Speech and Language Developmental Milestones

How do speech and language develop?

The first 3 years of life, when the brain is developing and maturing, is the most intensive period for acquiring speech and language skills. These skills develop best in a world that is rich with sounds, sights, and consistent exposure to the speech and language of others.

There appear to be critical periods for speech and language development in infants and young children when the brain is best able to absorb language. If these critical periods are allowed to pass without exposure to language, it will be more difficult to learn.

What are the milestones for speech and language development?

The first signs of communication occur when an infant learns that a cry will bring food, comfort, and companionship. Newborns also begin to recognize important sounds in their environment, such as the voice of their mother or primary caretaker. As they grow, babies begin to sort out the speech sounds that compose the words of their language. By 6 months of age, most babies recognize the basic sounds of their native language.

Children vary in their development of speech and language skills. However, they follow a natural progression or timetable for mastering the skills of language. A checklist of milestones for the normal development of speech and language skills in children from birth to 5 years of age is included below. These milestones help doctors and other health professionals determine if a child is on track or if he or she may need extra help. Sometimes a delay may be caused by hearing loss, while other times it may be due to a speech or language disorder.

What is the difference between a speech disorder and a language disorder?

Children who have trouble understanding what others say (receptive language) or difficulty sharing their thoughts (expressive language) may have a language disorder. Specific language impairment (SLI) is a language disorder that delays the mastery of language skills. Some children with SLI may not begin to talk until their third or fourth year.

Children who have trouble producing speech sounds correctly or who hesitate or stutter when talking may have a speech disorder. Apraxia of speech is a speech disorder that makes it difficult to put sounds and syllables together in the correct order to form words.

What should I do if my child’s speech or language appears to be delayed?

Talk to your child’s doctor if you have any concerns. Your doctor may refer you to a speech-language pathologist, who is a health professional trained to evaluate and treat people with speech or language disorders. The speech-language pathologist will talk to you about your child’s communication and general development. He or she will also use special spoken tests to evaluate your child. A hearing test is often included in the evaluation because a hearing problem can affect speech and language development. Depending on the result of the evaluation, the speech-language pathologist may suggest activities you can do at home to stimulate your child’s development. They might also recommend group or individual therapy or suggest further evaluation by an audiologist (a health care professional trained to identify and measure hearing loss), or a developmental psychologist (a health care professional with special expertise in the psychological development of infants and children).

What research is being conducted on developmental speech and language problems?

The National Institute on Deafness and Other Communication Disorders (NIDCD) sponsors a broad range of research to better understand the development of speech and language disorders, improve diagnostic capabilities, and fine-tune more effective treatments. An ongoing area of study is the search for better ways to diagnose and differentiate among the various types of speech delay. A large study following approximately 4,000 children is gathering data as the children grow to establish reliable signs and symptoms for specific speech disorders, which can then be used to develop accurate diagnostic tests. Additional genetic studies are looking for matches between different genetic variations and specific speech deficits.

Researchers sponsored by the NIDCD have discovered one genetic variant, in particular, that is linked to specific language impairment (SLI), a disorder that delays children’s use of words and slows their mastery of language skills throughout their school years. The finding is the first to tie the presence of a distinct genetic mutation to any kind of inherited language impairment. Further research is exploring the role this genetic variant may also play in dyslexia, autism, and speech-sound disorders.

A long-term study looking at how deafness impacts the brain is exploring how the brain “rewires” itself to accommodate deafness. So far, the research has shown that adults who are deaf react faster and more accurately than hearing adults when they observe objects in motion. This ongoing research continues to explore the concept of “brain plasticity”—the ways in which the brain is influenced by health conditions or life experiences—and how it can be used to develop learning strategies that encourage healthy language and speech development in early childhood.

A recent workshop convened by the NIDCD drew together a group of experts to explore issues related to a subgroup of children with autism spectrum disorders who do not have functional verbal language by the age of 5. Because these children are so different from one another, with no set of defining characteristics or patterns of cognitive strengths or weaknesses, development of standard assessment tests or effective treatments has been difficult. The workshop featured a series of presentations to familiarize participants with the challenges facing these children and helped them to identify a number of research gaps and opportunities that could be addressed in future research studies.

What are voice, speech, and language?

Voice, speech, and language are the tools we use to communicate with each other.

Voice is the sound we make as air from our lungs is pushed between vocal folds in our larynx, causing them to vibrate.

Speech is talking, which is one way to express language. It involves the precisely coordinated muscle actions of the tongue, lips, jaw, and vocal tract to produce the recognizable sounds that make up language.

Language is a set of shared rules that allow people to express their ideas in a meaningful way. Language may be expressed verbally or by writing, signing, or making other gestures, such as eye blinking or mouth movements.

Your baby’s hearing and communicative development checklist

Birth to 3 Months

Reacts to loud sounds

YES   NO  

Calms down or smiles when spoken to

YES   NO  

Recognizes your voice and calms down if crying

YES   NO  

When feeding, starts or stops sucking in response to sound

YES   NO  

Coos and makes pleasure sounds

YES   NO  

Has a special way of crying for different needs

YES   NO  

Smiles when he or she sees you

YES   NO  

4 to 6 Months

Follows sounds with his or her eyes

YES   NO  

Responds to changes in the tone of your voice

YES   NO  

Notices toys that make sounds

YES   NO  

Pays attention to music

YES   NO  

Babbles in a speech-like way and uses many different sounds, including sounds that begin with p, b, and m

YES   NO  


YES   NO  

Babbles when excited or unhappy

YES   NO  

Makes gurgling sounds when alone or playing
with you

YES   NO  

7 Months to 1 Year

Enjoys playing peek-a-boo and pat-a-cake

YES   NO  

Turns and looks in the direction of sounds

YES   NO  

Listens when spoken to

YES   NO  

Understands words for common items such as “cup,” “shoe,” or “juice”

YES   NO  

Responds to requests (“Come here”)

YES   NO  

Babbles using long and short groups of sounds (“tata, upup, bibibi”)

YES   NO  

Babbles to get and keep attention

YES   NO  

Communicates using gestures such as waving or holding up arms

YES   NO  

Imitates different speech sounds

YES   NO  

Has one or two words (“Hi,” “dog,” “Dada,” or “Mama”) by first birthday

YES   NO  

1 to 2 Years

Knows a few parts of the body and can point to them when asked

YES   NO  

Follows simple commands (“Roll the ball”) and understands simple questions (“Where’s your shoe?”)

YES   NO  

Enjoys simple stories, songs, and rhymes

YES   NO  

Points to pictures, when named, in books

YES   NO  

Acquires new words on a regular basis

YES   NO  

Uses some one- or two-word questions (“Where kitty?” or “Go bye-bye?”)

YES   NO  

Puts two words together (“More cookie”)

YES   NO  

Uses many different consonant sounds at the beginning of words

YES   NO  

2 to 3 Years

Has a word for almost everything

YES   NO  

Uses two- or three-word phrases to talk about and ask for things

YES   NO  

Uses k, g, f, t, d, and n sounds

YES   NO  

Speaks in a way that is understood by family members and friends

YES   NO  

Names objects to ask for them or to direct attention to them

YES   NO  

3 to 4 Years

Hears you when you call from another room

YES   NO  

Hears the television or radio at the same sound level as other
family members

YES   NO  

Answers simple “Who?” “What?” “Where?” and “Why?” questions

YES   NO  

Talks about activities at daycare, preschool, or friends’ homes

YES   NO  

Uses sentences with four or more words

YES   NO  

Speaks easily without having to repeat syllables or words

YES   NO  

4 to 5 Years

Pays attention to a short story and answers simple questions about it

YES   NO  

Hears and understands most of what is said at home and in school

YES   NO  

Uses sentences that give many details

YES   NO  

Tells stories that stay on topic

YES   NO  

Communicates easily with other children and adults

YES   NO  

Says most sounds correctly except for a few (l, s, r, v, z, ch, sh, and th)

YES   NO  

Uses rhyming words

YES   NO  

Names some letters and numbers

YES   NO  

Uses adult grammar

YES   NO  

This checklist is based upon How Does Your Child Hear and Talk?, courtesy of the American Speech–Language–Hearing Association.

Where can I find additional information about speech and language developmental milestones?

The NIDCD maintains a directory of organizations that provide information on the normal and disordered processes of hearing, balance, taste, smell, voice, speech, and language.

Use the following keywords to help you find organizations that can answer questions and provide information on speech and language development:


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What Is Conscious Parenting — and Should You Try It?

Before your baby arrived, you probably read an endless stack of parenting books, listened to thousands of stories from other parents, and maybe even swore to your partner that you’d do the opposite of everything your parents did.

You may have felt confident in your parenting choices for your not-yet-a-challenge-because-they-weren’t-born-yet baby.

Then, your baby arrived, sprouted quickly into a small person with their own thoughts and desires, and suddenly the whirlwind of it all left you feeling completely unprepared and confused.

Feeling pressure to make tough parenting decisions, you may have started looking for groups of fellow parents to seek out advice.

Through those groups, one newer (sometimes controversial) parenting approach you may have started to hear about is conscious parenting. What is it though? And does it actually work?

What is conscious parenting?

Conscious parenting is a term used by various psychologists (and others) to describe a style of parenting that usually focuses more on the parent and how mindfulness can drive parenting choices.

It’s rooted in a combination of Eastern-style philosophy and Western-style psychology. (In other words, a bringing together of meditation and self-reflection.)

Put most simply, conscious parenting asks that instead of striving to “fix” your child, parents look inward at themselves. Conscious parenting views children as independent beings (though admittedly still developing over time), who can teach parents to become more self-aware.

One of the figureheads of this approach to parenting is Shefali Tsabary, PhD, a New York–based clinical psychologist, author, and public speaker. (In case you’re wondering how popular she is, the Dalai Lama wrote the opening to her first book, Oprah has considered her one of the best interviews she’s ever had, and Pink is a fan of her books, which include: The Conscious ParentThe Awakened Family, and Out of Control.)

Shefali suggests that through serious consideration of cultural legacies — or to put it more bluntly, family baggage and personal conditioning — parents can begin to let go of their own checklists for how life should be done.

By releasing these checklists, Shefali believes parents free themselves from forcing beliefs on their children. When this occurs, children become free to develop their true identity. Ultimately, Shefali argues this will help children connect with their parents since they’re being accepted for who they really are.

Supporters of conscious parenting believe this model prevents children from having an identity crisis later in life. They also feel it creates closer bonds with children and that the conditioning and authoritative style common in many parental relationships are responsible for the large number of children who pull away from parents.

Key elements of conscious parenting

While there are many elements to conscious parenting, a few key ideas include:

  • Parenting is a relationship. (And not a one-way transmission process!) Children are their own unique people who can teach a parent.
  • Conscious parenting is about letting go of a parent’s ego, desires, and attachments.
  • Instead of forcing behaviors on children, parents should focus on their own language, their expectations, and their self-regulation.
  • Instead of reacting to issues with consequences, parents should establish boundaries ahead of time and use positive reinforcement.
  • Instead of trying to fix a momentary problem (e.g., a temper tantrum), it’s important to look at the process. What led up to this event and what does it mean in a bigger picture?
  • Parenting is not just about making a child happy. Children can grow and develop through struggles. A parent’s ego and needs should not prevent a child’s growth!
  • Acceptance requires being present and engaging with whatever situations present themselves.

What are the benefits of conscious parenting? 

A conscious parenting approach requires parents to engage in self-reflection and mindfulness on a daily basis. This may be beneficial to more than just your parenting.

Engaging in mindful self-reflection regularly can bring benefitsTrusted Source like reduced stress and anxiety. Daily meditation can also produce a longer attention span, has the potential to reduce age-related memory loss, and can even decrease blood pressure and improve sleep.

Additionally, its supporters say that conscious parenting can encourage more respectful language use (by both parents and children) as well as overall increased communication.

One of the key tenets to conscious parenting is that children are full individuals who have something to teach adults. Truly accepting this belief requires parents to speak to children with a certain level of respect and to communicate with them frequently.

Having frequent respectful conversations with adults models healthy, positive relationship skills for children to use in other areas of their life.

A 2019 study also suggests there are benefits to adults engaging children with high-quantity and high-quality language in early childhood. Researchers note the types of conversations promoted by the conscious parenting style may result in improved cognition, fewer signs of aggression, and advanced development in children.

What are the drawbacks of conscious parenting?

For parents seeking a quick, clear-cut fix to parenting challenges, conscious parenting may not be a great match for several reasons.

First, it can take a long time to achieve the amount of self-reflection and internal control necessary to parent in the way called for by this style. After all, supporters of conscious parenting believe it’s necessary to release your own baggage to allow your child to be true to their authentic self, and that won’t happen overnight!

Second, conscious parenting requires that parents give their children the opportunity to struggle and fail. This, of course, means that it may be messy and take time.

Supporters of conscious parenting believe that this time and struggle is necessary for a child to grapple with important issues that will define them. However, for some parents watching it happen may be difficult if they have a chance to prevent their child from experiencing failure or pain.

Third, for parents who like black-and-white answers to handling problems with their children, conscious parenting can be troubling. Conscious parenting does not endorse an if A, then B approach to parenting.

This style of parenting requires that adults relinquish significant amounts of control to their child. (Less dictation means things may get a little fuzzier and less predictable.)

Instead of there always being a clear course of action, conscious parenting insists that parents work with children to sort through issues as they arise and stay in the moment.

Additionally, conscious parenting may pose unique challenges when parenting younger children. There are times when, for safety, a parent needs to take action immediately. It’s not always possible to pause and reflect when your first responsibility is to keep your child safe.

Finally, for some parents, the key beliefs behind the conscious parenting perspective can hit a nerve. For example, one of the more controversial lines in “The Conscious Parent” states, “Parenting is not that complicated or difficult once we become conscious because a conscious person is naturally loving and authentic.” It’s likely that most parents have sometimes — if not daily — felt that parenting is, in fact, pretty complicated and often difficult.

When considering any parenting philosophy, there may be times another philosophy makes more sense. Conscious parenting may not be the right fit for every situation or child, depending on other parenting views and the personalities of those involved.

Most parents rely on a mixture of parenting philosophies when raising their children and base their actions on a complex combination of factors.

Examples of conscious parenting 

Confused about what implementing this might look like in real life? Don’t worry, you’re not alone. So, here’s a real-life example of the conscious parenting style in action.

Imagine that your 5-year-old has been left alone and gotten hold of the scissors (every parent’s worst nightmare!) They decided to play barber shop and use their new cutting skills on their hair. You’ve just walked in and seen the result…

1. Breathe

Instead of reacting in rage or horror, providing an immediate punishment, or placing blame on the child, as a parent practicing conscious parenting you’d take a second to breathe and center yourself. Take a moment to move the scissors to a safe location.

2. Reflect

It’s important to take time to reflect on any triggers or emotions this event may have stirred inside yourself before expressing them towards your child. Chances are at least a little part of you is thinking about what all the other parents on the playground will think when they see your child next! Time to let that go.

3. Set boundaries

Conscious parenting does include setting boundaries (particularly when it comes to requesting respectful communication). So if your child asked to use the scissors earlier and was told that it could only occur with a parent present for safety reasons, this would be a time to mention the violation of the boundary that had been set.

However, you also need to consider how you can help your child going forward, like moving the scissors to a location they can’t access on their own. Remember: Conscious parenting strives for connection and authentic relationships while focusing on the bigger picture that long term this isn’t about ill-cut hair.

4. Accept

Finally, instead of getting upset that your child’s hair may not look the most professional, conscious parenting would ask that you accept the hair for where it is now. No need to mourn the past hairdos! It’s time to practice releasing your ego.

You could even use this as an opportunity to work with your child to create a new hairdo if they desire one!


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Two Kids – Can I Handle It?

When I found out that I was pregnant with my second child, I was excited, but also very terrified. Our daughter was the center of our world for almost two years and I wasn’t sure if I could ever love another child the way that I loved her!

I wanted to write this blog to let expectant moms or new moms know that you aren’t alone if you are feeling this way. To also let everyone know, that YES, yes you can love both of your children the same, in fact, I think my love has even grown.

The Beginning

When I became pregnant with my daughter Nora in 2016, I was excited, nervous, and anxious – all of the emotions a first-time mom feels. It was a very easy pregnancy and I had no complications, so I consider myself extremely lucky. 

From the moment I saw her, I was hooked. I loved her more than I thought I could ever love a person. Although I loved Nora and was in awe of what my husband and I had created, I suffered through postpartum depression until Nora was about 9 months old. 

It was a horrible, dark part of my life, that I’m glad I never repeated with my son. Looking back on those times, I was afraid to ever have another child because I didn’t want to feel those feelings again.


 It was one of the main reasons I was hesitant to have another child. It wasn’t because I didn’t think we could handle it; I was just concerned with suffering through depression again.

Luckily, I have an amazing husband who supported me through the process, and a family that was there for more when I needed it the most. 

Another Baby?

When Nora was around 1.5, we started talking about having another child. I wanted Nora to have a sibling because I knew all the benefits that having a little brother or sister could provide to her. She’d have someone to grow up with, confide in, and who would support her. 

After only a few months, I found myself pregnant again. Once I saw those two little lines, that’s when I started to feel weird. I worried about loving the second baby as I loved Nora. Nora was my little partner. She was my mini-me and was always by my side.

Throughout my pregnancy, we made sure to spend as much time as possible with Nora and include her in decorating his room, got her big sister books, and let her talk to my belly whenever she wanted to. 

I feel like that helped her A LOT when it came to preparing for Nicholas being born. 

He’s Here!

Nicholas was born in 2019 when Nora was almost 2.5 years old. He was perfect, and that fear of not loving him the way I loved Nora? Not possible. It immediately went away when I held him for the first time. 

If you’re an expectant momma and you’re worried about the same thing – don’t be! Your love grows with every child you have.

The first time Nora and Nicholas met, is still one of my favorite memories of my life. Nora wanted to hold him right away and I knew that Nicholas felt calm in her arms. That sibling bond existed even when Nicholas was only a day old. 

Once I saw the way they were together, I knew everything would be okay. That bond has only strengthened as Nicholas has grown.


In fact, the way Nora was as a big sister made the transition to two kids much easier. She wanted to help change his diaper, would get him toys to look at, would try and comfort him when he was crying, and would try and make him laugh. There are still times that he will only calm down when she is with him!


I’m in no way, shape, or form an expert, but I can tell you what worked for us as we transitioned!

  1. Spend alone time with your firstborn every now and then. Either I or my husband would take Nora for ice cream, to the park, or anywhere special by herself so she just got individual time. We still do that so she knows we love her just the same.
  2. Give yourself forgiveness. There are days I lose my crap. After that happens, I feel like a terrible mom. I am not a terrible mom. We all hit breaking points, especially with a newborn. You’re running on little to no sleep and can’t even nap when you want to because you have a toddler running around!
  3. Take all of the pictures! These moments go way too fast and you’ll want to look back and see how small your babies were! On tough days, I look back at the pictures and remember that every moment passes.
  4. Go for walks. My kids love going for walks and getting outside. Even with a newborn, you can do that! Strap them to your chest, put your older child in a stroller, and get some fresh air!
  5. Don’t be afraid to ask for help. We relied on my in-laws a bunch with both babies. You may have a hard time leaving, but trust me, parents are better when they have time to themselves.


Credit to:

Stacie Bennett

Speech-Language Pathologist , Trenton , New Jersey


The Company expressly disclaims any and all liability (including liability for negligence) in respect of the use of the information provided. The Company recommends you seek independent professional advice prior to making any decision involving matters outlined in these publications.


How to Get Toddlers to Listen and Cooperate

Ahh, yes. No one and nothing can compare to the strong-willed nature of a toddler. They want what they want, when they want it and they don’t really care if you say ‘no.’

I don’t know about you, but I didn’t totally picture my life being a 24-hour-a-day giver-of-snacks or a meltdown soother because I wouldn’t let my daughter pet the dead mouse my cat caught, but yet here I am!

If you’re like most, you’ve tried everything from the calm and deliberate approach to the frazzled raised voice and threats of screen time loss. Toddlers are an obstinate bunch and it can be difficult to get through to them, especially without yelling or tears (yours or theirs!). 

Luckily, here are some parenting tips for toddlers to, hopefully, make those sassy toddler years a little more bearable!

Why Can’t They Listen?

First of all, it’s important to understand why it seems our toddlers can’t/won’t listen to us when we tell them something the first time. As it turns out, there is quite a bit of psychology around this behavior. Kids’ brains are actually hard-wired to seek control. Think about it: most of their lives are completely controlled by adults, from what they wear to the foods they eat, so choosing not to listen is a way that toddlers are asserting their power.


So, here’s where things get a little tricky. We want kids to assert themselves and be advocates for their little bodies, BUT we also need to set boundaries as parents so that our kids don’t turn out to be spoiled, entitled brats. 

Get Down on Their Level

Even in therapy, kids react much better if you are down on their level. Whether that’s playing, reading, or having conversations. When kids aren’t paying attention, they usually aren’t making eye contact – which means they aren’t listening to you. A good way to get their attention and to make them focus is to sit down in front of them. 

This type of communication is much more impactful than hollering across the room or giving a command while your back is turned at the stove. You will be shocked at how your little one pays attention when you are on their level. 

Eliminate the Word “Don’t”

I’m totally guilty of doing this with my kids. It seems like I’m always telling them to not do something, instead of encouraging them to do something different.

As it turns out, our phraseology is actually making it more difficult for them to comprehend. Negative requests and commands require toddlers to double-process. That is, they first have to determine what we want them to stop doing, then figure out what we want them to do instead.

Say “Yes” More Often 

Toddlers have the behavior of asking for the same thing multiple times a day.

If you’re like me, the knee-jerk reaction is to just keep saying ‘no.’ That doesn’t make us bad parents. It’s hard to listen to the same sentence or phrase day after day without having a reaction. Plus, there are times when ‘no’ is totally justified and we have to say it. 

However, because our children are hearing our canned ‘no’ responses over and over, they begin to tune us out. For this reason, it’s important to look for opportunities to say ‘yes’ to their requests. 


For example, if your child wants candy at 8 a.m., you can say something like, “how about you have some chocolate for your afternoon snack?”

You’ve still accomplished your goal of not feeding your child chocolate so early in the morning, but this feels like a win to your toddler, too. Not only did he get a positive response, but you also gave him a choice to offer him even more control in the situation. Part of getting your toddler to listen to you is listening to them as well. 

Stop Counting to 3

Sorry parents, but this tactic just doesn’t work. If it does, it’s only a matter of time before your child learns that this means he gets multiple times where he gets to not listen to you before there’s a consequence. 

We are virtually ensuring that they will never listen the first time. I know it’s tempting to use this tactic when you are in the moment. However, do yourself a favor and discontinue counting in order to save yourself more stress in the future. Instead, employ one of the four strategies above.

It’s very easy to get frustrated with your toddlers when they aren’t listening, but it’s important to remain calm and remember that they aren’t necessarily meaning to be so defiant. Parenting is never easy and this time in life can be especially challenging. We will get through it, with a few more gray hairs, but we will survive!!



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Seven tips to manage your mental health and well-being during the COVID-19 outbreak

Feeling overwhelmed by a lockdown and the need to suddenly adopt e-learning? Keep connected and compassionate, says clinical psychologist Desiree Dickerson.

I am a clinical psychologist who specializes in academic mental health and well-being. In mid-March I was due to run a resilience and well-being workshop in Sweden for doctoral candidates, but was instead facing day eight of quarantine with two small children in my apartment in Spain. Like many people’s, my sense of resilience feels increasingly frayed. When our minds are consumed by the spread of the coronavirus and its impact on our health, loved ones, home countries, economy and students — not to mention our research programme, funding or employment status, and an abrupt transition to e-learning — how do we maintain our own mental health and well-being and that of our community?

Here are some tips that have resonated from discussions I have held with academic leaders and students about responding to COVID-19:

Manage your expectations

This is unlikely to be the writer’s retreat that you have long dreamt of. The suggestion that periods of quarantine might bring unprecedented productivity implies we should raise the bar, rather than lower it. Do not underestimate the cognitive and emotional load that this pandemic brings, or the impact it will have on your productivity, at least in the short term. Difficulty concentrating, low motivation and a state of distraction are to be expected. Adaptation will take time. Go easy on yourself. As we settle into this new rhythm of remote work and isolation, we need to be realistic in the goals we set, both for ourselves and others in our charge.

Know your red flags

One way to manage moments of distress is to identify key thoughts or physical sensations that tend to contribute to your cycle of distress and feelings of being overwhelmed. Our thoughts (“Why can’t I concentrate?”), feelings (frustration, worry, sadness), physical sensations (tension, upset stomach, jitters) and actions (such as compulsively checking the latest COVID statistics) each feed into and amplify these negative emotional spirals. Addressing one aspect of this loop by, for example, actively reducing the physical symptoms (I use box breathing: breathe in for four counts, hold for four, breathe out for four and hold for four, then repeat) can de-escalate the cycle and help you regain control.

Routine is your friend

It helps to manage anxiety, and will help you to adapt more quickly to this current reality. Create clear distinctions between work and non-work time, ideally in both your physical workspace and your head space. Find something to do that is not work and is not virus-related that brings you joy. Working in short bursts with clear breaks will help to maintain your clarity of thought.

Be compassionate with yourself and with others

There is much that we cannot control right now, but how we talk to ourselves during these challenging times can either provide a powerful buffer to these difficult circumstances or amplify our distress. Moments of feeling overwhelmed often come with big thoughts, such as “I cannot do this,” or “This is too hard.” This pandemic will cause a lot of stress for many of us, and we cannot be our best selves all the time. But we can ask for help or reach out when help is asked of us.

Maintain connections

Even the most introverted of us need some sense of connection to others for our mental as well as our physical health. Many working groups have created virtual forums where you can contribute or just sit back and enjoy the chatter. Staff teams have instigated virtual coffee groups, online book clubs and co-working spaces where you can work in the (virtual) presence of others. We are in social isolation, but we need not feel alone. Reach out to those who might be particularly isolated.

Manage uncertainty by staying in the present

Take each day as it comes and focus on the things you can control. Mindfulness and meditation can be great tools.

This will probably be a stressful time for all of us, and will test the mental-health policies and practices of many research institutes, just as it is testing much else in the world. By embracing good mental-health and well-being measures, and by relying on others when necessary, we can protect ourselves and those around us.

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How ADHD Sometimes Gets Worse

WHEN WE SAY THAT A PERSON'S ADHD HAS GOTTEN WORSE, what we usually mean is that the person’s executive functions, his ability to manage himself, have not yet developed enough to meet task requirements usually expected for a person of that age. As a child gets older, family, teachers, friends, and the wider community increase their expectations for how much a person is able to demonstrate adequate self-management. If the discrepancy between what that individual and most other persons of similar age are able to do is too great, people tend to say that he or she is behind in his or her development.

ADHD is a syndrome of impairments in certain brain functions that may cause more or less difficulty, depending on what that person needs to do in daily life. It is important to keep in mind that ADHD is not like an infection or a tumor that gets worse or better. It is a syndrome of impairments of the brain’s development and cognitive functioning. To think about such impairments always involves the question, “Impairment for what?” ADHD tends to impair certain functions in affected persons as they encounter tasks that they are expected to perform by a specific age. For example, a young child in preschool or kindergarten is not expected to be able to sit at a desk and do written assignments. If a child with ADHD in fourth grade is consistently unable to work independently on that task, the problem is not really that his ADHD has gotten worse. The problem is that his ability to master the demand for increased attention and self-control has not improved as much as is usually expected for that age.

Perhaps it would make more sense to ask, “What factors make a person’s ADHD more problematic?” than to ask, “How does ADHD become ‘worse’?” A number of factors may make an individual’s ADHD symptoms become more problematic at a particular time of life or in particular situations. Some of these include the following factors.

Being required to undertake new challenges without sufficient support.

Most people would not expect or allow a 3-year-old child to cross a busy street alone. A child that young would not be expected to be able to look carefully at traffic coming from both directions, to estimate accurately the speed of oncoming vehicles, and to move carefully to cross when there is adequate space to get across safely. Any reasonable adult would want to provide careful assistance to help that young child get safely across the street until the child has matured enough to learn, remember, and use the skills needed safely to cross a busy street alone. We also know that some children need much longer to develop these skills than do others.

For some children with ADHD, academic skills such as learning to read, preparing for a spelling test, writing a book report, and keeping track of homework assignments are acquired as readily as for most others of similar age. However, for some, such tasks may be as challenging as it would be for a 3-year-old to cross a busy street alone. Some children with ADHD are very quick to pick up academic skills, but they consistently struggle more than most of their peers with social skills. They are slower to pick up cues from others about when they are being too pushy or too demanding. They feel chronically bewildered about how to respond to classmates’ teasing or how to get others to let them join in a conversation or a game. They may repeatedly be too bossy and be excluded by playmates, or they may simply retreat into solitary activities, avoiding the risk of peer rejection by immersing themselves in playing video games.

Some children with ADHD need much more support from parents or teachers for doing their schoolwork and/or managing social interactions. This need for extra support may emerge early in preschool years, or it may not become noticeable until the child enters middle school or high school when more independent self-management is expected. For some, the need for extra support does not emerge noticeably until the adolescent is preparing to move away from home to go to college. For those who need such support and do not receive it or who receive too much support and do not have ample chances to learn to manage for themselves, such activities at various stages of development may become almost as perilous as trying to cross a busy street before they have learned how to do it.

Being criticized or punished repeatedly or harshly for failures they cannot adequately control.

Because children and adolescents with ADHD often fail to meet the usual expectations for their age, many are subjected to what they experience as endless criticism or harsh punishment from teachers, parents, siblings, and/or peers. “Why do you always keep doing what I’ve asked you repeatedly to stop doing?” “You keep promising that you will write down your assignments in your plan book, and then you keep coming home without doing it!” “Why should I keep helping

you with your homework when you don’t even bother to hand it in and get credit for it?” “You spend hours intently focused on playing your video games, but you claim you can’t focus for just 20 minutes on doing your social studies homework.”

Some children and adults report a long history of having been told frequently while growing up that they were hopelessly lazy, stubborn, and stupid and destined for a life of failure. Usually, such verbal attacks result from intense and persistent frustration experienced by parents or others mystified by the child’s seeming refusal to do what is expected, despite a variety of repeated efforts by the adult to encourage appropriate behavior. Such frustration is often intensified as the adult witnesses the child showing strong ability to focus and work persistently on a few self-selected tasks while consistently acting incapable of devoting comparable attention and effort to tasks the adult views as important. This is the result of parents not understanding the “mystery of ADHD:” that ADHD symptoms are situationally variable and that there is much intra-individual variability in the symptoms of this disorder.

Suffering from additional emotional, cognitive, or behavioral problems that may be co-occurring with ADHD.

Individuals with ADHD have a greatly increased likelihood of suffering from one or more psychiatric disorders at some time in their lifetime than do most others. One study of children with ADHD found that 62% had at least one other psychiatric disorder, whereas only 19% of population-based control subjects had any such disorder by the same age (Yoshiasu et al. 2012). This is a threefold increased risk of a comorbid disorder for those with ADHD. More than one-third of the children with ADHD in that study had two or more comorbid disorders, whereas just 8% of the control subjects had more than one. A nationally representative study found that adults with ADHD were more than six times as likely as the comparison sample to have an additional psychiatric disorder (Kessler et al. 2005, 2006).

For many individuals, ADHD impairments are made worse by their struggles with excessive anxiety, persistent depression, compulsive behaviors, difficulties with mood regulation, learning disorders, or other psychiatric disorders that may be transient, recurrent, or persistently disruptive of their ability to perform the tasks of daily life.

One comorbid problem that warrants special mention is excessive use of alcohol and/or other drugs. A study based on pooled samples of more than 4,000 persons with ADHD and more than 6,000 control subjects without ADHD assessed at an average age of 18.9 years showed the magnitude of difference between these groups. Those with ADHD had 1.7 times the risk of a substance use disorder with alcohol, 2.05 with cocaine, 2.29 with marijuana, and 2.84 with nicotine. Overall, those with ADHD had more than two and a half times the risk of having a substance use disorder with one or more of these addictive substances by early adulthood (Lee et al. 2011).

For many persons with ADHD, the overuse of alcohol, marijuana, or other drugs begins with an effort to self-medicate. Often, they struggle daily with feelings of frustration, embarrassment, disappointment, or shame resulting from their ADHD impairments. Occasional use of these substances may, for a time, bring welcome, although very temporary, relief from these painful emotions. The problem is that occasional use can readily lead to more chronic use, which can rapidly lead to a persistent cycle of addiction from which it may be extremely difficult to recover. Addiction to these substances can result in worsening of ADHD impairments in multiple aspects of schooling, employment, social relationships, and other aspects of daily life.

Stresses resulting from environmental adversities.

Although the primary causes of ADHD are genetic, adverse environmental factors may have considerable negative impact on the life experience of children and adults with ADHD. Examples of environmental adversities include serious medical or psychiatric illness of a parent or other close family member, domestic violence, living in a dangerous neighborhood, separation or divorce of parents, layoff or loss of employment, multiple changes of residence, lack of or loss of health insurance, and serious disability or death of a parent or other close family member.

Such adversities may occur in isolation with just transient effects followed by full recovery. In other cases, adversities may be persistent and may trigger additional adversities. For example, if a parent who has been the primary wage earner for the family suffers a major injury or protracted disabling illness, the parent could lose his or her job and with it health insurance for himself or herself and the family; this could also result in eviction, forcing a move into a more dangerous neighborhood.

Although such adversities can create overwhelming difficulties for any family, their impact may be compounded in a family in which one or more family members have ADHD; the difficulties can worsen considerably if one or both parents have ADHD and are trying to cope with the added stress that results from raising children with ADHD. One study of more than 200 adult patients with ADHD found that those whose ADHD symptoms were more severe tended to have more major adversities than did those whose ADHD symptoms were less impairing (Garcia et al. 2012). One secondary effect of such difficulties is that some adolescents in families suffering significant adversities feel an obligation to remain at home longer than they might otherwise, sometimes sacrificing their own educational or employment opportunities to provide economic and/or emotional support to parents, siblings, or other family members.

Bodily changes of aging along with their ADHD symptoms.

Many discussions of ADHD refer to it as a developmental disorder, but generally, the focus of such discussions is limited to the first decade or two of life; they do not encompass the full range of development across the lifespan. Yet the few studies that have explored ADHD during adulthood, especially those that have looked at midlife and beyond, clearly indicate that for those individuals whose ADHD persists into middle adulthood and beyond, significant impairments tend to remain and sometimes worsen.

One population-based study of more than 2,000 men and women ages 47–54 years found that 6.2% reported significant symptoms of ADHD; no difference in ADHD symptoms was found between men and women in this sample (Das et al. 2012). Evaluation of those who reported significant ADHD impairments found that those individuals were less likely to be employed full-time, struggled more with physical health problems, and reported more problems in personal relationships and in their personal finances as well as lower quality of social life and well-being.

With or without ADHD, there are a number of physical changes associated with aging in both males and females. Imaging studies have demonstrated age-related decline in various elements of the brain that provide infrastructure for executive functioning, even for healthy adults without ADHD (Backmanet al 2005; Gazzaley et al 2005; Raz 2005). Nora Volkow and her colleagues (1996) found a 6.6% decrease per decade of life in availability of dopamine transporters in healthy volunteers. Age-related decline in brain dopamine activity even in healthy volunteers has also been documented in several other regions of brain important for executive functions.

White matter decreases in the brain are also associated with aging in the general population. One study found that the total length of white matter fibers decreases by 10% per decade of life in the general population, up to a total decline of about 45% by age 80 years, with about a 16% greater average decline in females (Marner et al. 2003). It should be noted, however, that these percentages of decline in the general population are based on averages that may mask considerable variability among various individuals.

Very little research has assessed ADHD in the geriatric population. Many health care practitioners tend to assume that any attentional difficulties experienced by elderly individuals are due simply to the slow degenerative processes of aging or, possibly, to the early stages of dementia. Adult patients sometimes fear that their ADHD predisposes them to onset of Alzheimer’s or some other variety of dementia. Currently, there is no evidence to support that assumption.

ADHD in the older population may be mistakenly diagnosed as mild neurocognitive disorder, a disorder that involves some cognitive decline that does not interfere with the capacity for independence in everyday activities. Mild neurocognitive disorder is sometimes, but certainly not always, a prelude to onset of dementia. Screening for ADHD in any elderly person who presents with symptoms of mild neurocognitive disorder may be helpful not only for increasing understanding of possible relationships between these two disorders but also for identifying adults whose cognitive impairments may be due to lifelong problems with ADHD rather than to geriatric deterioration (Ivanchak et al. 2012).

Changes associated with menopause are an aspect of aging that is associated with cognitive impairments similar to ADHD. Women with no childhood history of ADHD, many of them well-educated and high-functioning business and professional women, report onset of ADHD-like impairments of working memory, organizational skills, and ability to sustain focus that appear coincident with their decline of estrogen and cessation of their menses. This association makes sense in that estrogen is one of the primary modulators of the release of dopamine in the female brain. Insufficiency of dopamine in the brain networks that manage executive functions is one of the major problems associated with ADHD. Studies published by groups at Yale and the University of Pennsylvania have demonstrated that medications used for treatment of ADHD may help to alleviate these midlife-onset impairments of executive functions (Epperson et al. 2011, 2015; Shanmugan et al. 2016).

Lack of appropriate diagnosis and treatment.

Another factor that may contribute to increased impairment from ADHD is lack of appropriate diagnosis and treatment. Among children in the United States ages 4–17 years who have been diagnosed with ADHD, approximately 17.5% received no treatment for their ADHD. However, there is great geographical variability in the availability and use of treatment for this disorder. An analysis of treatment patterns in the United States found that the percentage of children with ADHD who received treatment ranged from a low of 2% in some states to a high of 10.4% in others (Visser et al. 2014).

One survey reported that 49.7% of adults in the United States diagnosed with ADHD had received at least some professional care for emotional problems, but only 10.9% of those had received treatment specifically for ADHD. For most, treatment was given for anxiety, depression, or some other psychiatric problem, without treatments likely to be directly helpful for alleviating ADHD impairments (Fayyad and Kessler 2015).

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How to Handle Your Child’s Autism Diagnosis

When your child is diagnosed on the autism spectrum, what should you do? How should you cope? Here are resources to help you become your child's strongest advocate.

According to the Centers for Disease Control (CDC), autism affects 1 in 88 children, and hundreds of families are receiving news of an autism diagnosis every day. Autism is a developmental disability that significantly affects three areas: communication (verbal and nonverbal), social interaction, and behavior. It is a spectrum disorder, meaning it affects “each person in different ways and can range from very mild to severe,” the CDC notes.

Many autism and medical groups advocate for early intervention and intensive therapy to help achieve maximum progress and recovery for a child with autism. They also advise gathering a team of doctors to assess the best treatment. But when you're sitting in an office hearing the word “autism,” the immediate days that follow can be overwhelming, and it can be difficult to figure out what comes next. What should parents do in those first few days and weeks after receiving the diagnosis? What treatment should they seek? How do they find good doctors? How should they cope and move forward? Here are practical and helpful ways parents can come to terms with the diagnosis and devise a plan of action.


Make Sure It's the Right Diagnosis

When parents hear a doctor's diagnosis of autism, it can be the worst news to receive. Pamela J. Compart, M.D., a developmental pediatrician with HeartLight Healing Arts in Columbia, MD, stresses getting a diagnosis from the right people: “There's no slam dunk to diagnosis. Some kids are diagnosed through the school system and not through a professional, but your child should see a developmental pediatrician or a neurologist with an interest in autism.” Dr. Compart advises that children gets a hearing test because neurological hearing loss can seem like autism.

Autism has no known cure — no surgery, medicine, or therapy. There is no typical path of treatment that works for all children with autism, but there is treatment, says Dr. Compart. Before any treatment can be discussed, parents have to get past absorbing the news. “Even if you thought your child has autism, it's different when you hear the word. In the doctor's office, you'll hear lots of things, but you may forget them. You have permission to call your doctor back.”


Take Time to Grieve and Absorb the News

Receiving news about any difficult diagnosis is difficult. A thousand questions race through the mind: What does it mean to have a child with autism? What will the future hold? Can the child make strides and live a normal life? What should a parent do to help their child? First, parents must deal with feelings of grief about the diagnosis. “Your life has changed in that moment and nothing [bad] will happen to your child if you wait a week or however long it takes to get your bearings,” says Dr. Compart.

“Some parents do better by diving into research and looking for ways to help their child, but I've found that most need to grieve for what they thought was their child's future. It's not that they can't help their child have that future, but the journey will be different.” Dr. Compart suggests that parents talk to each other and figure out what they will tell the family, but be prepared for unexpected reactions. “You can't shift from grief to hope immediately. You have to go to the worst-case scenario and come back up.” Although autism awareness has risen extensively in the past several years, there is still uncertainty surrounding it.


Start Research and Get in Touch with Specialists

The one thing parents must do quickly is see autism specialists and pursue further testing and evaluations, but getting the help of educational services usually means being put on waiting lists. Every state has early interventional services (often for children ages 3 and under) as well as special education (often referred to as exceptional education). Procuring these services takes time, as does getting appointments. Lisa Goring, Vice President of Family Services for Autism Speaks, says getting on waiting lists is something families should pursue even while they go through the grieving process.

“Those first days, even if you take just 20 minutes to get the process started, it helps. Some families say they never knew it would take so long to get into certain programs or see certain doctors.” Goring suggests looking up local or state autism organizations in the area and contacting them to find out which doctors are recommended and which services should be pursued first. “Sometimes taking that first bit of action to get your child on the right waiting lists is the what parents need to do to help them process,” Goring says.

Become Familiar with Your Child's Rights

The terminology and information about the rights of a child with autism can be overwhelming. You have to learn a whole new language of laws and terms such as IEP (individualized education program), LRE (least restrictive environment), EI (early intervention), IDEA (Individuals with Disabilities Education Act), and FAPE (Free Appropriate Public Education). The sooner parents and caregivers familiarize themselves with these terms and the rights, the sooner they can become their child's toughest and best advocate.

The family services team of Autism Speaks, under the Goring's guidance, recently updated its “100 Days” kit, which provides guidelines on how parents can get through their first few months after receiving the diagnosis. A section about legal rights provides a good starting point for understanding special education services. Talk to other parents of children with autism to get more information. “Parents' support groups sharing experience and knowledge with each other is one of the most powerful things out there,” explains Asma Sadiq, M.D., Director of the Division of Child Development at Beth Israel Deaconess Medical Center in New York. Dr. Sadiq offers information to her patients about a parents' support group to join or consult for key hands-on practical information.


Helping Your Child With Autism

Gather a Team of Doctors Together

Treating autism is a team approach, with parents as the team leaders. A child with autism may need to see several doctors and therapists who will need to stay updated on any special problems. Depending on a child's problems this team might include a pediatrician who specializes in developmental behavior, a neurologist, a pediatric gastroenterologist, a doctor with expertise in biomedical interventions and autism treatment, a speech therapist, an occupational therapist, and a physical therapist, to name a few. Dr. Compart strongly advocates that parents secure medical doctors first as one of the first steps.

“The child could have traditional medical problems,” she says. “Does your child need his hearing or vision tested? Does he need an EEG to look for seizures? Thyroid or genetic testing? You need someone who will think about your child from a traditional medical standpoint. Get that appointment; get on that waiting list. If your life is flexible enough for cancellations, get on that cancellation list.” Simultaneously, look into finding educational experts, therapists and a biomedical specialist. Special-education experts help parents navigate the complexities of getting appropriate state or county-funded educational services for a child with autism. Biomedical specialists can offer treatments that address autism from a biological, chemical, and medical standpoint by exploring diets, vitamins, and supplements to help regulate the child's biochemistry, but these treatments often require more money and financial resources.


Consider Adding a Biomedical Expert

Food sensitivities, vitamin and mineral deficiencies, intestinal yeast overgrowth, gut and brain inflammation, allergies, gastrointestinal problems, and heavy metals are among the litany of medical issues that can be associated with autism. Alternative treatments may include gluten and casein-free diets, vitamin and mineral supplements, vitamin B12 shots, anti-inflammatory treatments, yeast treatments and gut support, detoxification support, and chelation therapy treatments. Brain inflammation, yeast, detoxification, allergy sensitivities, and gastrointestinal problems are among the many medical issues and alternative treatments associated with autism.

According to the Autism Research Institute (ARI), the amount of research on biomedical therapies and the number of parents who use them have risen exponentially in the past several years. After traditional diagnosis and traditional therapies have been tackled, Dr. Compart says the biomedical aspect should be addressed. “I tell parents we're going to try to answer two questions: 'Are your child's body and brain getting what they need to function at their best? Is there something getting into your child's body and brain that is interfering?' It's a simple premise, but answering those questions can get incredibly complicated.”

ARI and Talk About Curing Autism (TACA) both offer lists of doctors, by state, who specialize in biomedical therapies, but finding these doctors can mean painstaking medical testing and documentations of what does and doesn't work. Biomedical therapies aren't cheap, either; most physicians who specialize in them do not accept insurance, and the supplements and special foods are costly. A family can sink hundreds of thousands of dollars into such treatment over the years. Dr. Compart says, “You need to do this with guidance. You have to consider your resources. This can help, sometimes immensely, and sometimes in smaller ways.” Dr. Compart feels biomedical treatments are synergistic with educational and therapy services. Helping a child's brain work better internally allows him to benefit optimally from these external supports.


Learn the Tools of Therapy

As recently as 10 years ago, autism and the Applied Behavior Analysis (ABA) were synonymous. ABA is one of the oldest and best-researched types of therapies for treating children with autism; it works with the principles of rewarding (or positively reinforcing) a child when he learns something or exhibits good behavior. It has worked wonders for some children and has the most research to support its effectiveness in reducing the symptoms of autism. It is often the first therapy parents pursue for their children, but is not the only or the right therapy for all.

Now there are several other effective forms of therapies for children with autism: the Floortime method, the rapid prompting method, the Picture Exchange Communication System, verbal behavior analysis, sensory diets, and speech, occupational, and physical therapies. Goring says it's important to remember that a combination of therapies may be needed and that one therapy can work for a while before it plateaus. “There's no road map to what will work best for your child,” she explains. “Go online and research first. Talk to other parents to see what you may want to try with your child. Document the progress. I started making a video diary of my son when he was diagnosed 14 years ago. It was a visual way to see what was working, when things started working, and when we needed to change things up.”


Organization Is Key

Start Your Financial Planning Early

It's a costly road ahead, and reviewing finances is an important and sobering thing to do. You'll need to learn what your insurance will or will not cover. State laws vary on insurance autism coverage (25 states have enacted autism insurance reform laws). In 2006, Michael Ganz, the Adjunct Assistant Professor of Society, Human Development, and Health at Harvard School of Public Health, led a study on the lifetime costs of caring for a person with autism, which appeared in the book Understanding Autism: From Basic Neuroscience to Treatment, edited by Steve Moldin and John Rubenstein. He found that it can cost about $3.2 million to care for a person with autism over her lifetime. In a Harvard School of Public Health press release, Ganz stated that the figure likely underestimates the true costs because alternative therapies can be paid out-of-pocket by families.

Often one parent takes on the brunt of care while the other one works, and one salary may not be enough to cover the expenses. Dr. Sadiq says, “I always tell my patients to secure an educational and medical model and get done the evaluations and tests that are covered by their insurance first. Nutrition is a simple and potent tool to start with. Some of the complex testing done using the biomedical model can be quite expensive and not all covered by insurance. This must be planned and done on a gradient. Parents must also avail themselves of the system and get what they're entitled to through the Board of Education.” Most parents decide early on that they won't compromise on treatment because of costs, Goring says. As the years go by, the expenses pile up and the financial burden can be a huge strain. “In those early days, if you don't already have a handle on your income — what's going in, what's going out — you should. Start your financial planning early.”


Get Organized and Keep Good Records

As parents of children with autism embark on treatment and therapies for their child, one of the most important things they can do is to keep accurate and organized records. “Over the years, as we got bogged down with progress and regression, it was often hard to see and remember what my son had learned, what he had accomplished, how far he had come, and what he still needed to learn,” Goring remembers. “So we'd go back and watch the videos we made of him from certain points in his life to remind ourselves of how much he had accomplished versus how he was now.” With evaluations from doctors and schools, educational records, detailed data from behavioral, medical, and biomedical therapies, and doctor's notes and recommendations, the vast amount of records and paperwork can bury parents.

Some parents organize their child's records within binders, year by year. Others create files grouped by subject: medical, educational, therapy, etc. Many autism organizations now advise scanning all documents and saving them in online file-sharing sites to reduce paper trails. “Figuring out a good organizational method early on is key,” Goring says. “You need to hold on to pretty much everything because you need to be able to look back on what you have done, how you have paid for treatment, and what has and hasn't worked.”


Always Remember to Ask for Help

Helping your child manage autism is a lifelong journey, and your child's best friend, advocate, and supporter from day one is you. “The analogy many parents of children with autism hear is that this is a marathon, not a sprint. And you will exhaust yourself. You need to pace yourself because this is for the rest of your life,” says Goring. As important as it is to seek the best interventions and therapies when your child is still at a young age, it is also important to get help when you need it and look after your own health and well-being and that of other family members. “No one can run on empty and no one can do it alone. You are on the road to becoming an expert in autism and all its many facets. You are absorbing stress levels that can be detrimental to a marriage,” Goring says.

Most parents of children with autism emphasize the need to decompress, take breaks, and ask for help. Dr. Sadiq recommends to many of her patients' families that they do whatever they can to keep the family healthy. “Join a support group, talk it out, get outside and take a walk, ask family members to give you some respite. Or look into what your state offers by way of respite services,” she says. “Often, the parents I see leave my office thinking they have to go at this alone, and that is not the case. Everyone needs to ask for help. We all must put an emphasis on seeking happiness.”


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The Company expressly disclaims any and all liability (including liability for negligence) in respect of the use of the information provided. The Company recommends you seek independent professional advice prior to making any decision involving matters outlined in these publications.



How Parents Of Autism Can Deal With Stress And Online School During Coronavirus

As the working mother of a child with autism, I know all too well the incredible strain the coronavirus pandemic has caused for my autistic son. Like most children with autism, he responds best to routine, structure, and familiarity. Once schools began providing services online, and we were asked to quarantine, the difficulty of adapting to change has been noteworthy. Universally, those with autism may be experiencing emotional distress, frequent meltdowns, and social isolation during the coronavirus. Even though the debate continues as to whether or not children should return to school, it’s clear that educating our children may have to be done online for longer than we hoped.

Joyce Halpert, a school psychologist who works as a counselor for children with disabilities in two NYC public school special education programs, noted that, “In a broad sense, we need to recognize the inherent challenge in acclimating to a new learning structure, particularly for children with disabilities. Whenever we are back in buildings, students will need to readjust to the expectations of a school-based learning environment, and that will take time, too. There is a commitment to making remote learning as enriching as possible to mediate that concern.”

The prevalence of autism spectrum disorder has increased in the last 20 years. In 2004, the incidence of autism was 1 in 166. At present, the Centers for Disease Control (CDC) estimates that now, 1 in 54 children are on the autism spectrum.

There was a study done by the Journal of Autism and Developmental Disorders in 2009 that showed mothers of those with autism experience chronic stress comparable to combat soldiers and struggle with frequent fatigue and work interruptions. You can only imagine what that study would show now.

In supporting our children during this unprecedented time, the stress of work interruptions and serving as a supplementary online school initiative adds a whole new layer. How do working parents with special needs children keep their jobs, their sanity, and still somehow act as a “fill-in” paraprofessional to help them in achieving their educational goals?


Can Working Parents Help Their Autistic Child Learn?

“For many children with autism, the goal is to increase joint attention and develop shared goals,” Halpert advises. “We hope to have kids attend to us and engage with our human qualities to hone skills of community awareness, theory of mind, and social perspective. To do so, we do our best to make ourselves engaging, animated, and interesting for our students. This is harder to do through a screen, because we are competing with other media personalities our kids love so much! There are undoubtedly profound limits to our play and socialization when we can’t physically be together.”

The lack of someone physically keeping an autistic child’s attention to learn best is where the strain can land on the parent. In the past, a child with autism would typically work one-on-one with their speech therapist, guidance counselor, or occupational therapist. Now, with remote learning, parents need to be on hand and more involved than ever.

“Before the pandemic, the goal was to work directly with the child and teach the parent how to carry things over at home,” Dr. Elise Vetere shares. “Now, the parent IS the primary interventionist with their child.”

Dr. Elise Vetere is a Diplomate in School Neuropsychology with Extensive Experience Evaluating, Diagnosing, and Providing Behavioral Interventions for Over 25 Years. She is also the Director and Founder at Early Start, which provides evaluation and services for children with developmental delays between the ages of 0 to 3-years-old. She said that at the beginning of the pandemic, both parents and the therapists at Early Start had to discern the best approach.

“My dissertation was about various special needs categories and the perceived stress of the primary caregiver. The highest group for anxiety was for children on the autistic disorder because of the behavior management issues. It cuts across to manage my child, teach my child, etc. and that’s why it was so hard for parents,” Dr. Vetere adds. “Parents have more demands and stress right now, but those who are continuing to opt for teletherapy are seeing they have fewer behavioral management issues. They can work more cooperatively with the therapist.”

She said that while it took a learning curve to process the best way to train parents and get down a routine that would be effective, expectations were better managed. That alleviated some of the pressure on working parents.

“In some homes, sick family members, work demands, or challenging childcare arrangements make addressing the health or financial stress of a family of paramount importance,” Halpert weighs in. “When circumstances have allowed parents to be actively involved in their children’s remote learning, we have heard about promising academic growth. Everyone has been impacted differently by the pandemic so that we can expect similarly ranging outcomes of remote learning.”

How Can Parents Approach Online School?

One of the concerns many parents are dealing with is how do you go from a corporate in-office job to essentially home-schooling your child? For my son, I sense that he is confused while I’m asking to do something school-related while he’s at home. It’s as if he’s thinking, “This is my house. We don’t do that here.” I asked ways parents like myself could try to introduce and reinforce this new approach to how they are being taught.

“We can often get children in the rhythm of completing schoolwork they dread most by putting it in our schedules, sticking with it at all costs, and following it with rewarding activities. You may want to skip a writing activity that your child hates just this one time because they are screaming and flailing, and everyone is exhausted! But that may make it even harder to return to, from a functional behavior perspective. It’s important to reflect on the behavior we’re reinforcing and to think long-term when it is incredibly compelling to disregard those goals in moments of distress.”

“Your frontal lobe understands cues and or the context. It’s the part of the brain that controls cognitive skills such as emotional expression, problem-solving, language, judgment, etc. In short, a child with autism only understands what they see. You can help them by creating a separate space dedicated to online school. Even if it’s a corner of their room – you are designating a place they can go to for school. You can have a timer or clock to assist in managing the schedule and create a routine either on their iPad or a simple picture schedule using drawings.”

How Involved Can Parents Realistically Be?

There have been countless articles on how parents can balance their careers and their children. In many of those cases, it’s around neurotypical children. With those who have children on the autism spectrum, it’s that much more difficult. You need to make an extra effort to engage your child, take a more active role in remote learning, manage the behaviors they are exhibiting due to the disruption to their routine, and more. Can we do it all? What’s more, should we even try?

“First of all, you want to love and enjoy your kids.” Dr. Vetere recommends. “Just live your life as a learning opportunity. If you know what you want to teach, it doesn’t have to be always a separate sit-down moment. Try to generalize it. For example, if you want them to learn to count, and you are putting blueberries into a bowl for a snack, count the blueberries together. I tell parents all of the time that more is not always better and can become countertherapeutic. If you’re constantly trying to work with your child, you’ll get stressed, and they get exhausted.”

Dr. Vetere also suggests continuing a “hybrid” role as much as possible. While the current circumstances we’re all in wasn’t intentional, it does support that the more parents are involved, even if it’s merely during the telehealth sessions, it can make a difference. There was a report on the Use of Telehealth in Early Intervention in Colorado: Strengths and Challenges with Telehealth as a Service Delivery Method. International journal of telerehabilitation11 (1), 33 that supports this. It showed that telehealth and family coaching strategies proved to increase family engagement and empowerment.

Halpert suggests that to help create realistic expectations, you need to create a set plan and stick to it as much as possible. “As far as best practices for home, we always emphasize the importance of schedule and routine. Routines are as important for adults as they are for our children! That can be especially helpful now, when ritualized experiences can be the only predictable aspects of our days. Maintaining set times for schoolwork, bedtime, meals, and play can be very soothing.”

Advice and Resources for Parents

As we try to look ahead, any extra tool, option or avenue to pursue can aid in keeping us sane. “Everyone is thrown off and adjusting. I think communication and social outreach is vital – to seek out support or to offer it,” Halpert proposes. “School staff understand that parents are doing their best, and I’ve seen teachers and service providers adapt to the needs of families in extraordinary ways. Lessons can be thoughtfully scheduled or recorded, homework can be modified, and virtual resources can be utilized to help parents feel less overwhelmed. There is a growing pool of great resources available for our children. Organizations like Autism Speaks have compiled lists of virtual activities to keep children engaged and occupied. Museums, zoos, and community spaces worldwide have developed virtual tours to help kids access exciting new content.”

Dr. Vetere offers these words of comfort, “I can only say this that parents usually take on their children’s failures and successes. Please know that if they aren’t flourishing as well as they once were, it’s not a result of what you could or couldn’t do. Maybe there is a regression, but they are safe, and if they learned specific skills, once, they will learn it again. In the end, they will adjust to this new normal and just like they adjusted to the old normal.”


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The Company expressly disclaims any and all liability (including liability for negligence) in respect of the use of the information provided. The Company recommends you seek independent professional advice prior to making any decision involving matters outlined in these publications.



Juggling Homeschooling and Working from Home

Like many parents across the United States, my husband and I are navigating the new normal of homeschooling our children while also working from home. Our oldest son is in preschool, and as any parent of very young children call tell you, some days can feel like the wild west over here!


As a result of COVID-19, we received word last week that my son’s preschool would stay closed this fall. My husband and I both run businesses from our home and have limited childcare help. Over the past few months of juggling this together we have figured out some tips and approaches about working from home and homeschooling that have helped us be productive, and also gave our oldest the dedicated homeschooling time he needs.

Have a Schedule

The only way we are able to make homeschooling and working full time work is by having a schedule. This allows us to utilize time-blocking, which is what I’ve found is the best way to make sure we have time to do both school AND our jobs.

In our home, our “schedule” is two different things: a daily schedule for the boys, and a weekly schedule of every meeting or event that we need to be aware of.

Each Sunday night after the boys have gone to bed, my husband and I map out our week. We put everything on a Google calendar with links to both of our phones, as well as a calendar with large fonts that we can easily see. Every single appointment or important deadline goes on this, from doctor appointments, work meetings, play dates, and more.


Having an idea of our weekly schedule also allows my husband and I to map out our work time and how we will supervise the boys. If I have a tight deadline on Wednesday, he might jump in and manage the kids all day on Tuesday. Very often we divide our workdays by before lunch and after lunch: he watches the kids one day from 8:30am – 12:30pm, and then I’m “on duty” from 12:30pm – 5pm, and the next day we switch.

When we started homeschooling, we set up a schedule for the boys that we try very hard not to deviate from, and which allows us to make this time-blocking work. Here’s an example day for reference:

7 am: Wake up the boys, have breakfast, get ready for the day

9 am: Put the baby down for a nap; our oldest has his first chunk of school time 

11 am: Baby wakes up, and it’s time to play outside until lunch and nap time

1 pm: Both my husband and I work while the boys nap

3:30 pm: Both of the boys wake up and we have more school time

Be Strategic with Your Worktime

My biggest piece of advice when it comes to working from home while also homeschooling your children is to accept that you will have to work in increments. Unless you have another adult who is able to homeschool your children full time while you work, you won’t be able to work a normal eight-hour workday.

Realize that you might need to work untraditional hours. Sometimes I get up early before the kids if I have to accomplish something really important that day. Other times, I work after the kids have gone to sleep.

Map Out Schoolwork

Mapping out schoolwork becomes even more important with older kids. If your child has to sign into their digital learning platform at a certain time for each class, make sure you write this down for both you and them.


When assignments and projects are given, build this into their schoolwork schedule in advance as well. Make a list of everything that needs to be accomplished or is due at the beginning of each week. For example, if your daughter has a book report that is due on Thursday, carve out time on Wednesday to touch base. If she has a test on Friday, be sure you have dedicated time for preparation throughout the week.

Be sure to take this schoolwork schedule and compare it with your work deadlines and meetings! Most importantly, reevaluate this plan as the week goes on. New assignments will pop up and need attention.

Ask for Help

Also, the corona virus and working from home and homeschooling your kids is incredibly hard. If you don’t have help at home, find someone you trust who can provide it from time to time. Whether it’s your own parents, a neighbor, or a trusted friend. And don’t forget to schedule some quiet time, too! Good luck!


Credit to:

Siobhan Alvarez

Executive Director of the Atlanta Autism Consortium , Atlanta , Georgia



The Company expressly disclaims any and all liability (including liability for negligence) in respect of the use of the information provided. The Company recommends you seek independent professional advice prior to making any decision involving matters outlined in these publications.



Getting back to school at home – tips to support your family

We work collaboratively across industry, government and with schools to reach UK families with tools, tips and resources to help children benefit from connected technology smartly and safely.

Since back to school (at home) has started again after the holidays, we have some tips and tricks to help get your kids back into learning mode.


  • Try to follow what would be a regular school day. For example, get them dressed, have breakfast before they start their day
  • If you haven’t already, create a timetable which includes the subjects of the day, along with regular breaks – involve your child with this process (see below for recommended learning from home resources)
  • Have a designated workplace (If you have the space) – set up a space specifically designed for schoolwork, this should be a clear cut off space – away from distractions
  • If you have more than one child and/or at different age groups, why not try combining their timetables, for example: exercising together
  • Children with SEND may have different needs and wants – The Department of Education have some great resources


Have realistic expectations


  • Children aren’t expected to learn as they would do in school, so don’t be hard on yourself or them either as you’re not expected to become teachers overnight. Just simply providing your kids with structure can help
  • Take some time for yourself – be kind to yourself and look after your wellbeing. Schedule some time for yourself – whether this be for relaxation or receiving advice on mental health and wellbeing (see resources below)
  • Relax screen time rules – accept children will be spending more time watching TV on their devices – it’s ok but ensure to set some screen time limits. See our balancing screen time diet tips for more information
  • Speak with your children’s teachers – Teachers are all online and available if you need them – you are not in this alone. Contact them if you have an issue with something
  • Talk to other parents for support – If you are a part of a parent Facebook or WhatsApp group reach out to them for home-schooling hacks


Stay active and healthy


  • As part of their timetable, ensure that you include an hour or two of exercise. Check out our ‘Get active with tech’ article for some ideas if you’re stuck
  • If you have a garden, use it regularly, if you don’t you can go out a least once a day (following the government’s advice) and if you’re unable to go outside try a YouTube exercise class or a game all the family can get involved with. Also, Sport England have some great indoor activities


Socialise safely with tech


Stay in touch with family and friends using apps like Skype, FaceTime, Zoom and social media platforms or set up virtual playdates with your children. Ensure you check your privacy settings are set up before use


Have regular conversations and check-ins


  • Have regular conversations at the end of their ‘school day’ to ask them how they feel with the current situation and if they have any stresses or worries. It is best to be prepared for these types of concerns. Dr Linda shares some great advice on supporting children during the lockdown
  • If you have concerns about your child’s mental wellbeing, there are many resources to help: Check out our article following PHE’s guidance for more information. Also, see the BBC OWN It app which has updated it’s keyboard function to respond to the COVID-19 pandemic
  • With children spending more time on their devices there is a lot of misinformation and fake news they may come across. Be sure they know what is fake and what is fact. Check out our expert opinion’s Fake News blog for guidance



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The Company expressly disclaims any and all liability (including liability for negligence) in respect of the use of the information provided. The Company recommends you seek independent professional advice prior to making any decision involving matters outlined in these publications.



Online Therapy: Is it Right for You?

Whether you’re seeking psychotherapy for stress, relationship difficulties, bereavement, depression, anxiety, or another mental health problem, online counseling or teletherapy may be an effective solution. Here’s all you need to know.

What is online therapy?

Online therapy is the provision of professional mental health counseling via the internet, usually through live video chat, messaging app, email, or over the phone. Also known as teletherapy, telemental health, e-therapy, or online counseling, the practice has grown rapidly in popularity since the start of the COVID-19 pandemic, allowing a patient to connect with a qualified therapist from the safety—and comfort—of their own home.

Traditional, in-person therapy usually takes place in a therapist’s office, and has long been used as an effective treatment for many different mental and emotional health problems. Talking to a professional can help you overcome obstacles in your life, gain awareness of the root cause of your problems, manage symptoms, and heal. As an example, studies have shown that cognitive behavioral therapy (CBT) can be as effective as antidepressants in treating moderate to severe depression—but without the risk of harmful or unpleasant side effects.

You don’t have to be dealing with a diagnosed mental health problem such as depression or anxiety to benefit from therapy, though. If you’re going through a difficult time in your life, such as a bereavement, divorce, or unemployment, therapy can help. Even if you’re facing everyday concerns like overwhelming stress, low self-esteem, or trouble sleeping, the right therapist can provide expert support and guidance and help you make positive changes.

Is online therapy effective?

While online therapy is a much newer form of therapy, current evidence suggests that for many people it can be just as effective as in-person therapy. Talking from the security of your own home may even make it easier for you to open up about your problems. Online therapy also enables you to communicate with a qualified specialist from anywhere in the world, while avoiding the expense, travel time, and inconvenience of having to meet in-person.

Of course, there can be some significant drawbacks to online therapy as well. While connecting via text or messaging app, for example, may be a more comfortable way of communicating for some, especially younger people who grew up using the technology, the lack of face-to-face interaction robs the therapist of gauging your all-important body language and tone of voice. It can also make it much harder to build trust and a supportive rapport between therapist and patient which is crucial to the success of therapy. That can really only be achieved in-person or via a live video link.

Ultimately, how well online therapy works often depends on the same factors that determine the success of any type of therapy: the level of connection you make with your therapist, how much you’re able to open up, and the work you’re willing to put into the process. In addition to attending your sessions, you need to apply what you’re learning to real life situations and make the healthy lifestyle changes that can support your mood and emotional health. While no therapist—online or in-person—can do the hard work of healing and growth for you, a good therapist can use the available technology to help you gain new insights and change your life for the better.

Online therapy vs. in-person therapy

Online therapy can take different forms—and the benefits and drawbacks compared to in-person therapy can vary with each. Some therapists offer online therapy through their own private practices, while others use third-party websites or directories to connect with patients. Some of these services limit the contact between therapist and patient to messaging or live texting, while others also include weekly phone calls or live video chats. It’s the latter that provides the closest experience to traditional, in-person therapy—and is therefore most likely to offer the same rewards.

While being able to call, email, or message your therapist between live sessions can be extremely helpful, experts agree that it’s most effective when used in addition to face-to-face interaction—either in-person or via video—rather than as a replacement for it.

Why therapy requires face-to-face interaction

Body language and other nonverbal cues play an important role in how we communicate as human beings. Your facial expressions, mannerisms, posture, and tone of voice can communicate far more than your words alone. In a therapy setting, the subtleties of nonverbal communication can be crucial in helping the therapist pick up on any inconsistencies between your verbal and nonverbal responses. It can also help them to recognize the things that you may be unwilling or unable to put into words, and understand the true meaning behind what you’re saying.

[Read: Nonverbal Communication and Body Language]

Similarly, interacting face-to-face with a therapist—even on a video screen—can help forge a connection between you that’s so important to the success of therapy. It’s much easier to build a sense of trust with someone when you can see the emotions and empathy they’re communicating nonverbally—rather than just reading their written messages or listening to a faceless voice.

In addition to the importance of face-to-face interaction, there are other aspects to consider when comparing online to in-person therapy.

Benefits of online therapy include:

Convenience. Online therapy means you can access help from anywhere you have a fast Internet connection. You don’t need to spend time and money traveling to appointments, fighting traffic or dealing with public transport, parking, sitting in a waiting room, paying for child care, or taking time off from work. Many of the obstacles that prevent people from seeking in-person therapy are eliminated by the convenience of online therapy.

Comfort and safety. Seeing an online therapist from the comfort and security of your own home can often help you to open up, be more vulnerable, and better cope with difficult emotions that may arise during a therapy session. If you have mobility issues, chronic illness, or a condition that can make it difficult to leave your home—such as agoraphobia or social anxiety disorder, for example—online therapy can be the ideal solution.

Selection. Online, a qualified therapist is accessible to you even if you live in a remote area. No matter where you live, the greater selection of specialists online also means that you’re more likely to find a therapist with experience dealing with your specific problem. (While in theory you have access to therapists from all over the world, in some areas you are limited to providers licensed in the state or country where you live.) With increased choice comes another important benefit of online therapy: it’s often easier to keep changing therapists until you find the right match for you.

Ease of communication. When you meet with a therapist for just an hour a week, it’s sometimes difficult to recall everything you’ve been through in the preceding week. Being able to email or message your therapist between live sessions enables you to articulate your emotions and problems in real time as they arise. The messaging aspect of some online therapy services can also be useful in keeping track of your progress and monitoring any setbacks.

Privacy. Many people still feel a stigma about getting treatment for mental health issues. It’s easier to receive treatment online anonymously than it is visiting a therapist in-person. Connecting online, there’s never any fear of bumping into someone you know in the therapist’s parking lot or waiting room, for example.

Drawbacks of online therapy include:

Technical issues. With online therapy, you’re reliant on the speed of your internet connection and reliability of your electronic devices. If you’re unable to stream movies online, it’s unlikely you’ll be able to sustain an uninterrupted video chat with a therapist. Of course, even the best connections and equipment can experience problems at times, disrupting or curtailing your therapy session.

Loss of emotional connection. As effective as video conferencing can be, when you’re not physically sharing the same space as the therapist, it may be harder to connect emotionally. Even when talking via video, some body language signals can be lost. The therapist may not see your tapping leg under the table, for example, or you may find it harder to pick up on the therapist’s empathy and caring.

Unqualified providers. As with seeking any service online, there’s always the risk of falling prey to an unqualified or disreputable provider. It’s important to always check a therapist’s credentials or use a reputable third-party service that screens all the counselors on their list.

Online therapy isn’t right for everyone

There are still some situations where in-person therapy is preferable to online therapy. If you’re currently suffering from a severe mental illness such as schizophrenia, for example, or you’re feeling suicidal, facing another crisis situation, or have an intellectual disability, a therapist will be in a much better position to help you working in-person, rather than remotely.

How to get the most from online therapy

The key to any type of therapy—online or in-person—is to find the right therapist for you. Qualifications, experience, and philosophy can be important, but it’s the relationship you develop with the therapist that will often define the success of your therapy.

Finding the right online therapist can take some time and effort, so don’t be afraid to ask questions, read reviews, and take advantage of any free introductory sessions. An online therapist will become your partner in healing, recovery, and growth so it’s important to choose someone who makes you feel understood, supported, and cared about. You need to trust this person enough to talk comfortably about intimate and often difficult subjects and to be honest about what you’re thinking and feeling.

Other tips for getting the most out of online therapy

Compare online counselors, platforms, and the services they offer. But give preference to therapists who provide weekly live video sessions where you can connect face-to-face in real time. Text and messaging services may be useful if you already see an in-person therapist and are just looking for additional support, but they’re unlikely to be an effective way to build the necessary bond with a therapist.

[Read: How to Find a Therapist Who Can Help You Heal]

Do your research first—but be open to change. It can sometimes feel overwhelming to scan a long list of available online providers. Understanding a little about the different types of therapy and therapists can make it easier to make a selection. But once you’ve chosen a therapist, be open to making a change if it doesn’t feel right. Trust your instincts. An advantage of selecting an online counselor from a third-party service is that it’s easier to keep changing therapists until you find one that’s a good fit for you.

Understand what you want to achieve from therapy. The clearer you are about your goals for starting online therapy, the easier it will be to measure your progress and ensure you’re getting the most out of the process. You may be seeking help to address a specific mental health problem, for example, or cope with a particular aspect of your life that’s not working. Whatever your reasons, make sure you communicate them to your therapist and ensure they’re being addressed during your time together.

Be open and honest with your therapist. It’s common for disturbing or painful emotions to arise during therapy. Open up and share your feelings with your therapist. If something is too difficult to talk about, let them know. The more open and honest you are, the better your therapist will be able to help you.

Be prepared to put in the work. Online therapy requires more than just logging on to talk once a week. A counselor may give you homework to do between sessions or ask you to try out techniques in real-world situations. To get the most from the experience, be prepared to put in the time and effort. And if you find yourself frequently skipping therapy sessions, ask yourself why—and discuss it with your therapist.

Limit distractions at home. Talking to a professional from the comfort of your own home is extremely convenient—but you’re not going to get as much from therapy if your sessions are disrupted by kids, other family members, noisy neighbors, phone calls, or other interruptions. Choose a time for therapy when your home is at its quietest, ask other family members not to disturb you, turn off your phone, and mute any other apps.

Ensure you have a fast and reliable internet connection. Your therapy experience will suffer if your sessions are frequently interrupted by connection or computer problems. Address any technical issues you experience, whether that’s by upgrading your internet speed or updating the software or app you’re using.

Finding and paying for online therapy and counseling

While online therapy is often cheaper than in-person therapy, the cost can vary considerably according to where you live in the world, the benefits you have access to, and the type of service being offered.

In the United States, for example:

  • Some health insurance companies now cover online therapy sessions, although you may need to get a referral from your primary care doctor.
  • Depending on your income, you may be able to obtain low-cost online therapy via a community clinic or Federally Qualified Health Center (FQHC).
  • Colleges and universities usually offer counseling services—online or in-person—via the psychology department or a campus social worker.
  • Some larger companies provide employee assistance programs that can include free online therapy trials or other types of support.

Whatever country you live in, you also have the option of paying for online therapy privately. Many third-party services offer monthly or yearly subscriptions to reduce the cost, or packages that allow you to purchase multiple sessions at a discounted rate. Some online therapy services even offer free trials so you can sample interacting with a therapist to help gauge if it’s right for you. Others deliver free or reduced rates by connecting you with trained volunteers rather than professional therapists.

Any of these methods can help lower the cost of online therapy and make it as affordable as it is convenient.



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The Company expressly disclaims any and all liability (including liability for negligence) in respect of the use of the information provided. The Company recommends you seek independent professional advice prior to making any decision involving matters outlined in these publications.



How ADHD Ignites Rejection Sensitive Dysphoria

For people with ADHD or ADD, Rejection Sensitive Dysphoria can mean extreme emotional sensitivity and emotional pain — and it may imitate mood disorders with suicidal ideation and manifest as instantaneous rage at the person responsible for causing the pain. Learn more about potential treatments here.

What is Rejection Sensitive Dysphoria?

Rejection sensitive dysphoria (RSD) is extreme emotional sensitivity and pain triggered by the perception that a person has been rejected or criticized by important people in their life. It may also be triggered by a sense of falling short—failing to meet their own high standards or others’ expectations.

Dysphoria is Greek for “difficult to bear.” It’s not that people with attention deficit disorder (ADHD or ADD) are wimps, or weak; it’s that the emotional response hurts them much more than it does people without the condition. No one likes to be rejected, criticized or fail. For people with RSD, these universal life experiences are much more severe than for neurotypical individuals. They are unbearable, restricting, and highly impairing.

When this emotional response is internalized (and it often is for people with RSD), it can imitate a full, major mood disorder complete with suicidal ideation. The sudden change from feeling perfectly fine to feeling intensely sad that results from RSD is often misdiagnosed as rapid cycling mood disorder.

It can take a long time for physicians to recognize that these symptoms are caused by the sudden emotional changes associated with ADHD and rejection sensitivity, while all other aspects of relating to others seem typical. RSD is, in fact, a common ADHD symptom, particularly in adults.

When this emotional response is externalized, it looks like an impressive, instantaneous rage at the person or situation responsible for causing the pain.

[Self-Test: Could You Have Rejection Sensitive Dysphoria?]

RSD can make adults with ADHD anticipate rejection — even when it is anything but certain. This can make them vigilant about avoiding it, which can be misdiagnosed as social phobia. Social phobia is an intense anticipatory fear that you will embarrass or humiliate yourself in public, or that you will be scrutinized harshly by the outside world.

Rejection sensitivity is hard to tease apart. Often, people can’t find the words to describe its pain. They say it’s intense, awful, terrible, overwhelming. It is always triggered by the perceived or real loss of approval, love, or respect.

People with ADHD cope with this huge emotional elephant in two main ways, which are not mutually exclusive.

  1. They become people pleasers.They scan every person they meet to figure out what that person admires and praises. Then they present that false self to others. Often this becomes such a dominating goal that they forget what they actually wanted from their own lives. They are too busy making sure other people aren’t displeased with them.

[ADHD, Women, and the Danger of Emotional Withdrawal]

  1. They stop trying.. If there is the slightest possibility that a person might try something new and fail or fall short in front of anyone else, it becomes too painful or too risky to make the effort. These bright, capable people avoid any activities that are anxiety-provoking and end up giving up things like dating, applying for jobs, or speaking up in public (both socially and professionally).

Some people use the pain of RSD to find adaptations and overachieve. They constantly work to be the best at what they do and strive for idealized perfection. Sometimes they are driven to be above reproach. They lead admirable lives, but at what cost?

How do I get over RSD?

Rejection sensitivity is part of ADHD. It’s neurologic and genetic. Early childhood trauma makes anything worse, but it does not cause RSD. Often, patients are comforted just to know there is a name for this feeling. It makes a difference knowing what it is, that they are not alone, and that almost 100% of people with ADHD experience rejection sensitivity. After hearing this diagnosis, they’re relieved to know it’s not their fault and that they are not damaged.

Psychotherapy does not particularly help patients with RSD because the emotions hit suddenly and completely overwhelm the mind and senses. It takes a while for someone with RSD to get back on his feet after an episode.

There are two possible medication solutions for RSD.

The simplest solution is to prescribe an alpha agonist like guanfacine or clonidine. These were originally designed as blood pressure medications. The optimal dose varies from half a milligram up to seven milligrams for guanfacine, and from a tenth of a milligram to five tenths of a milligram for clonidine. Within that dosage range, about one in three people feel relief from RSD. When that happens, the change is life altering. Sometimes this treatment can make an even greater impact than a stimulant does to treat ADHD, although the stimulant can be just as effective for some people.

These two medications seem to work equally well, but for different groups of people. If the first medication does not work, it should be stopped, and the other one tried. They should not be used at the same time, just one or the other.

The second treatment is prescribing monoamine oxidase inhibitors (MAOI) off-label. This has traditionally been the treatment of choice for RSD among experienced clinicians. It can be dramatically effective for both the attention/impulsivity component of ADHD and the emotional component. Parnate (tranylcypromine) often works best, with the fewest side effects. Common side effects are low blood pressure, agitation, sedation, and confusion.

MAOIs were found to be as effective for ADHD as methylphenidate in one head-to-head trial conducted in the 1960s. They also produce very few side effects with true once-a-day dosing, are not a controlled substance (no abuse potential), come in inexpensive, high-quality generic versions, and are FDA-approved for both mood and anxiety disorders. The disadvantage is that patients must avoid foods that are aged instead of cooked, as well as first-line ADHD stimulant medications, all antidepressant medications, OTC cold, sinus, and hay fever medications, OTC cough remedies. Some forms of anesthesia can’t be administered.


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The Company expressly disclaims any and all liability (including liability for negligence) in respect of the use of the information provided. The Company recommends you seek independent professional advice prior to making any decision involving matters outlined in these publications.



Defense Mechanisms

Sigmund Freud (1894, 1896) noted a number of ego defenses which he refers to throughout his written works.  His daughter Anna Freud (1936) developed these ideas and elaborated on them, adding ten of her own.  Many psychoanalysts have also added further types of ego defenses.

Defense mechanisms are psychological strategies that are unconsciously used to protect a person from anxiety arising from unacceptable thoughts or feelings.

Why do we need Ego defenses?

We use defense mechanisms to protect ourselves from feelings of anxiety or guilt, which arise because we feel threatened, or because our id or superego becomes too demanding.

Defense mechanisms operate at an unconscious level and help ward off unpleasant feelings (i.e., anxiety) or make good things feel better for the individual.

Ego-defense mechanisms are natural and normal.  When they get out of proportion (i.e., used with frequency), neuroses develop, such as anxiety states, phobias, obsessions, or hysteria.

Here are a few common defense mechanisms:There are a large number of defense mechanisms; the main ones are summarized below.

  1. Denial
  2. Repression
  3. Projection
  4. Displacement
  5. Regression
  6. Sublimation
  7. Rationalization
  8. Reaction Formation
  9. Identification with the Aggressor

1. Denial

Denial is a defense mechanism proposed by Anna Freud which involves a refusal to accept reality, thus blocking external events from awareness.

If a situation is just too much to handle, the person may respond by refusing to perceive it or by denying that it exist.

As you might imagine, this is a primitive and dangerous defense – no one disregards reality and gets away with it for long!  It can operate by itself or, more commonly, in combination with other, more subtle mechanisms that support it.

What is an example of denial?

Many people use denial in their everyday lives to avoid dealing with painful feelings or areas of their life they don’t wish to admit.

For example, a husband may refuse to recognise obvious signs of his wife’s infidelity. A student may refuse to recognise their obvious lack of preparedness for an exam!

2. Repression

Repression is an unconscious defense mechanism employed by the ego to keep disturbing or threatening thoughts from becoming conscious. 

Thoughts that are often repressed are those that would result in feelings of guilt from the superego.

This is not a very successful defense in the long term since it involves forcing disturbing wishes, ideas or memories into the unconscious, where, although hidden, they will create anxiety.

Repressed memories may appear through subconscious means and in altered forms, such as dreams or slips of the tongue ('Freudian slips').

What is an example of repression?

For example, in the oedipus complex, aggressive thoughts about the same sex parents are repressed and pushed down into the unconscious.

3. Projection

Projection is a psychological defense mechanism proposed by Anna Freud in which an individual attributes unwanted thoughts, feelings and motives onto another person.

What is an example of projection?

Thoughts most commonly projected onto another are the ones that would cause guilt such as aggressive and sexual fantasies or thoughts. 

For instance, you might hate someone, but your superego tells you that such hatred is unacceptable.  You can 'solve' the problem by believing that they hate you.

4. Displacement

Displacement is the redirection of an impulse (usually aggression) onto a powerless substitute target. The target can be a person or an object that can serve as a symbolic substitute.

Displacement occurs when the Id wants to do something of which the Super ego does not permit. The Ego thus finds some other way of releasing the psychic energy of the Id. Thus there is a transfer of energy from a repressed object-cathexis to a more acceptable object.

What is an example of displacement?

Someone who feels uncomfortable with their sexual desire for a real person may substitute a fetish. 

Someone who is frustrated by his or her superiours may go home and kick the dog, beat up a family member, or engage in cross-burnings.

5. Regression

Regression is a defense mechanism proposed by Anna Freud whereby the the ego reverts to an earlier stage of development usually in response to stressful situations.

Regression functions as form of retreat, enabling a person to psychologically go back in time to a period when the person felt safer.

What is an example of regression?

When we are troubled or frightened, our behaviors often become more childish or primitive. 

A child may begin to suck their thumb again or wet the bed when they need to spend some time in the hospital.  Teenagers may giggle uncontrollably when introduced into a social situation involving the opposite sex.

6. Sublimation

Sublimation is similar to displacement, but takes place when we manage to displace our unacceptable emotions into behaviors which are constructive and socially acceptable, rather than destructive activities. Sublimation is one of Anna Freud's original defense mechanisms.

Sublimation for Freud was the cornerstone of civilized life, as arts and science are all sublimated sexuality.  (NB. this is a value-laden concept, based on the aspirations of a European society at the end of the 1800 century).

What is an example of sublimation?

Many great artists and musicians have had unhappy lives and have used the medium of art of music to express themselves.  Sport is another example of putting our emotions (e.g., aggression) into something constructive.

For example, fixation at the oral stage of development may later lead to seeking oral pleasure as an adult through sucking one's thumb, pen or cigarette.  Also, fixation during the anal stage may cause a person to sublimate their desire to handle faeces with an enjoyment of pottery.

7. Rationalization

Rationalization is a defense mechanism proposed by Anna Freud involving a cognitive distortion of “the facts” to make an event or an impulse less threatening. We do it often enough on a fairly conscious level when we provide ourselves with excuses. 

But for many people, with sensitive egos, making excuses comes so easy that they never are truly aware of it.  In other words, many of us are quite prepared to believe our lies.

What is an example of rationalization?

When a person finds a situation difficult to accept, they will make up a logical reason why it has happened. For example, a person may explain a natural disaster as 'God's will'.

8. Reaction Formation

Reaction formation is a psychological defense mechanism in which a person goes beyond denial and behaves in the opposite way to which he or she thinks or feels.

Conscious behaviors are adopted to overcompensate for the anxiety a person feels regarding their socially unacceptable unconscious thoughts or emotions. Usually, a reaction formation is marked by exaggerated behavior, such as showiness and compulsiveness.

By using the reaction formation, the id is satisfied while keeping the ego in ignorance of the true motives.

Therapists often observe reaction formation in patients who claim to strongly believe in something and become angry at everyone who disagrees.

What is an example of reaction formation?

Freud claimed that men who are prejudice against homosexuals are making a defense against their own homosexual feelings by adopting a harsh anti-homosexual attitude which helps convince them of their heterosexuality.

Another example of reaction formation includes the dutiful daughter who loves her mother is reacting to her Oedipus hatred of her mother.

9. Identification with the Aggressor

Identification with the aggressor is a defense mechanism proposed by Sandor Ferenczi and later developed by Anna Freud. It involves the victim adopting the behavior of a person who is more powerful and hostile towards them.

By internalising the behavior of the aggressor the 'victim' hopes to avoid abuse, as the aggressor may begin to feel an emotional connection with the victim which leads to feelings of empathy.

What is an example of identification with the aggressor?

An extreme example of this is the Stockholm Syndrome, where hostages establish an emotional bond with their captor(s) and take on their behaviors.

Patty Hearst was abused and raped by her captors, yet she joined their Symbionese Liberation Army and even took part in one of their bank robberies.  At her trial, she was acquitted because she was a victim suffering from Stockholm Syndrome.

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Self-Help Techniques for Coping with Mental Illness

Living with mental illness is not easy. It’s a consistent problem without a clear solution. While treatments like medication and psychotherapy are incredibly helpful, sometimes people experiencing mental health conditions need to do more day-in and day-out to feel good or even just okay.

Some common self-help suggestions people receive are to exercise, meditate and be more present, which are helpful and work for many people. However, other proven methods aren’t mentioned as often. Many of them are quick and simple techniques that can easily be added to daily routines.

Finding the right coping mechanism takes time and patience, but it can enormously impact how you feel. If you haven’t had success with techniques you’ve tried, or you’re looking to add a few more to your toolkit, here are seven coping mechanisms recommended by mental health professionals worth trying out.

Radical Acceptance

Radical acceptance is “completely and totally accepting something from the depths of your soul, with your heart and your mind,” according to Marsha Linehan (creator of dialectal behavior therapy). Included in this definition is the idea that no matter what, you cannot change a situation. For example, imagine a tornado is coming your way. Obviously, you can’t do anything to stop the tornado; that’s not possible. But if you accept the fact that it’s coming, then you can act, prepare and keep yourself safe. If you sit around trying to will the tornado to stop or pretend that there is no tornado, you’re going to be in real trouble when it comes.

The same applies to mental illness. You cannot change the fact that you have a mental illness, so any time you spend trying to “get rid of it” or pretend it doesn’t exist is only draining you of valuable energy. Accept yourself. Accept your condition. Then take the necessary steps to take care of yourself.

Deep Breathing

Breathing is an annoying cliché at this point, but that’s because the best way to calm anxiety really is to breathe deeply. When battling my own anxiety, I turned to the concept of “5 3 7” breathing:

  • Breathe in for 5 seconds
  • Hold the breath for 3 seconds
  • Breathe out for 7 seconds

This gentle repetition sends a message to the brain that everything is okay (or it will be soon). Before long, your heart will slow its pace and you will begin to relax—sometimes without even realizing it.

Opposite-To-Emotion Thinking

Opposite-to-emotion thinking is how it sounds: You act in the opposite way your emotions tell you to act. Say you’re feeling upset and you have the urge to isolate. Opposite-to-emotion tells you to go out and be around people—the opposite action of isolation. When you feel anxious, combat that with something calming like meditation. When you feel manic, turn to something that stabilizes you. This technique is probably one of the hardest to put into play, but if you can manage it, the results are incredible.

The 5 Senses

Another effective way to use your physical space to ground you through a crisis is by employing a technique called “The 5 Senses.” Instead of focusing on a specific object, with “The 5 Senses” you run through what each of your senses is experiencing in that moment. As an example, imagine a PTSD flashback comes on in the middle of class. Stop! Look around you. See the movement of a clock’s hands. Feel the chair beneath you. Listen to your teacher’s voice. Smell the faint aroma of the chalkboard. Chew a piece of gum.

Running through your senses will take only a few seconds and will help keep you present and focused on what is real, on what is happening right now.

Mental Reframing

Mental reframing involves taking an emotion or stressor and thinking of it in a different way. Take, for example, getting stuck in traffic. Sure, you could think to yourself, “Wow, my life is horrible. I’m going to be late because of this traffic. Why does this always happen to me?”

Or you can reframe that thought, which might look something like, “This traffic is bad, but I’ll still get to where I’m going. There’s nothing I can do about it, so I’ll just listen to music or an audiobook to pass the time.” Perfecting this technique can literally change your perspective in tough situations. But as you might imagine, this skill takes time and practice.

Emotion Awareness

If you live in denial of your emotions, it will take far longer to take care of them, because once we recognize what we’re feeling, we can tackle it or whatever is causing it. So, if you’re feeling anxious, let yourself be anxious for a couple of minutes—then meditate. If you’re feeling angry, let yourself be angry—then listen to some calming music. Be in touch with your emotions. Accept that you are feeling a certain way, let yourself feel that way and then take action to diminish unhealthy feelings.

You can’t control that you have mental illness, but you can control how you respond to your symptoms. This is not simple or easy (like everything else with mental illness), but learning, practicing and perfecting coping techniques can help you feel better emotionally, spiritually and physically. I’ve tried all the above techniques, and they have transformed the way I cope with my mental health struggles.

It takes strength and persistence to recover from mental illness—to keep fighting symptoms in the hopes of feeling better. Even if you feel weak or powerless against the battles you face every day, you are incredibly strong for living through them. Practical and simple methods can help you in your fight. Take these techniques into consideration, and there will be a clear change in the way you feel and live your life.



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The Company expressly disclaims any and all liability (including liability for negligence) in respect of the use of the information provided. The Company recommends you seek independent professional advice prior to making any decision involving matters outlined in these publications.



Depression Symptoms and Warning Signs

Do you think you might be depressed? Here are some of the signs of depression to look for—and tips for getting the help you need.

What is depression?

Feeling down from time to time is a normal part of life, but when emotions such as hopelessness and despair take hold and just won’t go away, you may have depression. More than just sadness in response to life’s struggles and setbacks, depression changes how you think, feel, and function in daily activities. It can interfere with your ability to work, study, eat, sleep, and enjoy life. Just trying to get through the day can be overwhelming.

While some people describe depression as “living in a black hole” or having a feeling of impending doom, others feel lifeless, empty, and apathetic. Men in particular can feel angry and restless. However you experience the problem, left untreated it can become a serious health condition. But it’s important to remember that feelings of helplessness and hopelessness are symptoms of depression—not the reality of your situation.

No matter how hopeless you feel, you can get better. By understanding the causes and recognizing the different symptoms and types of depression, you can take the first steps to feeling better and overcoming the problem.

Signs and symptoms

Depression varies from person to person, but there are some common signs and symptoms. It’s important to remember that these symptoms can be part of life’s normal lows. But the more symptoms you have, the stronger they are, and the longer they’ve lasted—the more likely it is that you’re dealing with depression.

10 common depression symptoms

  1. Feelings of helplessness and hopelessness. A bleak outlook—nothing will ever get better and there’s nothing you can do to improve your situation.
  2. Loss of interest in daily activities. You don’t care anymore about former hobbies, pastimes, social activities, or sex. You’ve lost your ability to feel joy and pleasure.
  3. Appetite or weight changes.Significant weight loss or weight gain—a change of more than 5% of body weight in a month.
  4. Sleep changes. Either insomnia, especially waking in the early hours of the morning, or oversleeping.
  5. Anger or irritability. Feeling agitated, restless, or even violent. Your tolerance level is low, your temper short, and everything and everyone gets on your nerves.
  6. Loss of energy. Feeling fatigued, sluggish, and physically drained. Your whole body may feel heavy, and even small tasks are exhausting or take longer to complete.
  7. Self-loathing. Strong feelings of worthlessness or guilt. You harshly criticize yourself for perceived faults and mistakes.
  8. Reckless behavior. You engage in escapist behavior such as substance abuse, compulsive gambling, reckless driving, or dangerous sports.
  9. Concentration problems. Trouble focusing, making decisions, or remembering things.
  10. Unexplained aches and pains. An increase in physical complaints such as headaches, back pain, aching muscles, and stomach pain.


The link between depression symptoms and anxiety

Depression and anxiety are believed to stem from the same biological vulnerability, which may explain why they so often go hand-in-hand. Since anxiety makes depression worse (and vice versa), it’s important to seek treatment for both conditions.

Is it depression or bipolar disorder?

Bipolar disorder, also known as manic depression, involves serious shifts in moods, energy, thinking, and behavior. Because it looks so similar to depression when in the low phase, it is often overlooked and misdiagnosed.

This can be a serious problem as taking antidepressants for bipolar disorder can actually make the condition worse. If you’ve ever gone through phases where you experienced excessive feelings of euphoria, a decreased need for sleep, racing thoughts, and impulsive behavior, consider getting evaluated for bipolar disorder.


Depression and suicide risk

Depression is a major risk factor for suicide. Deep despair and hopelessness can make suicide feel like the only way to escape the pain. If you have a loved one with depression, take any suicidal talk or behavior seriously and watch for the warning signs:

  • Talking about killing or harming one’s self.
  • Expressing strong feelings of hopelessness or being trapped.
  • An unusual preoccupation with death or dying.
  • Acting recklessly, as if they have a death wish (e.g. speeding through red lights).
  • Calling or visiting people to say goodbye.
  • Getting affairs in order (giving away prized possessions, tying up loose ends).
  • Saying things like “Everyone would be better off without me,” or “I want out.”
  • A sudden switch from being extremely down to acting calm and happy.

If you think a friend or family member is considering suicide, express your concern and seek help immediately. Talking openly about suicidal thoughts and feelings can save a life.

How depression symptoms vary with gender and age

Depression often varies according to age and gender, with symptoms differing between men and women, or young people and older adults.


Depressed men are less likely to acknowledge feelings of self-loathing and hopelessness. Instead, they tend to complain about fatigue, irritability, sleep problems, and loss of interest in work and hobbies. They’re also more likely to experience symptoms such as anger, aggression, reckless behavior, and substance abuse.


Women are more likely to experience symptoms such as pronounced feelings of guilt, excessive sleeping, overeating, and weight gain. Depression in women is also impacted by hormonal factors during menstruation, pregnancy, and menopause. In fact, postpartum depression affects up to 1 in 7 women following childbirth.


Irritability, anger, and agitation are often the most noticeable symptoms in depressed teens—not sadness. They may also complain of headaches, stomachaches, or other physical pains.

Older adults

Older adults tend to complain more about the physical rather than the emotional signs and symptoms: things like fatigue, unexplained aches and pains, and memory problems. They may also neglect their personal appearance and stop taking critical medications for their health.

Types of depression

Depression comes in many shapes and forms. While defining the severity—whether it’s mild, moderate, or major—can be complicated, knowing what type you have may help you manage your symptoms and get the most effective treatment.

Mild and moderate depression

These are the most common types. More than simply feeling blue, the symptoms of mild depression can interfere with your daily life, robbing you of joy and motivation. Those symptoms become amplified in moderate depression and can lead to a decline in confidence and self-esteem.

Recurrent, mild depression (dysthymia)

Dysthymia is a type of chronic “low-grade” depression. More days than not, you feel mildly or moderately depressed, although you may have brief periods of normal mood.

  • The symptoms of dysthymia are not as strong as the symptoms of major depression, but they last a long time (at least two years).
  • Some people also experience major depressive episodes on top of dysthymia, a condition known as “double depression.”
  • If you suffer from dysthymia, you may feel like you’ve always been depressed. Or you may think that your continuous low mood is “just the way you are.”

Major or clinical depression

Major depression (otherwise known as major depressive disorder) is much less common than mild or moderate and is characterized by severe, relentless symptoms.

  • Left untreated, major depressive disorder typically lasts for about six months.
  • Some people experience just a single depressive episode in their lifetime, but major depression can be a recurring disorder.

Atypical depression

Atypical depression is a common subtype of major depressive disorder with a specific symptom pattern. It responds better to some therapies and medications than others, so identifying it can be helpful.

  • People with atypical depression experience a temporary mood lift in response to positive events, such as after receiving good news or while out with friends.
  • Other symptoms include weight gain, increased appetite, sleeping excessively, a heavy feeling in the arms and legs, and sensitivity to rejection.

Seasonal affective disorder (SAD)

For some people, the reduced daylight hours of winter lead to a form of depression known as seasonal affective disorder (SAD). SAD affects about 1% to 2% of the population, particularly women and young people. SAD can make you feel like a completely different person to who you are in the summer: hopeless, sad, tense, or stressed, with no interest in friends or activities you normally love. SAD usually begins in fall or winter when the days become shorter and remains until the brighter days of spring.

Causes and risk factors

While some illnesses have a specific medical cause, making treatment straightforward, depression is far more complicated. Certain medications, such as barbiturates, corticosteroids, benzodiazepines, opioid painkillers, and specific blood pressure medicine can trigger symptoms in some people—as can hypothyroidism (an underactive thyroid gland). But most commonly, depression is caused by a combination of biological, psychological, and social factors that can vary wildly from one person to another.

Despite what you may have seen in TV ads, read in newspaper articles, or maybe even heard from a doctor, depression is not just the result of a chemical imbalance in the brain, having too much or too little of any brain chemical that can be simply cured with medication. Biological factors can certainly play a role in depression, including inflammation, hormonal changes, immune system suppression, abnormal activity in certain parts of the brain, nutritional deficiencies, and shrinking brain cells. But psychological and social factors—such as past trauma, substance abuse, loneliness, low self-esteem, and lifestyle choices—can also play an enormous part.

Risk factors that can make you more vulnerable

Depression most often results from a combination of factors, rather than one single cause. For example, if you went through a divorce, were diagnosed with a serious medical condition, or lost your job, the stress could prompt you to start drinking more, which in turn could cause you to withdraw from family and friends. Those factors combined could then trigger depression.

The following are examples of risk factors that can make you more susceptible:

Loneliness and isolation. There’s a strong relationship between loneliness and depression. Not only can lack of social support heighten your risk, but having depression can cause you to withdraw from others, exacerbating feelings of isolation. Having close friends or family to talk to can help you maintain perspective on your issues and avoid having to deal with problems alone.

Marital or relationship problems. While a network of strong and supportive relationships can be crucial to good mental health, troubled, unhappy, or abusive relationships can have the opposite effect and increase your risk for depression.

Recent stressful life experiences. Major life changes, such as a bereavement, divorce, unemployment, or financial problems can often bring overwhelming levels of stress and increase your risk of developing depression.

Chronic illness or pain. Unmanaged pain or being diagnosed with a serious illness, such as cancer, heart disease, or diabetes, can trigger feelings of hopelessness and helplessness.

Family history of depression. Since it can run in families, it’s likely some people have a genetic susceptibility to the problem. However, there is no single “depression” gene. And just because a close relative suffers from depression, it doesn’t mean you will, too. Your lifestyle choices, relationships, and coping skills matter just as much as genetics.

Personality. Whether your personality traits are inherited from your parents or the result of life experiences, they can impact your risk of depression. For example, you may be at a greater risk if you tend to worry excessively, have a negative outlook on life, are highly self-critical, or suffer from low self-esteem.

Early childhood trauma or abuse. Early life stresses such as childhood trauma, abuse, or bullying can make you more susceptible to a number of future health conditions, including depression.

Alcohol or drug abuse. Substance abuse can often co-occur with depression. Many people use alcohol or drugs as a means of self-medicating their moods or cope with stress or difficult emotions. If you are already at risk, abusing alcohol or drugs may push you over the edge. There is also evidence that those who abuse opioid painkillers are at greater risk for depression.

The cause of your depression may help determine the treatment

Understanding the underlying cause of your depression may help you overcome the problem. For example, if you are feeling depressed because of a dead-end job, the best treatment might be finding a more satisfying career rather than simply taking an antidepressant. If you are new to an area and feeling lonely and sad, finding new friends will probably give you more of a mood boost than going to therapy. In such cases, the depression is remedied by changing the situation.

Whether you’re able to isolate the causes or not, the most important thing is to recognize that you have a problem, reach out for support, and pursue the coping strategies that can help you to feel better.

What you can do to feel better

When you’re depressed, it can feel like there’s no light at the end of the tunnel. But there are many things you can do to lift and stabilize your mood. The key is to start with a few small goals and slowly build from there, trying to do a little more each day. Feeling better takes time, but you can get there by making positive choices for yourself.

Reach out to other people. Isolation fuels depression, so reach out to friends and loved ones, even if you feel like being alone or don’t want to be a burden to others. The simple act of talking to someone face-to-face about how you feel can be an enormous help. The person you talk to doesn’t have to be able to fix you. They just need to be a good listener—someone who’ll listen attentively without being distracted or judging you.

Get moving. When you’re depressed, just getting out of bed can seem daunting, let alone exercising. But regular exercise can be as effective as antidepressant medication in countering the symptoms of depression. Take a short walk or put some music on and dance around. Start with small activities and build up from there.

Eat a mood boosting diet. Reduce your intake of foods that can adversely affect your mood, such as caffeine, alcohol, trans fats, sugar and refined carbs. And increase mood-enhancing nutrients such as Omega-3 fatty acids.

Find ways to engage again with the world. Spend some time in nature, care for a pet, volunteer, pick up a hobby you used to enjoy (or take up a new one). You won’t feel like it at first, but as you participate in the world again, you will start to feel better.

When to seek professional help

If support from family and friends and positive lifestyle changes aren’t enough, it may be time to seek help from a mental health professional. There are many effective treatments for depression, including:

Therapy. Consulting a therapist can provide you tools to treat depression from a variety of angles and motivate you to take the action necessary. Therapy can also offer you the skills and insight to prevent the problem from coming back.

Medication may be imperative if you’re feeling suicidal or violent. But while it can help relieve symptoms of depression in some people, it isn’t a cure and is not usually a long-term solution. It also comes with side effects and other drawbacks so it’s important to learn all the facts to make an informed decision.



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The Company expressly disclaims any and all liability (including liability for negligence) in respect of the use of the information provided. The Company recommends you seek independent professional advice prior to making any decision involving matters outlined in these publications.



Engaging young people in therapy

Across the life span, the prevalence of mental disorders is highest in those aged 12 to 25 years, with more than one in four young people dealing with a mental disorder in any 12-month period. Self-harm and suicide are significant risks for this age group, with suicide being the leading cause of death for Australians aged 15 to 24 (AIHW, 2014). Mental illness during this key developmental period can have significant long-term impacts, yet this age group is the least likely to accept the support they need.

There is often a resistance from young people to initially seek help. However, psychologists themselves have also often shied away from working with young people due to the difficulties of engaging youth in therapy.


Challenges engaging youth

Attitudes towards therapy

One of the greatest difficulties of working with young people is simply getting them through the office door and addressing their unhelpful beliefs about therapy. Negative beliefs are commonly held due to stigma surrounding mental health problems, or regarding their own or friends’ negative past help seeking experiences. As young people are regularly forced to attend therapy by their parents or other caregivers, they are also often in denial about the severity of the presenting problem, believe that the psychologist will not be helpful in addressing their particular concern, or that their difficulties will not be taken seriously.

Other barriers to youth’s engagement with therapy include not wanting to acknowledge that there is a problem, embarrassment or shame about the problem, a fear of judgement from others or that they will be seen as ‘crazy’, and concerns about their privacy and confidentiality. Identifying and addressing such fears – including where there are limits, such as duty of care and confidentiality – must be done quickly, empathetically and in developmentally appropriate language.

Young people’s ability to self-disclose

Operating under the current landscape of limited therapeutic sessions and ensuring evidence-based approaches are implemented, generally requires psychologists to undertake comprehensive psychosocial assessments in the first session. The expectation that an individual will be comfortable and willing to disclose such personal information to someone they do not yet know or trust is immense for clients of all ages, yet particularly problematic for young people who are still navigating social norms, struggling with their identity, possibly experimenting with risky behaviours, and in an unequal youth/adult relationship with their clinician. Young people often experience this personal and direct questioning, in an unaccustomed social format, to be intrusive and threatening, rather than as a supportive and caring attempt to understand them in their entirety. As a result, it is not uncommon for young people to not attend the subsequent session.

Not designed for adolescents

Most therapeutic approaches are developed for either children or adults. As such, young people often find these approaches ‘childish’, or may be challenged by techniques that are beyond their cognitive capacity. Additionally, many cognitive approaches rely on ‘rational’ thought processes, yet developmental processes in adolescence commonly involve experimenting and pushing boundaries beyond what an adult might consider ‘rational’ or safe.

Adolescence and early adulthood are crucial periods of physical, cognitive, emotional, psychological, and social development. During this period, young people experience a range of biological changes including sexual maturation, increases in height and weight, and changes in hormones. Cognitive style gradually shifts from a concrete ‘black and white’ understanding of the world to a more abstract view where ‘shades of grey’ become apparent. Young people gradually gain autonomy by moving away from a reliance on parents to a greater confidence with peers and romantic partners. Furthermore, their sexual identity is increasingly formed through periods of exploration and experimentation. Key social milestones are also achieved, such as finishing school, gaining work and new financial autonomy, moving out of the family home, beginning a serious intimate relationship, and/or having children. Each of these changes and milestones can detrimentally impact a young person’s thought processes, functioning and coping ability, or put them at risk of harm.

Clinicians who successfully engage with young people have an understanding of the developmental stage and cognitive capacity of their young clients and are able to adapt approaches accordingly. They must also delicately balance the need to ensure safety and challenge unhelpful thought patterns, while allowing the young person to engage in, what are generally considered, developmentally appropriate behaviours that allow for an exploration of their self-identity. Clinicians who struggle with this balance risk not adhering to their duty of care, deterring the young person from disclosing future thoughts or behaviours, or reduce the likelihood of youth clients returning to therapy at all.

Developing a therapeutic relationship

Arguably, one of the most important components in engaging young people in therapy is fostering strong therapeutic relationships. As young people are likely to enter therapy feeling unsure or threatened about the process, worried about what the clinician or others will think of them, and fearful that their parents will find out about any risky or illegal behaviours they might be engaging in, for therapy to continue beyond the first session, it is essential that clinicians are able to promptly put young people at ease and provide non-judgemental, developmentally appropriate support during the first session.

One way of fostering a supportive therapeutic relationship, while obtaining a holistic understanding of the young person in the first session, is to use a psychosocial interview guide especially developed for young people. First developed by Goldenring and Cohen (1988) and later updated by Klein, Goldenring, and Adelman (2014), the HEEADSSS 3.0 is recommended by both the Royal Australasian College of Physicians and New South Wales Health. HEEADSSS 3.0 stands for Home, Education and employment, Eating and exercise, Activities and peer relationships, Drug and Alcohol Use, Sexuality, Suicide and depression, and Safety (and/or Spirituality). Although not explicitly included, clinicians working in mental health specific areas should also ensure they discuss issues related to anxiety, psychosis and mania, and any conduct issues (Parker, Hetrick, & Purcell, 2013). The HEEADSSS 3.0 framework has been found useful in helping clinicians working in youth mental health services to engage with young people and build rapport, while providing accurate reflections of current mental health and functioning (Parker et al., 2013) .

HEEADSSS 3.0 does not dictate a formal interview; rather, it is a strength-based framework that reduces feelings of shame in young people while promoting their ongoing engagement in therapy by facilitating the development of a good therapeutic relationship. It does this by opening discussions with the arguably least threatening domains of home and education, and progressively moving through to the domains considered more embarrassing or stigmatised. This encourages young people to slowly increase their comfort with the therapist and the process of verbal disclosure, before they discuss difficult issues. Note that while the acronym works for most young people, where a young person might be experiencing difficulties in the earlier domains such as at home or school, it might be best to leave discussion of these domains until later in the initial session.

Essential to getting young people to open up and engage in this process, is using open-ended and non-judgemental questions (See Table).

Fostering ongoing engagement in therapy

Shared decision-making

Young people generally have a desire, and the capacity, to engage in decisions around their healthcare. Therefore, rather than providing an ‘expert’ opinion on the best course of treatment, one of the most important ways in ensuring ongoing engagement in therapy is to undertake an open discussion with the young person around their treatment options. This ‘shared decision-making’ approach ideally provides young people with the opportunity to select the treatment option that best fits their values and preferences. Engaging in such a discussion is likely to lead to greater treatment satisfaction, improved mood, and improved overall health outcomes.

Tracking of session satisfaction and outcomes

For young people to continue to engage in therapy, they also need to be satisfied in the approach and see evidence that it is working for them. When used effectively, session rating scales help diminish the perceived ‘power imbalance’ by providing young people the opportunity to give ongoing feedback as to whether they are satisfied with the therapist’s approach. Outcome rating scales allow for progress to be mapped over time, which helps young people review their experience, reflect on their success, and improves ongoing engagement in therapy.

While several different options for these types of scales exist, scales that have strong empirical evidence include the ‘Session Rating Scale’ and the ‘Outcome Rating Scale’ (Miller, Duncan, Brown, Sorrell, & Chalk, 2006). Both of these have several electronic options to aid tracking over time.

Use of technology in therapy

Young people are early adopters of technology, seamlessly integrating it into their everyday lives. Thus, therapy should be no different. Technology can be used to support processes at all stages of therapy. For example, when compared to verbal assessments, electronic assessments have been shown to increase rates of disclosure as young people experience reduced fears of judgement and a greater ability to articulate their emotions. Apps can also be used to track client satisfaction and outcomes as an alternative to traditional paper-based diaries and mood tracking.

While not all young people will want, or have the capacity, to use technology, the seamless integration of apps and other technology into therapy will increase engagement by many young people as it reflects how they operate in their everyday lives. However, seamless integration requires clinicians to be very comfortable with the technology themselves. The risk of disengagement from therapy following a young person’s observation that their psychologist is not comfortable using something they recommended to their client is problematic.

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Practical tips for engaging young people

Don’t begin a session by asking why the young person is here

Begin by engaging with the young person with non-confronting topics. For example, if they were listening to music in the waiting room, ask what they were listening to. Then ask if they have any expectations or past experiences of therapy and explain the process of both the first session and the full therapeutic approach. Being clear on the processes and guiding the initial discussion may help put young people at ease.

Be open and honest about confidentiality

Ensure that the discussion around confidentiality and privacy is held before any personal information is discussed. Such a conversation will likely need to address the type of information that might need to be shared with parents or other caregivers.

Ensure the development of the therapeutic alliance is paramount in the first session

While it is important to obtain as much clinically relevant information as possible in the first session, the primary goal should be the development of the therapeutic relationship to ensure the young person is going to return for a second session. There is little point in having all the necessary information if the young person does not return to engage in therapy.

Be genuine and authentic

Young people are likely to see through any attempt an adult makes to ‘be cool’. While they will respond to a relaxed and inviting atmosphere, do not use language or an approach that is not authentic to the way you work.

Provide sufficient time for a young person to respond and be okay with silence

The therapeutic environment is often new and challenging for a young person. Frequently, they may experience internal conflict regarding whether they want to answer a question, and too often clinicians will sense discomfort and change topics before a young person had a chance to answer. Provide time and space for them to contemplate their responses.

Use a strength-based approach and identify resilience

Young people often fail to see their own strengths and coping abilities. Helping them to realise these early in therapy can help them to feel success and may promote ongoing engagement.

Know your technology well and be flexible

Never get a young person to use an app or website that you have not fully investigated yourself. Be knowledgeable about what the app does and why you think it might be helpful for that young person. However, do not force technology onto them; suggest multiple options (including those that do not rely on technology) and ask them to try each and decide what works best for them.

Don’t be the ‘expert’

Be warm and friendly and do what you can to reduce the perceived power imbalance. Engage in shared decision-making processes and ask for young people’s ongoing feedback on whether your approach works for them.


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The Company expressly disclaims any and all liability (including liability for negligence) in respect of the use of the information provided. The Company recommends you seek independent professional advice prior to making any decision involving matters outlined in these publications.



What does the NDIS pay for?

There are currently more than 4.4 million Australians living with a disability, according to federal government data, and until recently there was no nationwide system in place to support their needs.

A report by the Productivity Commission in 2011 recommended the Federal Government create a national scheme to provide greater choice and certainty to people living with a disability, after finding the existing system was “underfunded, unfair, fragmented and inefficient”.

In 2013, legislation was passed to create the National Disability Insurance Scheme (NDIS), managed by the National Disability Insurance Agency (NDIA), to provide and co-ordinate disability support funding. As of November 2019 there were 310,000 Australians participating in the NDIS, according to the NDIS Quarterly Report. For 114,000 of these people, it’s the first time they’ve been able to access the support they require.

So, what exactly is the NDIS, who is eligible and what does it pay for to help support those with a disability in Australia?

What is the NDIS?

According to the NDIS website, it is a federal government-funded scheme which provides financial support to people with an intellectual, physical, sensory, cognitive (such as defective short-term memory) or psychosocial (arising as a result of a mental health condition) disability, as well as early intervention supports for children with developmental delay.

Trials for the NDIS were held in 2013, and it is currently being rolled out around the country, with the final stages of this rollout expected to be completed by 2020.

The government expects the NDIS to provide support for about 460,000 Australians who have a disability when it is fully operational. Individuals with NDIS funding primarily deal with Local Area Coordinators (LACs), Early Childhood Early Intervention (ECEI) co-ordinators, or NDIA planners who help participants access, understand and navigate the new system, and create, implement and review their plan. Participants can find LACs, ECEIs and NDIA planners in their area using the search tool on the NDIS website.

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What does the NDIS pay for?

The NDIS can help pay support funding for individuals based on their needs, including daily personal activities, transport and mobility (such as wheelchairs), access to work and education, household tasks, home and vehicle modifications and therapeutic support. Specific examples of things that may be funded under the NDIS include wheelchairs, speech pathology appointments and healthy meal delivery services.

The NDIA explains there are three types of NDIS “support budgets” that may be funded in a person’s NDIS plan:

  • The core supports budget, which includes consumables (everyday items such as continence aids), low-cost equipment to improve your mobility (such as a walking stick), help with daily activities (such as household cleaning and yard maintenance), social and community participation and transport;
  • The capacity building budget, which includes helping participants achieve their goals in areas such as employment (help to find and keep a job), health (exercise and diet advice), education (assessment and training to move from school to further education) relationships (advice to develop positive behaviours and interact with others) and living arrangements (help with finding a place to live); and
  • The capital support budget, which is used to fund assistive technologies such as wheelchairs or vehicle modifications, and modifications to your home, such as the installation of a hand rail in the bathroom or ramp into the home.

Who is eligible for the NDIS?

The NDIS is available to Australian citizens, permanent residents and special-category visa holders who live in Australia, are aged between seven and 65 years old, and who have a permanent and significant disability. Based on the NDIS criteria, a permanent and significant disability means you either need support from another person, use special equipment or require supports to reduce your future needs. You can check your eligibility through the NDIS website.

How do you apply for NDIS funding?

The NDIS website advises that if you believe you are eligible, the first step is to phone the NDIA, which runs the scheme, on 1800 800 110 and make an Access Request. When you call, you’ll need to confirm your identity and will be asked questions to verify your residency and eligibility. If you’re already receiving disability support services, the NDIA will contact you when NDIS funding becomes available in your area, if it isn’t already.

During the application process, you will be asked to provide evidence of your disability. This may include documents confirming your primary disability, how this disability impacts different areas of your life, descriptions of past treatments and outcomes, and future treatment options and the expected outcomes of these. This evidence can be completed by your treating health professional such as a GP, paediatrician, psychologist or allied health practitioner. This evidence should also include your date of diagnosis, details about how long the disability will last, and the treatments that are available.

If your application is accepted, you will then attend a planning meeting, where your needs and goals will be discussed. Be sure to take any relevant reports or assessments along with you to this meeting, so the resulting plan is right for your needs. After the meeting, the NDIA will process and approve your plan, and your ECEI co-ordinator, LAC or NDIA planner will let you know when this is complete.

How much NDIS funding can you get, and who manages it?

There is no set amount of funding you will receive under the NDIS, according to the scheme’s website. Instead, participants develop an NDIS plan based on their individual needs and circumstances, in which they can request funding for ‘reasonable’ and ‘necessary’ support and services. This will then be reviewed and approved by an NDIA professional.

If you decide to self-manage your NDIS plan, you’ll be responsible for tasks such as buying the supports your require, making appointments, managing your funding, keeping invoices and receipts, and being able to show how you’ve used the funding when your plan is reviewed – usually once every 12 months. You will also need to advise the NDIA of any changes to your circumstances, and participate in payment auditing, if required.

If you decide not to manage the plan yourself, or are unable to do so, there is help available. You can choose to work with a plan manager from a registered provider (individual or organisation delivering a support or product registered under the NDIS Commission) who will help you with the above tasks. You can find a registered provider by using the Provider Finder tool in your NDIS myplace portal or checking on the NDIS website. Alternatively, you can choose to have the NDIS manage your plan which is called agency management. These options won’t cost you anything, as the NDIA pays your plan manager.

A parent, guardian or other responsible adult can manage an NDIS plan on behalf of a child aged under 18. Adult NDIS participants who are deemed not capable of managing their plan themselves can still use the self-management option. In this case, a nominee will be appointed by the NDIA to act or make decisions on behalf of the participant.

What assistance is not covered by the NDIS?

Some types of supports that are not covered by the NDIS include general living expenses such as rent, bills, food and entertainment, as well as direct school or study costs (such as general fees or stationary/books required by all students), according to the website. The NDIS also doesn’t cover supports that are already funded or partially covered by Medicare, such as visits to the GP, X-rays or blood tests. You may be able to have these items bulk-billed, although some types of appointments or tests may attract a fee, so it’s always a good idea to check this beforehand.

While you can get dietary or exercise advice related to your disability, the NDIS doesn’t fund gym memberships. Additionally, any home modifications claimed under the NDIS must be directly related to your disability.

How does the NDIS affect Centrelink payments and other benefits?

According to the NDIS website, transport-related supports form part of your NDIS plan, so if you are receiving a Centrelink mobility allowance, this will cease when your NDIS funding is approved. However, you’ll still be able to keep your Health Care Card, if you’re eligible for one.

The funding you receive from the NDIS is not considered taxable income, and as such won’t affect any disability support, income support or child support payments you may pay or receive, according to the Australian Taxation Office. If you’re unsure how the NDIS may affect your existing payments or entitlements, contact the NDIA or Centrelink.

Can you use NDIS funding on holiday?

You can use your usual NDIS funding while on holiday, or to make your holiday activities more accessible. According to the website, the NDIS, however, does not pay for expenses such as flights, accommodation or entertainment that are incurred by travellers, only expenses directly related to your disability.



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The Company expressly disclaims any and all liability (including liability for negligence) in respect of the use of the information provided. The Company recommends you seek independent professional advice prior to making any decision involving matters outlined in these publications.