this link to check it out:

YA Friday: Welcome! This is your first time with BTS, right?

SO I WRITE

Fragile men veiled in narcissism
Raised me, taught me to speak. The rule of thumb—
Tell me but let me have my way
A fluent protégé 
To selfish masters disguised as teachers
True believer
Sequestered in the open
Socially inarticulate, friendships partial or broken
I. Still. Can’t. Say. What’s. Really. On. My. Mind. To. The. People. That. Matter. The. Most.
My true words tie me a whipping post
Flog me with self-hate
Seal my fate
Deaf and mute but to men’s jargon
Visibly hidden behind wrinkled curtains
Frowning at my bad decisions
Unable to verbalize my true wishes

SO I WRITE.
 

FOOD EXTREMISM CAN BE DANGEROUS

There are no solid medical studies (randomized placebo controlled trials) to prove that any type of dietary restriction (plant-based diets, veganism, vegetarianism, gluten-free, sugar-free, cleanses, etc.)  has definitive long-term benefits on growing children and teens (or adults, for that matter). Yet, many parents and youth are seduced by the lure of dietary extremism. As a physician who provides psychotherapy to kids and teens with depression, anxiety, eating disorders, PTSD, adjustment issues, etc., I need to express my deep concern about this. There are multiple levels of physical and emotional damage that can occur as a result of engaging in restrictive food behavior. And no matter how mature youth may seem, their abstract thinking is still in development and they may not fully comprehend that "cutting out carbs" may not just be "cutting out carbs." It may be a way to feel more in control of their chaotic lives. It may be a way to lose weight because they think that'll make them feel better about themselves. It may be a subtle holier-than-thou attitude they pick up from grown-ups in their lives. The list goes on.

Today’s food restriction culture is dangerous, especially for our youth. Even if well-meaning parents, adults, documentaries, and magazines don’t say the following exactly, many teens tell me that the underlying nutrition lessons are: “deny yourself and you’re better,” “restricting is not an option,” “if you don’t eat organic, you might as well eat fast food.” These smart youth describe first world food restriction as "privileged" and "elitist"  but they nevertheless feel compelled to subscribe to it. They feel alienated from their parents and peers who follow extreme diets but can't help but to follow suit. And then...oh the dark, dark places they reveal their vulnerable, developing minds go…

Bottom line: unless a youth has a serious, diagnosed medical condition that requires dietary restriction or is being raised in a family with longstanding religious dietary guidelines, it's worthwhile to take a step back from all the food hoopla and consider the potential harm in unfounded claims of miracle, cure-all, one-size-fits-all food plans and diets. 

I advise parents of my patients to keep it simple. Eat well-balanced, nutritious, and home-cooked meals with your kids as often as possible. Briefly express gratitude to the cook or comment on the deliciousness of the food, but avoid negative or black-and-white food judgments or opinions that aren't backed by science  (like “bread is crap,” “the piece of fat on the steak is so gross,” “sugar is horrible,” etc.). Kids will learn to choose good, nutritious, varied foods in appropriate portions if it’s role modeled at family meals.

Food is fuel. Meals and snacks bring people together and teach social skills and reinforce positive self-worth. Beyond that, thinking, controlling, and restricting food isn’t necessary and can be harmful.

Here are some “food for thought” articles about the pitfalls of food extremism:

https://www.vox.com/science-and-health/2017/7/25/16018658/what-the-health-documentary-review-vegan-diet

https://www.jad-journal.com/article/S0165-0327(16)32391-6/pdf

https://www.self.com/story/i-used-to-be-a-wellness-influencer


 

My Own Hero

It took decades to escape the prison

Of Indian & American patriarchy and I’m newly arisen

Sober from the narcosis of Bollywood heroin: to be a heroine-

long-haired, buxom woman in need of a male “good samaritan”

To save her. To validate her worthiness.

Not so anymore. These days I am my own hero, impervious

To misogynistic fog, walking tall in my Timberlands

Stomping over narrow-minded hoopla, ready to withstand

The negativity that keeps coming when I’m brave & use my well-intentioned voice

To help others discover their truth and choices.

Free from the shackles of giving a fuck what you think

Cuz you haven’t lived in my skin or been on my brink.

IN LIGHT OF TOMORROW'S TRUMP ADMINISTRATION DEADLINE SET BY JUDGE SABRAW, I HAVE TO POST THIS.

Tomorrow is July 26, 2018. US District Judge Dana Sabraw ordered that by then, all migrant children separated from their parents who are eligible for reunification must be reunited. This deadline will most likely not be met. Either way, damage to those children has been done.

In light of this, I'd like to share a few of the slides from the continuing medical education lecture I'm giving to pediatricians and psychiatrists tomorrow at a local hospital.

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  IN COMPARISON TO INDIVIDUALS REPORTING NO ACEs, INDIVIDUALS WITH 4 OR MORE ACEs HAD SIGNIFICANTLY GREATER ODDS OF REPORTING THE ABOVE (2.2 TIMES THE ODDS OF ISCHEMIC HEART DISEASE, ETC.) THE MORE ADVERSE CHILDHOOD EXPERIENCES AN INDIVIDUAL HAS SURVIVED, THE INCREASED ODDS OF REPORTING AN ILLNESS OR HEALTH RISK BEHAVIOR. 

IN COMPARISON TO INDIVIDUALS REPORTING NO ACEs, INDIVIDUALS WITH 4 OR MORE ACEs HAD SIGNIFICANTLY GREATER ODDS OF REPORTING THE ABOVE (2.2 TIMES THE ODDS OF ISCHEMIC HEART DISEASE, ETC.) THE MORE ADVERSE CHILDHOOD EXPERIENCES AN INDIVIDUAL HAS SURVIVED, THE INCREASED ODDS OF REPORTING AN ILLNESS OR HEALTH RISK BEHAVIOR. 

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Anxiety Sucks, but Trump Could Use Some.

I don’t normally wish a psychiatric disorder on anyone, but I wish Trump had Generalized Anxiety Disorder (GAD). See then he’d overthink everything instead of being so brazen. Then he’d get stuck on thinking and thinking and thinking about how other people viewed him. His anxious brain would force him to attend to other people’s feelings before his own. I’m convinced that a Trump with GAD would be a toned down more empathetic human being.

But, for most people afflicted with any of the anxiety disorders, especially kids and teens, life is extra challenging.

A major component of anxiety disorders is overthinking. So when presented with a situation, a youth with anxiety disorder will automatically and effortlessly come up with every possible cause and effect of said situation. If the situation is dangerous, than this overthinking is a good thing. A biologic, rewired brain, protective thing (Anxiety disorders like PTSD can develop after or during exposure to adverse experiences such as abuse). But when the situation is no longer dangerous and it’s just plain old life, the overthinking is detrimental. It prevents the youth from being in the moment, developing their complete identity & positive self-worth, and making good decisions. They end up trapped in an endless loop of negative automatic thoughts, feelings, and behaviors based on what they perceive will keep others happy even if they harm themselves or someone else. Here’s a common example of overthinking that teen girls tell me about in the office: “I was at a party, the parents were out of town. And the guy I was kind of dating wasn’t there. This popular boy started talking to me. I used to like him so I was all giddy inside. Anyway, he gave me a beer and I didn’t really want to drink it but I did. He started touching me and it was cool at first. But then I wasn’t sure. I tried to move his hand away, but he was like, ‘Come on, I’ll be gentle. Don’t give me blue balls.’ I told him I had a boyfriend but he said ‘he doesn’t have to know.’ I knew that was wrong but he kept trying to convince me. I’d never had sex before and I didn’t want to but I couldn’t say no. If I said no he would get mad. He’d tell everyone I was a loser. He’d hate me and then everyone would hate me. So I let him. Hey, I’d rather deal with it than risk having him mad at me.”

Woah, right? But that is how powerful anxiety is. It makes youth do things their rational selves wouldn’t do.

In addition to overthinking, anxiety disorders can also make youth hold the opinions of others as definitively true. They have difficulty creating thought and feeling boundaries and are often unable to cling to rational thoughts of themselves. And this can have tragic effects. A common example of poor thought and feeling boundaries that teens tell me about: “The kids at school teased me about being fat ever since I was in second grade. It was so bad. I didn’t tell anyone. No one helped me. I even started making fun of myself. I hated what they said but I hated myself more. I started skipping meals. Exercising in my room at night. By the time I got to high school, I was binging and throwing up everyday. I still got teased. Nothing I did made me lose weight. I couldn’t stop thinking about what a worthless piece of shit I was. Am. I wanted to die. I tried to kill myself a couple of times…”

In med school and residency, I’ve gotten top notch training on how to help kids and teens with anxiety disorders. But more than that, I have an anxiety disorder and I’ve come to understand how it almost destroyed my life—this has made me passionate about helping anxious youth find their way through the quagmire of overthinking. And I practice what I preach. I practice being mindful and in the moment. I practice doing cognitive behavioral therapy on my automatic negative thoughts. I get enough sleep. I eat regularly. I exercise regularly. I don’t partake in social media. I try to work on expressing my true thoughts and feelings in the moment even though it takes everything inside of me to do so sometimes.

My latest battle is not internalizing the harsh negative online reviews people have posted about me as a psychiatrist. Things like, "I didn't like her at all" or I'm "unprofessional." My personal favorite, I'm "the worst psychiatrist." Luckily, these days I can fight off the anxious overthinking that tries to make me ignore all the evidence that points to the opposite of their disapproving opinions—that there are more positive reviews online than negative, that reviews shouldn’t really matter at all because I know in my heart that I give my all to my patients in every session (even if that means pointing out things that they don’t want to hear since I know this will give them a better chance of truly healing), that I don’t just do fifteen minute medication checks, that I will not prescribe medication unless it is medically necessary, that I insist on family therapy if indicated because youth don’t exist in a vacuum, that I do intensive talk therapy with youth with the goal of making them assertive, self-confident, and able to utilize a myriad of coping strategies to recover from—and/or live with at a manageable level—whatever psychiatric disorder(s) that plague them. All that and I’m not Trump.

It Keeps Coming Back to Trauma

My childhood continues to hold me hostage though I'm an adult. I’ve spent years unknowingly recreating my toxic family dynamic in relationship after relationship, hoping to find someone who could save me from the pain I’d always felt inside—self-hate, depression, and anxiety that led to terrible decision making. Of course, back then I didn’t have insight that all those negative symptoms and behaviors were my young brain's survival mechanisms- hardwired strategies that stemmed from a fundamental denial that my family relationships were harmful. And so I grew into adulthood with this flawed approach to life and relationships all the while keeping the secrets of my family dysfunction. But my defensive structures fell apart as I tried to form my own stable relationships with no blueprint. It got really bad, culminating in hurting the person I loved the most to see that I had a problem. That I needed to break away from my past and save myself.

These days I’m not reenacting my past. I’m no longer an object for men to use. But trauma still appears in my life everyday because I think about it all the time. I think about how childhood trauma comes in many forms but the biologic effects on a developing child can be similarly devastating. I think about how trauma can change our DNA and be passed onto future generations. I think about all the ways I can continue to protect my own children from suffering my fate. I think about how I can best help the abused youth I treat in my child and adolescent psychiatry practice because I don’t want them to grow up as prisoners of their traumatic childhoods. I don’t want them to be vulnerable to patterns of unstable relationships or re-victimization. I don’t want them to keep speaking their pain through their low self-worth, negative thoughts and feelings, self-harm, and poor decisions. I want them to find the power of their voices. I want them to discover their true identities. I want them to move towards recovery faster than I did.

I also write about trauma a lot. I write rap and poems about trauma. I write young adult novels that tell different tales but all involve youth who have survived adverse childhood experiences and somehow find healing.

So you see I'm always thinking about trauma- only now I'm thinking about how I can help assuage the profound detrimental impact that trauma confers on youth.

I can’t not think or write about trauma. It’s shaped everything about me and even though I’ve mostly healed, I can still feel it in my bones.

Trump's "Zero-Tolerance" Immigration Policy Might Alter the DNA of Future Generations

Trump’s “zero-tolerance” immigration policy that involves separating families at the U.S.-Mexico border is “government sanctioned child abuse” according to Dr. Colleen Kraft, president of the American Academy of Pediatrics (AAP). The position of the AAP is that “children in the custody of their parents should never be detained, nor should they be separated from a parent, unless a competent family court makes that determination.” (1)

Child abuse. These two words shouldn’t exist together. But they do because it happens, and our current administration is a perpetrator.

Child abuse can also be described as child maltreatment, childhood trauma, and adverse childhood experiences. It can be emotional abuse, neglect, sexual abuse, physical abuse, bullying, parental substance abuse, maternal depression, exposure to domestic violence, etc. It can also be exposure to gun violence, war, genocide, and, slavery. And our current administration has added detention and separation of children from their parents at the U.S.-Mexico border.

Child abuse can lead to devastating, long-lasting effects—risky health behaviors (smoking, alcoholism, drug use, etc.), chronic medical conditions (diabetes, STDs, cancer, heart disease, obesity, stroke, COPD, broken bones, etc.), mental health conditions (depression, suicide attempts, suicide, PTSD, anxiety, DID, etc.), low life potential (lower graduation rates, academic achievement, lost time from work, etc.), and early death.

How?

Let me break it down.

Child development is not just nature versus nurture, it’s nature working with nurture over time. That means that nature and nurture influence each other beginning in utero, continuing through infancy, childhood, and beyond. During this time board time range, if a child or teen is exposed to adverse experiences, and there are not enough protective factors, than the youth’s biology—at a cellular and DNA level—can be altered for the worse. Their gene expression can be altered and so can the development of their neural circuits. Repeated or chronic adversity can overactivate their stress response (the hypothalamic-pituitary-adrenocortical axis and the sympathetic-adrenomedullary system) and dysregulate stress hormones and a network of physiologic mediators leading to chronic wear down of multiple organs including the brain. Their brain structure and function can change permanently (altered sizes of the amygdala, hippocampus, and prefrontal cortex). They can have difficulties learning, avoiding danger, interacting with other people, and expressing their true thoughts and emotions. They can develop PTSD, depression, anxiety, dissociative identity disorder, etc. They can have suicide attempts. They might complete suicide. They might end up vulnerable to repeated trauma and/or inflicting violence on others.

And that’s just the short version.

But it gets worse.

There is mounting evidence that the effects of childhood adversity may be transgenerational. The science of epigenetics is burgeoning and there is some evidence to suggest the transgenerational transmission of DNA methylation changes from parents to children. (2) The transgenerational effects may manifest as medical and mental health problems.

Let’s bring it back to the Trump administration’s “zero-tolerance” policy. As a result of this “government sanctioned child abuse,” not only can the kids who are being traumatized at this very moment suffer possible genetic changes to their own DNA but they might pass on these changes to their own children someday.

To Trump and his administration, be advised that there is growing scientific evidence that your policies are harming generations to come.

(1) Linton JM, Griffin M, Shapiro AJ, AAP COUNCIL ON COMMUNITY PEDIATRICS. Detention of Immigrant Children. PEDIATRICS. 2017; 139(5):e20170483.

(2) Youssef NA, Lockwood L, Su S, Hao G, Rutten BPF. The effects of trauma, with or without PTSD, on the transgenerational DNA methylation alterations in human offsprings. Brain Sciences. 2018; 8(83):doi:10.3390/brainsci8050083.

SUICIDE THOUGHTS ARE NOT LITERAL EDICTS BUT THE MIND’S RED FLAG

In 2016, suicide was a leading cause of death in the United States—tenth overall, second for ages 10-34, and fourth for ages 35-54—and there were twice as many suicides as homicides (1). The rate of suicide increased 28% from 1999 to 2016 (2).

My patients, many of whom suffer from anxiety, depression, bipolar disorder, or substance abuse issues, are often plagued with suicide ideation and suicide attempts. No demographic is spared. Suicide intentions are a common discussion point in my office. Just yesterday, a 12-year-old and a 19-year-old were in the throws of intense suicide ideation and we spent the sessions (along with a parent for the 12-year-old) figuring out ways for the young people to distance themselves from those life-ending considerations.

Given the tragic and heartbreaking suicides of Kate Spade and Anthony Bourdain this week, I wanted to offer one of my psychiatric perspectives on suicidal thoughts, perhaps it can contribute a little to the conversation. When patients with anxiety and/or depression reveal active suicide ideas or plans, or a history of, I teach them that suicidal thoughts are their mind’s red flag, a warning that they’re completely overwhelmed and need to ask for help, not a literal edict to kill themselves. I will start the discussion with something like this, “I’m so sorry you’re having these scary suicidal thoughts. I know they seem unavoidable but let’s take a step back for a bit, ok? What if I told you the suicidal thoughts are your mind’s red flag and it’s waving it, shouting, ‘Hey! Stop! You haven’t asked for help with all the spiraling negative thoughts and feelings and now you’re completely overwhelmed! I need some relief, I need to feel in control. Please get some help, ASAP!’ What if I told you that not only are your suicidal thoughts a red flag but also your mind’s secret code, and that you and I can decipher the code and get to the real issues, which are NOT anything that involve killing yourself. Imagine if you had asthma and you were around smoke or allergens, you’d probably cough or wheeze, right? The coughing and wheezing are symptoms of the asthma when you are around an irritant. Similarly, the suicidal thoughts are a symptom of your anxiety and depression when you are overwhelmed and haven’t expressed your true thoughts and feelings to others, which we’ve been working on in therapy but takes awhile to master. It’s important that you don’t act on the suicidal thoughts, but accept that they are your mind’s tricky signal that you need to figure out what’s really going on. Let’s do that now. Tell me about…”

Depending on the age of the patient, I will make the above discussion more or less sophisticated. It is wonderful when patients have their aha moment with suicidal thoughts being a red flag, and not a word for word command.

Suicide prevention is multifaceted. Here are some basics that I hope everyone becomes familiar with:

  1. Know the sign and symptoms of someone thinking about suicide. Examples include: talking about wanting to die or kill themselves, talking about feeling hopeless or having nothing to live for, making plans or researching ways to kill themselves, talking about feeling shame, unbearable pain, or being a burden to others, using drugs or alcohol more often, acting different (more anxious, agitated, or withdrawn), more intense mood swings, giving away possessions, or saying goodbye.

  2. Know the risk factors. Common ones include: depression, other mental disorders or substance abuse disorders, some medical conditions, chronic pain, a prior suicide attempt, family history of a mental disorder, substance abuse, or suicide, family violence and/or abuse, having guns in the home, or being exposed to others’ suicidal behavior (like a family member, friend, or celebrity).

  3. Have an action plan.

    • Ask them if they are thinking about killing themselves. Don’t worry, asking directly “Are you thinking about killing yourself?” doesn’t make them do it.

    • If the suicidal person has a plan, try to get them away from lethal items or places.

    • Listen and talk to the person. This will not increase suicidal thoughts, but rather the opposite.

    • Connect them.

      1. National Suicide Prevention Lifeline 1-800-273-TALK (8255)

      2. Family member or friend

      3. Mental health professional

    • Keep in touch with them if possible.



1 Centers for Disease Control and Prevention WISQARS Leading Causes of Death Reports

2 Centers for Disease Control and Prevention Fatal Injury Data Visualization

Three Simple Rules That Can Have a Life-changing Impact on Kids and Teens

My teenager looked over my shoulder as I finished typing the first draft of this blog post. She proceeded to roll her eyes and mutter, “Ugh. This is our household.”

I smiled a satisfied smile to myself because, yes, this is our household.

Outside of my household, I’m a child and adolescent psychiatrist and I have the privilege of guiding young people through individual talk therapy to help them overcome mental health issues such as anxiety, depression, eating disorders, post-traumatic stress disorder, reactive attachment disorder, etc. Sometimes there are also complex family dynamics at play that require specific family interventions such as parent education or family therapy.

Over the years of doing individual child and adolescent talk therapy and family therapy, I’ve found that without a certain baseline, non-negotiable structure at home, therapy isn’t as effective or lasting. Because without this basic structure, it is that much more challenging to navigate the muddy waters of mental illness and that much more challenging to even begin to negotiate normal social, emotional, physical, and/or intellectual developmental tasks. Without limits and rules at home they may become even more entrenched in their mental illness. And a lack of boundaries doesn’t just affect youth with mental illness. It can negatively impact any young person.

So what is this baseline, non-negotiable structure I recommend? It’s three simple rules for children and adolescents that parents can enforce.

  1. Social media and screen time - 2 hours a day maximum, but less is better.

  2. Uninterrupted sleep time - 9-10 hours each night.

  3. Family meals - eat together as often as possible.

I apply these rules to my own tween and teen. I recommend the rules for all youth in general, as well as for the youth I treat. Let me give you a bit more detail on each rule.

Social Media and Screen Time

More studies are coming out about the detriment of social media and prolonged screen time. The bottom line is that excessive electronics isolates and prevents youth from learning about normal face-to-face interactions with people, which are an important part of development and happiness. The worst case scenario regarding isolation is that it is a risk factor for suicide. But being plugged in for two or more hours a day can also lead to a significant increase in suicide risk factors.

When youth have their heads buried in screens they are not self-reflecting or thinking independently. It’s not their fault that they want to stare at all the dazzling images and words on their screens. See youth do not have fully developed abstract thinking so they are more vulnerable than adults to being swayed by what flashes before their eyes. That’s also why they are more susceptible to peer pressure. So they see these fancy, filtered images and words and they may become convinced that they have to look and behave that way. They may think they have to get a certain amount of comments and likes to be worthy. They may engage in excessive texting or messaging that doesn’t allow them to learn the nuances of social communication (facial expressions, tones in voice, etc.). They may be vulnerable to online bullying. They may be constantly thinking they are missing out. They may live through their screens instead of in the moment. All of this can impair their ability to move through the normal stages of social, emotional, and intellectual development.

Incidentally, I quit social media. My tween and teen are not allowed to have social media. I figure I should practice what I preach, right?

Sleep

Poor sleep in youth can lead to negative outcomes such as struggles in school, car crashes, and/or depression. Numerous studies have shown that 9-10 hours of uninterrupted sleep is optimal for youth, especially teens because they are in an intense stage of physical, intellectual, and emotional growth.

It is helpful to remove all electronics from their bedroom at bedtime (except a good, old fashioned alarm clock) because teens will often surreptitiously use these devices in the middle of the night. They are not bad for doing this. Testing boundaries is part of normal teen development and it is up to parents to set and enforce the limits to help guide and teach them.

Most kids will not happily go to bed early, my kiddos included. They will most likely complain and fight it. They may also panic because they haven’t finished their homework. But in the long run, sleep is more important. Parents can rest assured that despite what their youth say, setting strict bedtimes helps with brain development and teaches youth to make more efficient use of their time. It may even bring up the issue of cutting back on extracurricular activities if there really isn’t enough time to get homework done. This raises another issue—that youth need time to be bored to help with their normal emotional and intellectual development. But that’s for another blog post.

Eating Meals As a Family

In this day and age of being overscheduled, I cannot overemphasize the importance of eating meals together as a family. I recommend decreasing youth activities if this will allow for more meals together. That’s how important it is. Eating meals together, especially dinners, teaches kids about face-to-face communication. It also can lead to better family relationships, improved nutrition and enjoyment of food, boosted grades and vocabulary, decreased depression and stress, increased ability to bounce back from bullying, improved overall mood, and fosters a positive outlook of the future.

As a side note, there is a trend in our society to eliminate more and more types of food from our diets. The science behind this “purer” eating is not crystal clear. There are many factors besides food that contribute to overall health and longevity.  Still, it is not uncommon for people who don’t have medical reasons for dietary restrictions to cut out all meat, gluten, dairy, sugar, etc. For adults, this is a personal choice and I’m not addressing that right now. But children and teens have different nutritional needs than adults and it can be dangerous for youth to be eating “pure,” “clean,” vegan, or some other restrictive diet unless they are properly monitored by a parent who can make sure they are getting enough calories, protein, vitamins, and minerals. Chronic lack of these nutrients can lead to medical problems and organ damage.

A typical example I see in my practice is the teen girl athlete who restricts her food intake and then doesn’t get enough calories to maintain her high activity level. She loses weight and stops having her period. Contrary to what some people think, it isn’t normal for a girl athlete to not have a regular menstrual cycle. Also parents need to be aware that restrictive diets can be a guise for eating disorders. In fact, "healthy," restrictive eating is the most common trigger for eating disorders in teens that present to my office. Eating disorders are complex and can have devastating consequences, including death.

If the family does not have long established exclusionary food preferences or practices (such as for religious or diagnosed medical reasons), I recommend that youth not be allowed to suddenly follow any restrictive diets. They can make up their own minds when they are eighteen but until then parents can protect them by normalizing inclusive, structured eating- regular meals and snacks, normal portions, preparing and offering a variety of foods, not making negative comments about certain foods, ingredients, or bodies. This makes it less likely that the youth will have disordered eating when they grow up. This makes it less likely that the youth will link food with control and self-worth. They will be more likely to grow up with the understanding that food is simply fuel and nourishment, not a means to happiness, and most certainly not who they are.







 

 


 

KEEP IT REAL OR YOU MIGHT DIE

FROM GUEST POST ON RICH IN COLOR  http://richincolor.com/2017/08/guest-post-sonia-patel/ 

GUEST POST: SONIA PATEL

Posted on 15 August, 2017 by Crystal

Please welcome Sonia Patel to Rich in Color today. Her newest book, Jaya and Rasa: A Love Story, will be available next month. We really enjoyed Rani Patel in Full Effect, her debut last year, and are looking forward to this new release.

KEEP IT REAL OR YOU MIGHT DIE.

Keep it real or you might die. Sound extreme? Let me explain this short but profound sentence I often use to help struggling teens in my child and adolescent psychiatry practice. I’ll start by breaking it down into two parts.

Keep it real = Determine your true thoughts and feelings in the moment and speak up for yourself in all honesty.
Or you might die = If you stay quiet and believe the negative automatic thoughts, feelings, and risky impulses that your mind is tricking you with then you might be more likely to go through with the risky impulses (suicide attempts, accidental excessive drug/alcohol use, unprotected sex, etc.) because there doesn’t seem to be any other way out of the intolerable swirl of chaos in your mind.

Obvious? Not to everyone, especially not to vulnerable teens. These are the pained teens—from all walks of life—I have the honor of treating. These are the teens who have a genetic predisposition to an emotional illness (such as depression or anxiety), have lived through trauma, or have dysfunctional family systems—or all three. These teens are more likely to remain silent about the unwanted, false, automatic negative thoughts, feelings, and impulses that plague them. For different reasons, these teens aren’t taught to speak up about, tolerate, or cope with all the negativity. This silent suffering becomes their invisible “teacher” and they learn to act out on their self-destructive impulses. Soon the only way they know how to minimize emotional distress is to act out with dangerous behaviors. It may become hardwired into their brains.

I value meaningful talk therapy as the foundation of my psychiatric treatment to teens. It is my goal to educate them on positive ways to maneuver through life. Over the course of weeks, months, or years we work together to discover how they can become self-aware, how they can say exactly what’s on their mind in any given situation, and how they can ride out the extremes of their negative thoughts, feelings, and impulses.

How they can keep it real so they don’t die.

I strive to be their keep it real coach. There is no better reward than to watch these teens learn to find their voices and be assertive. They become keep it real experts.

I also aim to be a keep it real author. I want to bring this powerful message to as many teens as I can. That is why I write YA novels the way I do—boiled down and raw.

In my office, teens who confide in me don’t speak in perfect prose when they share their innermost thoughts, feelings, impulses, and secrets. They might stumble on their words. They might not be able to find the right words. They might get straight to the point. They might ramble. They might swear. They might cry. They might scream. They might do a combination of all of that. So why would I write their stories in a pretty, elegant way? This is not to say these teens are not intelligent. They are. Some of them read at college level, take A.P. classes, and study hard. They know many big, fancy, SAT words. Those that don’t pursue academics to their full potential are still smart. But what I’ve found is that in the privacy of my office most teens prefer to talk in an informal manner rather than with refined formality. They choose to speak with their broken hearts.

It is with all this in mind that I wrote Rani Patel In Full Effect and the forthcoming Jaya and Rasa: A Love Story. I am excited for the world to meet Jaya and Rasa. They are blends of real patients I’ve had the privilege of treating (I must confess that there are also bits and pieces of me in Jaya!).

The way I write how Jaya experiences things in his life—such as private school, wealth, elitism, modern day Native Hawaiian oppression, lack of acceptance of his gender by his Gujarati Indian parents, bullying by his classmates, depression, self-blame for his parents’ fights, low self-worth, and the unconscious recreation of his parents’ relationships with Rasa—is how many of my patients describe their similar experiences.

The way I write how Rasa maintains a happy front while likening herself to a strong black widow spider is part of her response to trauma. It’s how she’s managed to survive her challenging circumstances. She’s learned to equate her body and sex as power and control over men who are actually abusing her. Under her black widow exterior is a vulnerable girl who hasn’t been given the chance to develop her self-worth or identity apart from being an object for others. She hasn’t had the luxury of a safe life in which her basic needs are met.

Neither Jaya nor Rasa have been taught or encouraged to become self-aware or speak their minds concerning their true thoughts, feelings, and impulses. So they’ve both stayed in their heads trying to survive their respective hardships. Their patterns of negative thoughts, feelings, and behaviors  become more and more ingrained as the years pass. That is, until they meet each other. The intense love that develops between them forces them to confront the flaws in their internalized ways of functioning in the world. They realize that they have to keep it real or they might die.