Monthly Archives: July 2011

Depression and anxiety during pregnancy linked to physical and emotional scars for children

Heather Rudow July 21, 2011

Expectant mothers are apt to avoid certain foods and drinks during pregnancy that could prove harmful to an unborn child, but studies are finding that high levels of anxiety and depression can also have lasting effects outside the womb.

According to a cohort study in the July issue of the Annals of Allergy, Asthma and Immunology, prenatal stress is linked to a risk of childhood asthma. Of the mothers polled, approximately 70 percent who said they experienced high levels of anxiety and depression during pregnancy reported wheezing in their children before age 5.

The study polled 279 pregnant African American and Dominican women between the ages of 18 and 35 who are living in the Bronx and Northern Manhattan areas of New York City.

Babies born to mothers with high stress and anxiety levels could struggle with physical and emotional difficulties throughout life. (Photo: Flickr/molly_darling)

The goal of the study, said Medscape Medical News, which originally reported the story, was to examine the association of maternal demoralization, or psychological distress, with wheeze, specific wheeze phenotypes and seroatopy in children residing in a low-income, urban community.

And German researchers have found that pregnant women in high-stress situations can leave lasting emotional effects on their children, according to a Daily Mail article. The study found that a gene, called the glucocorticoid receptor, which is involved with the brain’s response to stress, was far less active in children whose mothers reported accounts of domestic abuse by their partner while pregnant.

Researchers said the changes in the gene  change the way people can respond and handle stress, and that past studies have shown children of abused parents are more prone depression later in life.

UK study finds one in four children see sexually explicit content online, on cellphones

Heather Rudow July 20, 2011

A new poll finds 25 percent of 13-15-year olds have seen explicit sexual content online, and 26 percent have received sexual pictures on their cellphones. Of the 600 polled, 28 percent of the 13-15-year-olds have also received sexually explicit text messages.

The study also polled 800 parents, 87 percent of which said they felt their children were growing up too quickly, and 86 percent saying they believed the generation’s increased use of technology was a direct cause. The poll also found 74 percent of the parents believed the issues their face children today are much more difficult than those they experienced at the same age.

Medicaid at risk in budget talk

Scott Barstow July 18, 2011

Fundamental changes are being considered to Medicaid, which is the key component of the nation’s health care safety net. Members of Congress and President Obama have begun working toward an agreement to raise the nation’s debt limit, but time is running out before the limit is reached and the federal government begins defaulting on its financial obligations. Republicans in the House of Representatives are demanding deep longterm spending cuts as a precondition for approving a debt limit increase.

The budget proposal the House approved for Fiscal Year 2012 (H.Con. Res. 34) would end Medicare as it is known today. When individuals reach eligibility, they would be given a voucher with which to buy their own insurance in the private health care market. The size of the voucher would not keep pace with health care cost inflation, and beneficiaries’ out-of-pocket costs would almost double. This fundamental change in the Medicare program has become one of the more well-known — and unpopular — aspects of the Housepassed budget proposal, but similar changes are being discussed for the Medicaid program.

Medicaid was established at the same time as Medicare, in 1965. While Medicare covers 39 million people age 65 and older, plus another 8 million adults with permanent disabilities, Medicaid covers roughly 30 million children, 14 million low-income parents and adults, and another 14 million older adults and individuals with disabilities who need assistance covering their Medicare out-ofpocket costs.

The House budget resolution (aka the “Ryan Budget,” named for its author and House Budget Committee Chair Paul Ryan of Wisconsin) would cut Medicaid spending by $750 billion over 10 years and turn it into a block grant program. Beginning in 2013, states would receive a fixed contribution from the federal government, based on population growth and the consumer price index, to operate their Medicaid programs. According to the Congressional Budget Office, Medicaid would be cut in half by 2030 under this proposal.

In part because of its drastic effect on the viability of the Medicaid program, the Senate rejected the House-passed budget by a 57-40 vote on May 25. Nevertheless, policymakers are still attempting to make deep cuts in spending, and if defense and Medicare spending are kept off the chopping block, Medicaid may be at risk. Another proposal that threatens Medicaid is the idea of capping federal spending at a certain percentage of gross domestic product. Sen. Jay Rockefeller (D-W.Va.), a leading champion for Medicaid, considers this proposal as dangerous as turning Medicaid into a block grant because the spending cap would not take into account trends such as the aging of the population or health care cost increases.

Medicaid is the largest source of funding for mental health services, but because mental health and substance abuse services are classified as “optional,” states likely would be forced to cut these services under any significant reductions in federal support.

House education panel votes to end counseling program

Two bills demonstrate the diverging views of education reform among House members. On May 25, the House Committee on Education and the Workforce approved H.R. 1891, the Setting New Priorities in Education Spending Act, by a party-line vote of 23- 16. The goal of the legislation is “to repeal ineffective or unnecessary education programs in order to restore the focus of Federal programs on quality elementary and secondary education programs for disadvantaged students.” Sadly, among roughly 40 programs labeled “ineffective or unnecessary,” the legislation would get rid of the Elementary and Secondary School Counseling Program (ESSCP), the High School Graduation Initiative and the Arts in Education program. Rather than simply not funding the programs, H.R. 1891 would erase them from federal statute.

During consideration of the bill, Rep. Dave Loebsack (D-Iowa) offered an amendment to maintain school counseling services by expanding access to qualified school counselors and other qualified providers, supporting collaborative efforts between schoolbased service systems and mental health services systems, and supporting drug abuse and violence prevention programs. Unfortunately, Loebsack’s amendment was defeated by a party-line vote of 23-16.

The same day that H.R. 1891 was approved by committee, Loebsack introduced the Reducing Barriers to Learning Act of 2011 (H.R. 1995), which would establish an Office of Specialized Instructional Support within the U.S. Department of Education. The legislation would also authorize a competitive matching grant program for states to use in establishing and expanding specialized instructional support programs and services to address barriers to learning as well as to hire and support school counselors and other specialized instructional support personnel. The American Counseling Association applauds Loebsack for his work in championing school counseling services.

Counselors are encouraged to ask their representatives to cosponsor both H.R. 1995 and H.R. 667 (the Put School Counselors Where They’re Needed Act), while opposing H.R. 1891 and its elimination of ESSCP. School counseling services are often first on the chopping block when state and local governments run into budget problems. Congress’ work on reauthorizing federal education programs has just begun, and with grassroots support, we can maintain funding for school counseling services

Cross-cultural counseling of recent immigrants

Christina M. Rasmussen

It is a common belief that clients seek counseling to begin or continue change. In the case of recent immigrants, change is a significant, ongoing process. Deciding to leave one’s home country to make a new life somewhere else requires considerable bravery and faith that the future will be as good, if not better, in another place. But the enormous demands of such a transition often exceed even the most realistic expectations. I have friends who, upon visiting the United States for the first time, were awed by the openness and freedom of American culture but simultaneously startled by the traffic, grit and destitution they observed.

This is supposed to be the land of opportunity, but for many who live here, life is still very, very hard. The new immigrant will not only witness such disheartening scenes, but may, in fact, be living them out on a daily basis — a circumstance that can produce considerable disillusionment and regret. It is important for culturally sensitive counselors to recognize and validate the immigrant client’s culture shock and efforts to persevere in the face of these challenges and disappointments.

New arrivals to the United States often endure a considerable amount of psychosocial upheaval as they struggle to adapt to a new culture, language (possibly), social structure and financial reality. Their economic circumstances substantially impact such transitions. Individuals or families with adequate, stable incomes are likely to find such adjustments less difficult than those with minimal funds. Having the time and resources to maintain connections with significant others, either in the new community or back home, and the ability to access needed or desired products, such as traditional food items, can also affect the ease with which they adjust to their new environment.

Being unable to communicate in English is socially isolating and limits employment opportunities. Even immigrants who are verbally fluent and functionally literate may be puzzled by regional language patterns and colloquialisms, contributing to their sense of being out of sync with others. Dining and sleeping, activities that, depending on the immigrant’s culture, might previously have taken place on the floor, now involve tables and beds. Holiday customs, such as the exchanging of Christmas gifts, may be unfamiliar. Moreover, any obvious differences in speech or appearance can make these individuals vulnerable to unusual scrutiny or prejudicial treatment. For instance, during the sniper attacks that took place in the Washington, D.C., metro area in 2002, police stopped one of my students who was traveling in a vehicle similar to the one reportedly driven by the suspects and subjected him to particularly close examination because he was Turkish.

Political refugees and asylum seekers confront challenges of an entirely different order of magnitude. At best, they face the prospect of indefinite separation from family members who were unable to accompany them. At worst, they have witnessed the killings of loved ones or been tortured or maimed themselves. Survivors endure tremendous emotional losses, in addition to post-traumatic stress, and may require treatment for physical as well as psychic wounds. (The Center for Victims of Torture provides resources for survivors and clinicians through its websites: and

Although recent immigrants are subject to a myriad of stressors, counseling is unlikely to be the first resource to which these individuals ordinarily turn. Generally, family members form their most important support system. The immigration process itself has likely strained these relationships, however, either due to increased physical distance from loved ones or because relatives who immigrate together frequently adapt to the new culture at different rates and to varying degrees. When separated from one’s biological family, the larger circle of those with shared heritage and experiences may become an important substitute. Comfort might be derived from common religious observances or mere proximity to others who speak the same dialect.

Once an immigrant client does present for counseling, it is important to explore the circumstances leading up to this event. Although some of these clients come voluntarily, others may be mandated by the court to attend counseling. In the latter case, domestic relations or child-rearing practices are sometimes significantly different in the client’s country of origin, and the individual might not have a clear understanding of why his or her accustomed behaviors are not accepted in the new locale. Counselors may need to spend a substantial amount of time familiarizing these clients with American culture, including key aspects of the legal system, and helping them to identify healthy ways of accommodating new demands without abandoning traditional and personal values.

In certain instances, clients’ children or other relatives encourage them to seek professional guidance in coping with some life problem. One of my friends who is a therapist was recently approached by a former client, a college student who is a first-generation immigrant from Afghanistan. Her family still struggles with issues related to their relocation some years earlier and is attempting to cope with long-ago losses that continue to haunt them. My friend and I talked at length about the availability of low-cost or free services from a competent provider who would be willing to visit the family in their residence. We concluded it was also important to find someone who would recognize and honor the family’s cultural and religious principles.

Whatever the client’s presenting issue, it can be helpful to devote some time to exploring any ongoing cultural conflicts. One of my clients noted the substantial differences in etiquette between her Caribbean culture and that of Americans living in a semirural region of the Midwest. She was accustomed to greeting everyone with a pleasant “Good day” or “Good night” but found that this struck others as odd, particularly because “Good night” is generally used as a farewell rather than a welcome in the United States.

It is essential to view the immigrant client as an individual rather than as a stereotyped representative of a particular group, even if he or she identifies strongly with a certain faction or places high value on membership in a given community. For example, the term “South American” encompasses a wide variety of cultures and ethnicities, but it provides an insufficient description of a specific young mother whose ancestors were part of the indigenous population of Bolivia. Furthermore, people of common nationality may be members of tribes that have long been at odds with each other. Clients who were in the majority group in their home countries may suddenly find the tables turned, increasing their sense of displacement. In other cases, civil conflicts have resulted in the creation or dissolution of state boundaries, often without consideration for the ethnic identities of the affected people, many of whom were forced to flee their homes to escape the fighting. Among the places where this has occurred are the Balkan states, the Kashmir region of India, the former Soviet Union, Korea and various parts of Africa.

A key element of establishing rapport with immigrant clients is getting a sense of their internal rhythms and learning to work at a pace that is optimal for them. While at some point it may be appropriate to challenge these clients to stretch beyond their comfort zones, this cannot be broached effectively until trust is established and they feel respected and understood. Especially in the case of a cross-cultural counseling relationship, it is incumbent upon the therapist to become familiar with the client’s social traditions and principles. Prescriptively imposing one’s own standards implies a value judgment, which is likely to leave the client feeling further alienated.

As a counselor begins to understand the client in context, he or she might discover a wealth of sociocultural resources available to support the activities taking place in session. Members of the client’s family, religious organization or other community groups may be quite willing to encourage the client’s personal growth if the counselor explains the importance of their support and invites them to contribute their unique wisdom and understanding to the process. Working in concert with the client’s value system and traditions instead of against them is much more likely to result in a successful outcome.

Young and depressed

Jim Paterson July 12, 2011

A group of female classmates has been harassing 13-year-old Marie for a month, making fun of her clothing and her weight. She has stopped socializing, other than to check Facebook to ensure no other hurtful things are being said about her. She sleeps fitfully, has stopped eating regularly and her grades have dropped.

Robert, Marie’s classmate, didn’t make the basketball team, which represented his singular dream. His recently divorced parents and his teachers have noticed he has grown much more irritable, to the point that other students avoid him.

His older brother, Randy, was previously a high school honor student. Now his grades have plummeted.

Kaitlyn, the girl who sits behind Randy in chemistry, smokes marijuana. She is often high in school and nearly always high when she is with her new group of friends. Her younger brother in fourth grade calls his foster mother and goes home sick from school one or two times per week.

Another student, Juan, always seems very sad. For two years, teachers have told his counselor about his mood. In Juan’s file, the counselor finds similar reports dating back to middle school.

Under the current criteria, any one of these students might potentially be diagnosed with major depressive disorder, which generally involves a client experiencing six or more of nine common symptoms for a duration of two weeks, or dysthymic disorder, which presents as having a chronic depressed mood with two established symptoms for two years or more.

But based on proposed revisions, when the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is published approximately two years from now, new criteria will likely suggest that each of these students is depressed — by degrees.

“[The DSM-5] will introduce the idea of looking at disorders such as depression on a spectrum, with certain severity levels used as cut points to identify maladaptive symptoms and functioning, much like we associate blood pressure of 140 over 90 as higher risk,” says Gary Gintner, associate professor of counselor education and program leader at Louisiana State University. “Depression, too, will have a dimensional rating that notes severity.”

But no matter the process for diagnosis, experts would say that all of these students have serious symptoms of depression and need attention from counselors to help them feel better and address the problem early when it is easier to make inroads.

Gintner says at any one time, about 2 percent of children younger than age 12 have depressive disorders. That number rises to between 4 and 8 percent for those ages 12 to 18. Once adolescent girls hit puberty, their risk of depression is double that of their male classmates (see sidebar, page 34). The rate of depression among young people has increased every decade since the 1940s, according to Gintner, who trains counselors in the use of the DSM and is an expert in planned revisions for the DSM-5.

Each of the professionals interviewed for this article noted that an early diagnosis of depression can make it easier to treat the issue successfully, often with talk therapy.

The diagnosis

That means it is important for counselors — especially those in schools — to be the first line in identifying students struggling with depression.

According to Dr. Graham Emslie, a psychiatrist at Southwestern Medical Center in Dallas and a specialist in child depression, only about 40 percent of adolescents and children needing treatment get adequate care, often because the problem is not spotted. “It is a quiet problem,” he says. “We tend to relieve the symptoms or simply not identify it.”

One key indicator of depression among students is a precipitous drop in grades, he says, especially if accompanied by other symptoms of depression: low self-esteem, sleep problems, fatigue, apathy and feelings of worthlessness, changes in appetite, loss of pleasure in life and problems concentrating.

Gintner, a past president of the American Mental Health Counselors Association, a division of the American Counseling Association, notes that uncharacteristic or excessive irritability is a symptom associated with depressed adolescents and children. He adds that children may have temper tantrums, stomachaches or headaches associated with depression, while adolescents may be moody, act out or even injure themselves by cutting or burning their skin.

“Many times, the behavior is interpreted as oppositional, but the young person is actually depressed,” Gintner says. “The key thing to look for is if they have one of these other depressive symptoms (see sidebar, page 35). And it is critical to identify these problems early when there is a greater chance of treating them successfully.”

Often, experts say, life stressors cause depression. For children and adolescents, those stressors don’t necessarily stem from a serious personal failure or a major event such as the death of a loved one but rather from common daily hassles or interpersonal problems, such as changes in relationships with peers.

James Matta, an associate professor of counseling at Geneva College in Pennsylvania and senior research principal at the Western Psychiatric Institute and Clinic in Pittsburgh, says counselors should pay particular attention to feelings of hopelessness among young people. “It hinders an individual’s ability to form and maintain close relationships with family, friends and early romantic partners,” he warns.

Matta, an ACA member who presented on depression in young people at the 2011 ACA Annual Conference in New Orleans, adds that comorbidity is not adequately studied or identified, even though substance use disorders and depression are often linked. Depressed young people are twice as likely to have a substance abuse problem than other adolescents, he says, and “comorbidity is more often seen than not in adolescents with substance use disorders.”

Emslie says it is often difficult to determine whether certain characteristics and circumstances cause depression or whether they are symptoms of it. For instance, being bullied can cause children to become depressed, but depressed children might also be more likely to be targets of bullying because they are less likely to defend themselves and perhaps present themselves in a way that encourages bullies.

The treatment

When school counselors are concerned about a student, Matta says, it is critical that they develop a baseline for the student’s mood, demeanor and performance in school, using communications with former teachers and counselors as a guide. Early treatment is key, he says.

“We are determining — and it’s very affirming to counselors — that psychotherapy or talk therapy is most useful for those with mild to moderate levels of depression,” he says. “Cognitive behavior therapy (CBT) and interpersonal therapy seem to be very effective.”

Laura Choate, an associate professor at Louisiana State University and the author of books and papers on depression, particularly as it relates to young women (see sidebar, this page), says considerable research has reached that conclusion about treatment. She says the most effective components of CBT to date are psychoeducation about the nature of depression, the development of problem-solving skills, self-monitoring, building relationship skills, communication training (assertiveness, social interactions, family communication, active listening), cognitive restructuring and behavioral activation — for instance, increasing pleasant activities or setting small, achievable goals.

Choate, a member of ACA, notes that a popular “Coping With Depression-Adolescent” program from Kaiser Permanente’s Center for Health Research is “among the most studied CBT programs for adolescents and has the most empirical support.” The training manual and student workbook in individual and group formats are available for free

Meanwhile, through interpersonal therapy, young people improve relationships by building support and developing their interpersonal competence, Choate says. “Most counselors are not familiar with interpersonal therapy, but there is a strong line of research supporting its effectiveness with adolescents, particularly with girls of color from impoverished backgrounds,” she says, noting that Laura Mufson, a researcher and professor at the Columbia University Medical Center, has developed research and training material surrounding the treatment.

Gintner says counseling should include positive interactions, active listening, restoring hope and doing problem solving for real problems. Emslie adds that family therapy is also useful.

Matta notes the American Psychiatric Association released guidelines for treatment of depression in October that suggested talk therapy is most effective initially for clients with less severe cases of depression. “Four to six weeks into treatment, if they are not showing improvement — or in more severe cases — then you consider an antidepressant,” Matta says.

Emslie agrees: “Data would suggest that the persistence of the problem in spite of attempts to improve the situation is the best indicator for medication. Unfortunately, only 40 percent of young people who suffer from depression are treated, and only 20 percent of those treated use medication.”

A study that Matta helped conduct found that young people with comorbidity who received both talk therapy and the antidepressant fluoxetine (more commonly known by the brand name Prozac) did not have significantly better results than those receiving only talk therapy, though both groups showed significant within-group improvement.

“It was not the specific intent of this study,” Matta says, “but its results support the recent recommendation that psychotherapy intervention should be considered the first-line treatment in comorbid populations, with pharmacotherapy being offered to those who do not respond to psychotherapy intervention alone.”

But Gintner cautions that the “old class” of antidepressants such as Elavil isn’t helpful with children and youth, while selective serotonin reuptake inhibitors (SSRIs) only seem to work with adolescents. He also notes these drugs are not without risks.

“In 2000,” he says, “studies began to find risk of suicide ideation or suicidal behavior increased from 2 percent with a placebo to 4 percent on SSRIs. It’s a risk, but not a huge risk, so we have to weigh the risk versus the benefit and, sometimes, the benefit is significant.” Research has shown that Paxil seems to have a higher incidence of suicidal ideation and acts, he says, while adding that Prozac is the only SSRI approved for use with youth by the U.S. Food and Drug Administration. The FDA recommends that youth taking SSRIs be seen by a psychiatrist every week for a month and be monitored closely, he points out.

Still, experts say better treatment techniques and the refined use of medication are helping increasing numbers of young people. And Matta notes the weighty issue is not without positive data. “Adolescent recovery rate is 90 percent over one to two years from the onset of depressive disorder with treatment,” he says. “So we do know how to treat it.”

Jim Paterson is a writer and editor and the head of counseling at Argyle Middle School in Silver Spring, Md. Contact him

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