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.

 

RANI PATEL IN FULL EFFECT: WHY DID RANI GET THE SAME LAST NAME AS ME?

Why Patel?

I bet you know a Patel.  Patels are everywhere.  Literally.   The Patel diaspora from India is such that there are over 500,000 of them living in countries outside of India (1).  In the United States alone, there are over 145,066 Patels and according to the 2000 U.S. census, the surname ranks 174th on the list of most common surnames in the country (2). And they’re not all related.  

 Most Patels are from the Indian state of Gujarat.  Their is some debate over the exact origin of the Patel surname, but it’s likely the term Patel first referred to village leaders and/or a caste of landowners or farmers in Gujarat.  Nowadays, Patels are involved in many types of professional occupations ranging from doctors to lawyers to engineers, though they are most often associated with small business trades, particularly motels and franchises.

Patels immigrate to America for the many of the same reasons as people from other countries.   

For economic opportunities.  For educational opportunities for their children.  For a better life.  My parents were no exception- they immigrated in the early 70’s seeking the American dream.  

If you know a Patel,  it’s probable that you know someone who is hardworking, independent, bent on accumulating wealth, and driven to help their children find educational success.  Whether it’s the Patel motel owner.  The Patel husband and wife 7-11 owners whose tireless dedication to the business allows their two children the opportunities to become Dr. Patel and a Patel engineer.  Steve Zwick gives an interesting account of Patels on Devon Avenue in Chicago, highlighting their roots in Gujarat and their reasons for immigration to the United States (3).  These stories abound, and I’ve been witness to my fair share growing up as a first person on both sides of my family to be born in America.  Stories about the financial triumphs of friends of my parents. Stories of amazing academic achievement of the children of immediate and extended family members.  Stories of the prosperity of unrelated Patels that spread in family gossip like the colored powder on Holi.  

Patels often pay a price when they permanently move away from Gujarat.  The price could be working two jobs with no days to rest.  The price could be difficulty with adjusting to the American culture and language.  It could be discrimination.  The list is long, and not unique to Patel immigrants.  

But, there is something missing from the Patel immigrant story.  Something that casts a long, dark shadow.  Something that I fear many Patels, including myself, haven’t been able to name.  Something we don’t handle because we are so thankful to live in the land of opportunity.  It’s something that crept into the suitcases of our parents as they boarded the Air India flight from Mumbai to London to New York City.  Something that was easily caged or hidden in the cultural confines of Gujarat, where the close knit homogenous social network allowed for good of the whole and the good of the individual.  But, once out of this cultural safety net, the something started it’s slow sabotage.   And some Patels suffered.  Like fish out of water.

I’m sure many Patel immigrants escaped unscathed, and achieved the American dream shielding themselves from the explosive mixture of old and new.  But this wasn’t the experience for a number of the Patels I’ve known.  For although they may have secured some financial stability and perhaps even amassed great wealth, their most intimate relationships broke.   Couples.  Parents and children.  Adult siblings.   From the outside, no one could see the damage, because there might not have been divorce or CPS involvement.  No actual splitting of families.

But I’ve seen the collateral damage.  The problem is that Patels don’t talk about it.  Even as they whisper about rumors in the Patel community or chitchat over chai no one speaks of the long term emotional ramifications of malfunctioning interpersonal relationships in families.  Maybe in Gujarat, the endless social supports from other Patels provided enough cushion to prevent or diminish these negative emotional outcomes, but in the States, I’m sure it’s a different story.  Balancing adjustment to a new culture while trying to hold onto the old culture creates interpersonal relationship strains and situations unheard of in Gujarat. Some Patels weren’t ready.  And perhaps tending to the emotional needs of a spouse or child wasn’t as much of a priority as making it in America.  It’s the breakdown of the interpersonal relationships in some Patel families that I think has profoundly affected the succeeding generations.  Me included.  So much so that I chose the medical speciality of psychiatry, with a focus on children and adolescents, despite being told by several Patels that a psychiatrist is “not a real doctor.”  

One thing I know for sure from my years of helping children, teens, and adults in individual, couples, and family psychotherapy is that the healing process absolutely requires talking truthfully about the elephant in the room.  And that elephant in the room is often some sort of malfunctioning interpersonal relationship issue.  

Since my experience as a Patel was that no one speaks about interpersonal relationship issues, I often wonder how emotionally hurt Patels find healing.  I don’t think they go to psychiatrists.  Plus, there isn’t much out there in fiction or nonfiction about Patel interpersonal relationship issues, particularly in the young adult genre.  Either way, I want to shed light on these interpersonal issues that affect Patels just as much as they affect the families from every culture and nation, immigrant or not.

That’s why I chose the name Rani Patel for the main character in the young adult novel, Rani Patel in Full Effect.  Rani Patel, her parents, and their experiences are based on a subtle alchemy of Patel individuals and families I’ve known and some of the non-Patel teen and family patients I’ve treated.  Rani Desai, Rani Shah, or Rani Amin would not have had the same impact.  

You probably know a Patel.  It is my hope that Rani Patel in Full Effect challenges you to think beyond the Patel stereotypes and truly see their humanity in their family relationship complexities. There might be more than you could’ve imagined going on behind the closed doors of the Patel that you know.

1.Global Gujaratis: Now in 129 Nations. The Economic Times. July 4, 2015. http://articles.economictimes.indiatimes.com/2015-01-04/news/57663531_1_gujaratis-patels-united-nations

2.Global Gujaratis: Now in 129 Nations. The Economic Times. July 4, 2015. http://articles.economictimes.indiatimes.com/2015-01-04/news/57663531_1_gujaratis-patels-united-nations

3.Zwick, Steve.  Who Are All These Patels? Chicago Reader.  February 10, 2000.  http://www.chicagoreader.com/chicago/who-are-all-those-patels/Content?oid=901436