Vol 2

Understanding the Effects of Temporary Parent-Child Separation

The Commonality of Temporary Parent-Child Separation

Many children around the world experience a temporary separation from a parent for a variety of reasons. The United Nations estimates that 232 million people live and work outside of their native countries; as a result, their children experience temporary separations from one or more parents.[1] Children may also experience temporary absences from their parents due to a parent being deployed in the military; in the United States 1.2 million children have a parent on active duty and 730,000 have a parent on reserve military status. An additional 1.7 million U.S. children experience a separation from a parent due to incarceration.[2] Since children depend on their parents to successfully navigate stressful and traumatic events, parental separation can at times be considered a toxic stressor.[3]

Overall effects

As with any early life stress, parental separation takes a physical and psychological toll. Experiencing extreme stressors at a young age put children at risk for anxiety, depression, post-traumatic stress disorder (PTSD), lower IQ, obesity, decreased immune system functioning, cancer, heart and lung disease, stroke and morbidity.[4] Younger children are shown to be more likely to experience maladaptation immediately following separation and have diminishing problems over time.[5] However, the effects of parental separation can follow a child into adulthood, including increased risk for mental health problems, poor social functioning, insecure attachment and disrupted stress reactivity.[6] Additionally, stressors during adolescence can have lasting effects that do not become evident until adulthood.[7] 

Stages of childhood development also play a role in the effects of temporary separation as children left behind in the ages of 5-8 may experience delayed cognitive development. Further, adolescents that have been left behind/separated from their parent are more likely to take on greater responsibility for the family and perform more routine household tasks, increasing the adolescent’s vulnerability and potentially leading them to risky behaviors (e.g., alcohol consumption, smoking).[8]

The role of gender 

Multiple studies have revealed that the gender of both the child and the parent can play a role in the subsequent effects of temporary parent-child separation. In regards to temporary migrations, Antman’s research (2012) found that daughters who had their father migrate from Mexico to the United States when they were young were tied to higher educational attainment.[9] Antman’s findings tie with previous research that has found paternal migration is not always a stress factor for children left behind and can in times be tied with favorable well-being outcomes due to the changing social status experienced.[10] A study by Mazzucato et al. (2011), found that the effects of a migrating mother are more complex. While families tend to experience economic gain when the father or mother migrate for work,[11] Parrenas (2005) notes that the absence of a mother can lead to increased emotional problems in children (due to the disruption in traditional gender norms regarding child care).[12] 

Effects of the different kinds of separations 

Different kinds of temporary separation bring about their own complex effects on the children left behind. 

  • Incarceration: Children of incarcerated parents have greater odds of antisocial behavior in their youth, which may be tied to the stigma attached to incarceration making it more difficult for youth to search and find social support.[13] 

  • Migration: Individual studies on the effects of parental migration have reported youth have higher risk of diminished happiness, academic performance and social support seeking along with increased depressive symptoms.[14] The Society for Research in Child Development reports there is an increased mental health risk for both parents and children when they are separated in the immigration process. The Society furthers that native United States children who witness a parent’s border detention or deportation are at an increased risk of developing mental health problems (e.g., anxiety, depression, behavior problems, symptoms of PTSD).[15]

  • Military Deployment: Rodriguez et al. (2015) note that meta-analyses have shown statistically significant small increases over time in children’s mental health problems, behavior problems and school problems linked to parental military deployments.[16] Different kinds of deployments can also have different degrees of effects. Rodriguez et al. add that wartime deployments and deployments to an area directly involved in war are linked with increased distress and mental health problems among family members.[17] However, youth and parental ratings of family functioning are shown to improve with an increasing number of military deployments, most likely due to becoming accustomed with the situation.[18]

Communication is Key

Despite the afore-mentioned negatives, temporary parent-child separations can be an opportunity to foster quality communication between the parent and child, creating resilience in children. The level of communication between parent and child can have great effects on the child’s mental health and overall acclimation to a change in family functioning. Zhou et al. (2021) found that low frequency of parent-child communication put children aged 7-17 at higher risk for developing depressive symptoms; conversely, high frequency of communication was tied with enhanced quality of life for the children left behind/separated.[19] It has also been shown that youth who have contact with their incarcerated parents report less alienation and anger in regards to the incarcerated parent, and are less likely to have school problems.[20] 

Quality communication between the parent and child helps to foster resilience, the ability to recover from stressful experiences quickly and efficiently. Building such resilience is a great skill for any child to have since it can help them overcome the eventual hurdles of life. Other ways caregivers can foster resilience in children include:[21,22]

  • Explaining where and why the parent is leaving in advance of the departure 

  • Allowing the child to take part in leave-taking rituals (e.g., allowing the child to say goodbye to the parent even if the child is very young)

  • Trying to create routine and sticking to it (even when the parent returns)

  • Creating a safe environment for the child to speak freely

  • Acknowledging and validating the child’s concerns 

  • Reassuring the child they are not alone

  • Encouraging active play and skill building to teach children problem-solving skills in a fun setting

  • Sharing honest and age-appropriate information with the child

After a separation some sadness is completely normal, but if adjustment is not seen after a few weeks, there may be cause for concern. It may be helpful to increase the love, attention, and affection to the child and to encourage them to express their feelings.[23] Since it is common for caregivers to feel overwhelmed with responsibilities, asking other trusted adults for help can improve the situations for both caregiver and child.[24] If you feel like you or your child are experiencing negative emotional or behavioral effects due to a separation, please consider seeking licensed child- or family-counseling for help in navigating the situation. 

Contributed by: Maria Karla Bermudez

Editor: Jennifer (Ghahari) Smith, Ph.D.

1 Rodriguez, A. J., & Margolin, G. (2015). Parental incarceration, transnational migration, and military deployment: Family process mechanisms of youth adjustment to temporary parent absence. Clinical Child and Family Psychology Review, 18(1), 24-49. doi:https://doi.org/10.1007/s10567-014-0176-0

2 Ibid. 

3 The science is clear: Separating families has long-term damaging psychological and health consequences for children, families, and Communities. Society for Research in Child Development SRCD. (2018). Retrieved March 10, 2023, from https://www.srcd.org/briefs-fact-sheets/the-science-is-clear 

4 Ibid. 

5 Ibid. 

6 Rodriguez (2015)

7 SRCD (2018)

8 Antia, K., Boucsein, J., Deckert, A., Dambach, P., Račaitė, J., Šurkienė, G., Jaenisch, T., Horstick, O., & Winkler, V. (2020). Effects of International Labour Migration on the Mental Health and Well-Being of Left-Behind Children: A Systematic Literature Review. International Journal of Environmental Research and Public Health, 17(12). https://doi.org/10.3390/ijerph17124335

9 Antman F. M. (2012). Gender, Educational Attainment, and the Impact of Parental Migration on Children Left Behind. Journal of population economics, 25(4), 1187–1214. https://doi.org/10.1007/s00148-012-0423-y

10 Antia et al., (2020)

11  Mazzucato, V., & Schans, D. (2011). Transnational Families and the Well-Being of Children: Conceptual and Methodological Challenges. Journal of marriage and the family, 73(4), 704–712. https://doi.org/10.1111/j.1741-3737.2011.00840.x

12  Parrenas, R. S. (2005). Children of global migration: Transnational families and gendered woes. Stanford, CA: Stanford University Press.

13 Rodriguez (2015)

14 SRCD (2018)

15 Ibid. 

16 Rodriguez (2015)

17 Ibid. 

18 Ibid. 

19 Zhou, C., Lv, Q., Yang, N., & Wang, F. (2021). Left-Behind Children, Parent-Child Communication and Psychological Resilience: A Structural Equation Modeling Analysis. International journal of environmental research and public health, 18(10), 5123. https://doi.org/10.3390/ijerph18105123

20 Rodriguez (2015)

21 Church, C. (n.d.). Helping children through a parent's deployment. SMART Couples - University of Florida, Institute of Food and Agricultural Sciences - UF/IFAS. Retrieved March 12, 2023, from https://smartcouples.ifas.ufl.edu/married/military-couples-corner-/helping-children-through-a-parents-deployment/ 

22 Martoma, R. (2020, July 1). Tips to support children when a parent is in prison. HealthyChildren.org. Retrieved March 12, 2023, from https://www.healthychildren.org/English/healthy-living/emotional-wellness/Building-Resilience/Pages/Tips-to-Support-Children-When-a-Parent-is-in-Prison.aspx 

23 Church (n.d.)

24 Martoma (2020)

Deactivate Stress by Implementing CBT

Why Am I So Overwhelmed?

Stress is an unfortunate, yet inevitable, reaction to the pressure of life experiences that exceed one’s coping abilities. Work-related stress is one of the most prevalent experiences of heightened cortisol levels. However, several other areas of life can bring about feelings of stress such as relationships, health-concerns, bereavement, and difficulties with children.[1] Prolonged feelings of stress can have an impact on one’s behavioral, physical, and psychological health. For instance, heightened levels of stress can cause:[2]

While it is normal to experience stress during one’s life, an excessive amount of cortisol (i.e., the stress hormone) can lead to physical and psychological illness if not handled properly.[3] 

One way of understanding the origin of one’s stress is to analyze how specific personality traits and attitudes influence an individual’s ability to cope with stressors. For example, the concept of “locus of control” by Rotter (1960) suggests that individuals' perception of control over their lives has a significant impact on their behavior.[4] Individuals with an internal locus of control perceive themselves as having more power over their actions and greater understanding of what they can control in life. Whereas, individuals with an external locus of control perceive that they have little to no control over what happens in life and can potentially chalk negative events up to being unlucky.[5] When stressful situations maifest for external locus of control individuals, they are more likely to face the experience with a negative mindset such as, “Bad things always happen to me, I can’t cope anymore,” instead of deciding what they can do about it. 

The Power of CBT

Cognitive Behavioral Therapy (CBT) is a well-researched and evidence-based approach used to treat a range of mental health issues (e.g., depression, anxiety, substance use and eating disorders).[6] Cognitive theory suggests that a link exists between one’s feelings, thoughts, and behaviors. Therefore, CBT is utilized to help clients change problematic thinking patterns and in turn positively impact one’s feelings and behaviors.[7] Research has investigated the influence of CBT approaches on daily stressors. For example, a study by Barrett and Stewart (2021) investigated the efficacy of CBT in reducing work-related stress by instructing participants to identify occupational stressors as well as maladaptive patterns of thinking, feeling and behaving when responding to stress. CBT techniques were found to significantly decrease both stress and burnout among employees.[8] 

The American Psychological Association (2023) notes that CBT helps to reduce symptoms of stress through numerous techniques, including:[9] 

  • Gaining understanding of the link between thoughts and behaviors

  • Identifying and eliminating cognitive distortions

  • Developing problem-solving skills

  • Increasing self-confidence

  • Facing one’s fears

  • Learning to calm one’s body and mind

Daily CBT Practice

While CBT is best and ideally done under the guidance of a licensed mental health professional, there are steps individuals can take on their own to potentially reduce or lessen symptoms of stress. For instance, journaling is one activity that helps to identify feelings and thoughts that can lead to problematic behaviors. Being present and writing down thoughts can lead to a more logical understanding of thought patterns, potentially breaking the cycle of cognitive distortions.[10] Moreover, relaxation techniques such as meditation and yoga have been shown to target muscle tension and chronic pain. Clinical Psychologist, Michael Messina (2023), notes that incorporating breathwork and meditation into one’s daily practice can minimize overall anxiety and everyday stressors.[11] 

Eliminating Cognitive Distortions

Cognitive distortions are exaggerated patterns of thought not based on facts or logic. Distortions often perpetuate a negative filter for one’s perspective of themself and others.[12] For example, “Polarization” is a cognitive distortion that shows up as all-or-nothing thinking and causes one to view situations in terms of absolute. Polarization can lead to dwelling on mistakes or assuming that one will never be able to succeed instead of acknowledging an error and trying to move past it.[13] 

The unraveling of cognitive distortions is a primary goal of CBT that can be accomplished without the help of a therapist. Cognitive distortions must be identified and challenged to effectively reduce harmful automatic thoughts.[14] Once cognitive distortions have been identified, cognitive restructuring can take place by questioning how the distorted thoughts originally took root and why they are believed. For example, if a belief exists that having a high-paying job is the only way to be a respectable person, it is likely that the believer will think that they cannot be respected by others without a high-paying job. Instead of accepting faulty beliefs that lead to negative thoughts about oneself, one should stop to consider what actually makes a person “respectable,” including perspectives that have not been considered before.[15]

Other common examples of cognitive distortions include:[16]

  • Control Fallacy - Either feeling responsible for everything in your own life and other people’s lives, or feeling no control over anything.

  • Catastrophizing - Jumping to the worst possible conclusion in every scenario no matter how improbable it may be.

  • Overgeneralization - Turning one negative event into a never-ending pattern of loss and defeat. The terms, “always,” “never,” “everything,” and “nothing” tend to be frequent in one’s train of thought.

  • Shoulds - Having ironclad rules you set for yourself and others with no exceptions.

  • Discounting the Positive - Actively rejecting and invalidating good things that happen in your life.

To reduce the prevalence of cognitive distortions in one’s daily thought process, it is helpful to:[17] 

  • Become Aware - Step away, become present, and focus on your thought process.

  • Replace Absolutes - Replace absolute words like “always,” “never,” “everything,” and “nothing” with “sometimes”.

  • Avoid Labels - Instead of labeling yourself as “lazy,” consider, “I just didn’t clean today.” One action does not have to define you.

  • Look for the Positive - Think of three positive aspects per situation to build a new habit of thinking positively.

  • Invalidate Negative Thoughts - Investigate and question the validity of your thought process and realize that thoughts are not facts.

If feelings of stress are chronic and impact one’s everyday life, steps should be taken to reduce such negative experiences by contacting a licensed mental health professional for further guidance.[18]

Contributed by: Tori Steffen

Editor: Jennifer (Ghahari) Smith, Ph.D.

1 Puertas-Gonzalez, J. A., Mariño-Narvaez, C., Romero-Gonzalez, B., Sanchez-Perez, G. M., & Peralta-Ramirez, M. I. (2022). Online cognitive behavioural therapy as a psychological vaccine against stress during the COVID-19 pandemic in pregnant women: A randomised controlled trial. Journal of Psychiatric Research, 152, 397–405. https://doi-org.ezproxy.snhu.edu/10.1016/j.jpsychires.2022.07.016

2 Mayo Clinic. (2021). How stress affects your body and behavior. Stress management. https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/stress-symptoms/art-20050987

3 Puertas-Gonzalez et al., (2022)

4 Lopez-Garrido, G. (2023). Locus of Control Theory in Psychology: Definition & Examples. Simply Psychology. https://www.simplypsychology.org/locus-of-control.html

5 Puertas-Gonzalez et al., (2022)

6 American Psychological Association. (2023). What is cognitive behavioral therapy? American Psychological Association. https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral 

7 Ibid.

8 Barrett, K., & Stewart, I. (2021). A preliminary comparison of the efficacy of online Acceptance and Commitment Therapy (ACT) and Cognitive Behavioural Therapy (CBT) stress management interventions for social and healthcare workers. Health & Social Care in the Community, 29(1), 113–126. https://doi-org.ezproxy.snhu.edu/10.1111/hsc.13074

9 American Psychological Association (2023)

10 Messina, M. (n.d.). Practice cognitive behavioral therapy at home. Dr. Messina & Associates: Clinical Psychologists. https://www.drmessina.com/blog/practice-cognitive-behavioral-therapy-at-home

11 Ibid.

12 Ackerman, C. (2023). Cognitive distortions: 22 examples and worksheets. PositivePsychology.com. https://positivepsychology.com/cognitive-distortions/#experts-cognitive-distortions

13 Hartney, E. (2022). 10 cognitive distortions you'll learn about in therapy. 10 Cognitive Distortions That Can Cause Negative Thinking. Very Well Mind. https://www.verywellmind.com/ten-cognitive-distortions-identified-in-cbt-22412

14 Ackerman, C. (2023). CBT techniques: 25 cognitive behavioral therapy worksheets. 9 Essential CBT Techniques and Tools. https://positivepsychology.com/cbt-cognitive-behavioral-therapy-techniques-worksheets/#cbt-tools

15 Ibid.

16 Hartney (2022)

17 Ackerman (2023) Cognitive distortions

18 Mayo Clinic (2021)

Writing to Heal

A Basis in Bibliotherapy

The use of writing as a tool in the health field is not a new concept; it has roots in bibliotherapy, a form of therapy that began in the 5th century BCE. This therapy was based on the belief that literature could help people face the challenges that would arise in their daily lives, and was often used to treat melancholia (a condition of profound sadness and despair). It wasn’t until the 20th century that writing in therapy began to truly gain traction in the psychological world.[1]

Sigmund Freud, the founding father of psychoanalysis, is largely responsible for the growth of writing in therapy as a result of his 1907 presentation “Creative Writers and Day Dreaming” (which was eventually written and published). His speech bolstered the concept of writing as a therapy tool and it only continued to grow throughout the 1930s and 1940s, during which time the use of creative arts in therapy became popularized.[2] Currently, writing is one of the most commonly-used tools with patients in psychotherapy, even if it isn’t the focus of the therapy nor the core tool used.[3]

TYPES OF WRITING IN THERAPY

Writing can take several forms within a therapeutic setting. The first is free writing, which often comes in the form of journaling. When free writing, the client’s only instruction is to write what is on their mind; to put their thoughts on paper in whatever form they come in, without censoring or altering them.[4] Though this may seem basic, it’s entirely common for people to try and reject thoughts that they don’t find appealing. They often worry that, by acknowledging these thoughts, they’ll also be giving them credibility, or making them true.[5] However, repressing or denying thoughts instead of addressing them will only do more harm than good in the long run; thus, giving the client a space where they can express all of their thoughts (and easily reflect on them later) can be incredibly beneficial. 

Writing poetry is another often recommended outlet, for similar reasons. It provides a creative, positive avenue for a client to express their thoughts and emotions, and helps them channel even negative feelings into something productive.[6]

Letter writing is another common tool used in therapy. Essentially, the client is tasked with writing a letter; the recipient of the letter varies. It may be to themselves, to someone in their life they have unresolved issues with, or to a concept or issue that they’ve personified for the sake of the exercise. However, the letter will never actually be sent to anyone. Its purpose is to allow the client to communicate their feelings (on a given issue or person) to themselves more than to anyone else. By writing them down and expressing them in a way that would help the other person (whether they’re real or imaginary) understand their emotions and perspective, the client can gain a better understanding of their emotions on the matter.[7]

While it does not technically include writing, storytelling can also be used with young children in therapy in a manner very similar to (or even crossing over with) play therapy. One particularly famous example involves the use of dolls. In this exercise, the therapist gives their child client one or two dolls, and instructs them to tell the therapist a story using the dolls. In theory, the story the child tells using the dolls would be reflective of their own experiences, giving the therapist insight into the child’s understanding of and perspective on what they have gone through.

DISORDERS MOST-BENEFITED

Writing is commonly used to treat PTSD, anxiety and depression.[8] For all three psychological disorders, writing is helpful because it allows the patient to externalize their mental processes and emotions in a way that is productive and generally isn’t harmful to themselves or to others. Regarding PTSD, an example of writing therapy is demonstrated in a 2013 study by Lorenz et al.; they invited 70 women who experienced childhood sexual abuse to participate in five weekly 30-minute sessions that included writing therapy. In these sessions, participants would write about their traumas and sexual schemas. Then, at three different intervals—two weeks, one month and six months (post study) they were asked to complete questionnaires centered around their PTSD symptoms, depression, and sexual functioning. Not only did participants report fewer PTSD symptoms post-treatment, but those who wrote about their sexual schemas reported experiencing less sexual dysfunction.[9]

Writing can also be beneficial in treating anxiety. In 2020, the Tabriz University of Medical Sciences in Iran performed a study in which they administered three writing therapy sessions to pregnant women. Each week, they utilized writing therapy in different ways. In the first, the women were tasked with writing about concerns they had about their pregnancy and possible solutions. In the second, they were asked to write a story about their concerns, in which they applied the solutions they had brainstormed in the previous section. Finally, in the third, participants were led through a group discussion about their previous assignments. At the end of the study, the research team concluded that the women who had participated in writing therapy had much lower anxiety levels than the control group, despite having only experienced three sessions.[10]

Patients with depression can also benefit from writing therapy. In a 2014 study published in Cognitive Therapy and Research, two groups of undergraduate students were gathered and given separate tasks. The first was asked to engage in non-emotional writing (i.e., writing that does not focus on complicated emotions or traumatizing experiences). The second was asked to participate in emotional writing, with a special focus on emotional acceptance of traumatic experiences. At the end of the study, those who had engaged in emotional writing saw a reduction in their depressive symptoms, while those who had conducted non-emotional writing saw no change.[11]

Writing can also be used to treat issues that are not fully-fledged psychological disorders. When a person is looking to improve their self-esteem, process bereavement, find perspective or avoid relapses, their mental health provider may recommend incorporating writing into their treatment plan.[12] Writing is also frequently used with patients who have terminal or life-threatening illnesses. In addition to providing clients with an outlet for the undoubtedly complex, intense emotions they have about their condition, Murray (2002) notes that writing about one’s emotions and stress has been shown to improve immune functioning.[13]

ADDITIONAL BENEFITS OF WRITING THERAPY

There are numerous benefits to writing in therapy, including physical benefits. In addition to increasing immune function (though the exact explanation as to how has not yet been discovered),[14] Moy (2017) notes that writing has also been shown to lessen stress, lower blood pressure and can even improve liver function.[15] 

The benefits of writing extend beyond physical advantages. Students who engage in writing therapy often experience an improvement in their grades, likely in part because writing also strengthens a person’s memory (both in the sense of making them more apt to remember specific information and by improving their recall abilities). Writing also generally results in decreased symptoms of depression and reduced emotional distress, which can result in fewer missed days of work or school compared to those who don’t utilize writing therapy.[16]

Further, writing is a versatile tool that can be used in a variety of therapies, in one form or another. It also requires few resources, making it easily and readily available to clients.

LIMITATIONS

There are few disadvantages to writing therapy. Some patients will benefit with writing therapy more than others and some forms of writing will prove to be more effective than others, based on the individual. Therefore, it’s important to utilize different forms of writing until the one with greatest efficacy is determined. 

The biggest points of contention among psychologists regarding writing include: the discussion of venting vs. healing; and the risk of retraumatizing patients. Depending on the manner in which writing is utilized, a mental health provider may ask the patient to write about a traumatic experience that they endured. In doing so, the patient must, to some degree, relive the experience, and some psychologists worry that the process of reliving the trauma will only do the patient more harm than good.[17] Others argue that avoiding acknowledgment of the trauma is the real danger, and while the process of reliving the experience may be difficult or painful in the moment, the long-term relief will be worth the short-term struggle.[18]

If you’re interested in pursuing writing in therapy and exploring the psychological benefits of this modality, please reach out to a licensed mental health professional to discuss options and plan a course of action.

Contributed by: Jordan Rich

Editor: Jennifer (Ghahari) Smith, Ph.D.

1  Moy, J.D. (2017). Reading and writing one’s way to wellness: The history of bibliotherapy and scriptotherapy. New Directions in Literature and Medicine Studies, 15-30.  https://doi.org/10.1057/978-1-137-51988-7_2

2 Ibid.

3 Exploring Your Mind. (2018). Writing as a Therapeutic Tool.  https://exploringyourmind.com/writing-therapeutic-tool/

4 Tartakovsky, M. (2015). The Power of Writing: 3 Types of Therapeutic Writing. Psych Central. https://psychcentral.com/blog/the-power-of-writing-3-types-of-therapeutic-writing#1

5 Ibid.

6 Ibid.

7 Ibid.

8  Anderson, B. L., & Cyranowski, J. M. (1994). Women’s sexual self-schema. Journal of Personality and Social Psychology, 67(6), 1079–1100. https://doi.org/10.1037/0022-3514.67.6.1079

9  Lorenz, T. A., Meston, C. M., & Stephenson, K. R. (2013). Effects of expressive writing on sexual dysfunction, depression, and PTSD in women with a history of childhood sexual abuse: Results from a randomized clinical trial. The Journal of Sexual Medicine, 10(9), 2177–2189. https://doi.org/10.1111/jsm.12247

10  Esmaeilpour, K., Golizadeh, S., Mirghafourvand, M., Mohammad-Alizadeh-Charandabi, S., & Montazeri, M. (2020). The effect of writing therapy on anxiety in pregnant women: A randomized controlled trial. Iranian Journal of Psychiatry and Behavioral Sciences, 14(2). https://doi.org/10.5812/ijpbs.98256

11  Baum, E. S., & Rude, S. S. (2013). Acceptance-enhanced expressive writing prevents 

symptoms in participants with low initial depression. Cognitive Therapy and Research, 

37. 35-42. https://doi.org/10.1007/s10608-012-9435-x

12 Exploring Your Mind (2018)

13 Murray, B. (2002). Writing to Heal. Monitor on Psychology, 33(6), 54. 

https://www.apa.org/monitor/jun02/writing

14 Ibid.

15 Moy (2017)

16 Ibid.

17 Capozzi, B. (2021). The Benefits and Drawbacks of Therapeutic Writing. Step Up for Mental Health. 

https://www.stepupformentalhealth.org/benefits-and-drawbacks-of-therapeutic-writing/

18 Ibid.

Chemical Exposures That May Cause Depression

Agricultural Workers & Pesticides

At 55 years old, Matt Peters, an Iowa farmer, took his own life.[1] While there are known to be higher rates of depression amongst agricultural workers, his wife Ginny noticed that every year his mood shifted towards depression in the spring at the time when he sewed his field with pesticide-treated seeds and believes pesticide exposure may have caused this annual change in demeanor.[2] While this story, by itself, is anecdotal and does not prove correlation, in the past 30 years, a growing body of research has emerged exploring the relationship between chemical exposure and depression.

The etiology of depression is believed to be determined by a variety of influences including environmental, social, and genetic.[3] In 2012 and 2015, compared to the general occupational rate of 17.3 per 100,000, the highest suicide rates of 44.9 and 32.2 per 100,000 were found in those that worked in the agricultural, fishing, and forestry sectors.[4] The notion that there may be a relationship between depression in farmers and pesticides use emerged 30 years ago when Beseler et al., (2008) conducted a study from 1993 to 1997, and found farmers with cumulative high-intensity pesticide exposure were associated with higher rates of depression compared to controls.[5]

Pesticides are designed to be toxic by targeting systems of rodents, weeds, fungi, or insects - and these impacts can potentially be damaging to human systems, as well.[6] In 2013, Freire & Koifman conducted a systematic review of epidemiological evidence and found five studies that showed a statistically significant increased risk of psychiatric disorders associated with previous pesticide poisonings.[7] The same review found four studies demonstrating that in areas with intensive pesticide use there was an increased risk of suicide, though the authors recommend future prospective studies be conducted to explore these relationships.[8] These findings were similar to other reports including a 2008 study conducted by Browning et al. which found that White male farmers residing in North Carolina, South Carolina, and Kentucky had higher rates of suicide than the general White male population residing in the same states.[9] The epidemiological team led by Beard et al. (2014) found that out of 19,506 agricultural workers studied, depression was linked to those who used seven individual pesticides which fell into two specific classes: organochlorine insecticides and fumigants.[10] Diagnosis of depression was 90% more likely amongst farmers who used organochlorine insecticides and it was up 80% for those who used fumigants.[11] Similarly, Reed et al. (2020) conducted a systematic search of literature published from June 2019 to January 2020 and found thirteen studies on the relationship between exposure to pesticides/chemicals and the risk of depression/suicide.[12]

Based on their research, Reed et al., note that the awareness of depression in agricultural workers may prove especially challenging to address in rural areas where access to mental health may already be limited.[13] Additionally, despite a growing body of research exploring this correlation, conclusive results require further research. Previously published studies often use self-report methods which can make clear thresholds difficult to determine.[14] While most researchers conclude further scientific studies are needed on this topic, they simultaneously encourage occupational health providers to be aware of farm exposures that may influence symptoms of depression.[15]

Pregnancy & Early Childhood Development

Jacobsen et al., (2022) note that research indicates that women in both pregnancy and postpartum periods experience an increased susceptibility to environmental chemicals exposures.[16] Bisphenol A (BPA) and phthalates are sometimes referred to as “everywhere chemicals” because of their presence in ordinary products manufactured from polycarbonate plastics.[17] BPA is an endocrine-disrupting chemical that is often found in drink containers, sales receipts, and medical devices.[18] Even at low doses, it is known to interfere with hormone balances (via multiple steroid hormone receptors that mediate a myriad of cellular effects).[19]

Any chemicals that are endocrine disruptors can affect endogenous hormone levels, which may be more substantial during the dramatic psychological and hormonal changes that take place during pregnancy, delivery and childbirth.[20] In looking at the impacts of persistent organic pollutants, Jacobsen et al. (2022) found that studies analyzing the results of exposure to polybrominated diphenyl ethers (a class of chemicals used to increase fire resistance in household products)[21] during pregnancy consistently showed an increase in symptoms of perinatal depression.[22] It is recommended that further study in this area, including biospecimen collection and biomarkers, are needed to further understand this relationship.[23]

There are also indications that maternal chemical exposures during pregnancy and early childhood exposure may have ongoing impacts on mental health in later life. In children, there is evidence indicating that postnatal BPA exposure may be linked to other neurobehavioral impairments such as attention-deficit hyperactivity disorder (ADHD).[24] Perera et al. (2016) conducted an analysis of BPA in a group of mothers in Northern Manhattan from pregnancy through the first 10-12 years of the child’s age, monitoring levels of BPA in urine during the third trimester of pregnancy with follow up analysis of the children’s urine at ages 3 and 5.[25] The research showed significant positive association between higher levels of prenatal BPA and higher levels of anxiety and depression in boys 10-12 years of age with no corresponding relationship in girls.[26]

Lead exposure is another chemical exposure believed to impact mental health and may come through contaminated water, paint, mining, pottery, smoking, and industrial processes.[27] Children tend to absorb a higher amount of ingested lead than adults, and since lead accumulates in the body throughout life and is released slowly, exposure in early childhood and adolescence can have impacts later in life.[28] Research conducted by Bouchard et al. (2009) found young adults with blood-lead levels in the highest quintile were found to have 2.3 times the odds of being diagnosed with major depressive disorder.[29] A study conducted in Jintan, China involving 1,341 children showed that increased lead levels were associated with emotional problems, developmental problems, and anxiety.[30] Similar research from New Zealand indicates that early-life exposure during the era of leaded gasoline may have contributed to subtle changes in emotion and behavior.[31] The study followed 579 people for more than 30 years found a relationship between lead exposure and the development of depression, mania, phobia, and schizophrenia.[32] Lead in gasoline has since been banned in most countries, and while earlier exposure cannot be reversed, this information can be used to screen individuals with earlier lead exposure for symptoms of depression and provide treatment options that can improve their quality of life.[33]

While examining any chemical impacts on mental health, it is important to note that research is still emerging, and findings are sometimes mixed. A systematic review conducted by Cybulska et al. (2021) on the relationship between cadmium and lead levels in blood with symptoms of depression found that while nine out of thirteen studies did show an association between lead levels and depression there are many factors that can influence both the blood levels and the psychological diagnosis indicating the need for further research.[34]

Industrial Occupational Exposure

Occupational and environmental exposures to polychlorinated biphenyls (PCBs) have been shown to be related to symptoms of depression.[35] In the US, production of PCBs was banned by the Toxic Substances Control Act (TSCA) in 1979.[36] In international production, this group of chemicals (which was commonly used in manufacturing during the 20th century) was banned worldwide in 1995 by the United Nations Environmental Programme, but due to their high persistence, they can still be detected in the environment and exposure can occur in occupations that work with older electronic devices.[37] EPA regulations within the US also allow for the inadvertent generation of some PCBs under specified concentrations and conditions with required reporting to the EPA.[38]

The dangers of PCB exposure have been known for some time with the World Health Organization (WHO) stating in 1985 that exposure to organic solvents were known to be associated with memory complaints, sleep disturbance, depression, irritability, attention deficits, and fatigue.[39] Studies in both humans and animals show evidence that PCBs can influence the dopamine system leading to depressive symptoms.[40] A German study conducted by Gaum et al. (2017), collected data from 178 participants examining occupational exposure to high levels of PCB over a one-year period and found a positive correlation of PCB exposure with severity of depressive symptoms mediated by lower concentrations of homovanillic acid found in blood plasma as a surrogate biomarker for dopamine.[41] This analysis provides the foundation for a potential causal pathway between PCB exposure and increases in depression.[42] Products produced before 1979 that may contain PCBs include plastics, cable insulation, oil-based paints, transformers, electrical equipment, adhesives, floor finish and carbonless copy paper.[43]

PCBs are only one type of persistent organic pollutants (POPs) which are known to cause depression and anxiety after chronic exposure.[44] In comparison, both acute and chronic exposure to nonpersistent organic chemicals (including organometals, organophosphates, and solvents) are believed to be linked to more severe psychiatric symptoms which not only include depression and anxiety, but can also include psychosis, mania and aggression.[45] Research conducted by Saraei et al. (2022) studied 396 industrial workers to determine whether there was a relationship between solvent exposure (in the form of benzene, xylenes, ethyl benzene, and toluene) and depression.[46] This analysis showed that workers with a significant association of solvent exposure showed a high frequency of depressive symptoms.[47] It is recommended that individuals and clinicians be aware of potential psychiatric impacts following chemical exposures due to chemical accidents, solvent inhalation, or community exposure.[48]

Air Pollution & Global Mental Health

In addition to direct chemical exposure, there is growing research indicating that higher rates of specific types of air pollution may be associated with increases in depression both in the general population and specified age groups through either a direct or indirect causal pathway. An analysis conducted by Qiu et al. (2023) of those who lived in specified US zip codes found that prolonged exposure to high levels of air pollutants was linked to an increased risk of new diagnoses for depression in adults age 64 and older.[49] The cohort study analyzed data collected from 8,907,422 Medicare participants from 2005-2016 and found that for every increase in five units of long-term mean exposure to the air pollutants ozone (O3), nitrogen dioxide (NO2), and small particulate matter measuring ≤2.5 μm (PM2.5) was associated with a statistically significant increase in depression.[50] One potential pathway for this relationship is that the pollution exposure causes increased levels of oxidative stress in the brain, which then activates the hypothalamic-pituitary-adrenal axis, which can trigger the release of stress hormones and lead to depression.[51] These findings can potentially have implications on a global level since most of the world’s population are believed to reside in areas where particulate matter exceeds recommendations of the World Health Organization (WHO).[52]

A similar study conducted by Petkus et al. (2020) on three-year exposure to PM2.5 in 2,202 women aged 67-83 found a significant correlation between PM2.5 exposure and accelerated declines in free-recall memory and verbal learning, but no significant association with depressive symptoms.[53] However, there were associations found between reductions in episodic memory and increased symptoms of depression indicating that PM2.5 exposure may indirectly increase symptoms of depression.[54]

The American Psychological Association warns that exposure over time to the air pollutant ozone may be linked to increased depressive symptoms in adolescents.[55] The study conducted by Manszak et al. (2022) tracked whether neighborhood ozone levels over a four-year period affected depressive symptoms in 213 adolescents aged 9-13 at the beginning of the study.[56] Results indicated adolescents who lived in neighborhoods with higher levels of ozone showed increases in symptoms of depression even when ozone fell within acceptable levels of exposure by both state and national air quality standards.[57]

Additional research suggests exposure to air pollutants may be associated with higher rates of depression in the general population. A meta-analysis conducted by Borroni et al. (2022) looked at 39 studies and found an increased risk of depression associated with long term exposure to PM2.5 and nitrogen dioxide NO2.[58] Depressive symptoms were also found to be associated with short-term exposure to other air pollutants including sulfur dioxide (SO2), ozone (O3), carbon monoxide (CO) and particulate matter measuring ≤10 μm (PM10).[59] These findings correlate with research conducted by Szyszkowicz et al. (2009) in Canada showing an increase in emergency room visits for depression on days with higher levels of the ambient pollutants carbon monoxide, nitrogen dioxide, and sulfur dioxide.[60]

Practical Steps

Psychiatric disorders, including depression, are believed to have increased over 18% between 2005 and 2015, affecting 300 million people worldwide.[61] Research is still being conducted to evaluate whether further environmental factors influence depression, including noise pollution, urbanization, electromagnetic fields and pollen.[62] In contrast, there are also some indications that exposure to natural environments may have a calming effect that can potentially reduce the risk of depression.[63] Since it is generally considered healthy to be outdoors, being aware of what pollutants may be in the area (e.g., using weather alerts to monitor outdoor air quality) may allow individuals to still receive the mental health benefits of spending time outdoors while reducing exposure to potential pollutants.

While it may not be possible for an individual to isolate themselves from all potential chemical exposures, some precautions can be taken to avoid unnecessary risk. Individuals working with hazardous chemicals should read warning labels and adhere to safety guidelines utilizing personal protective equipment when recommended.

Regardless of known chemical exposure, if a person experiences symptoms of depression such as feeling sad, hopeless, anxious, or worthless it is advisable to speak with a licensed medical professional to determine if psychotherapy or medication may be beneficial.[64]

Contributed by: Theresa Nair

Editor: Jennifer (Ghahari) Smith, Ph.D.

REFERENCES

1 Bienkowski B. High rates of suicide, depression linked to farmers' use of pesticides. Scientific American Web site. https://www.scientificamerican.com/article/high-rates-of-suicide-depression-linked-to-farmers-use-of-pesticides/. Updated 2014. Accessed March 15, 2023.

2 Ibid.

3 van den Bosch M, Meyer-Lindenberg A. Environmental exposures and depression: Biological mechanisms and epidemiological evidence. Annual Review of Public Health. 2019;40(1):239-259. https://www.annualreviews.org/doi/pdf/10.1146/annurev-publhealth-040218-044106. doi: https://doi.org/10.1146/annurev-publhealth-040218-044106.

4 Reed DB, Claunch DT. Risk for depressive symptoms and suicide among U.S. primary farmers and family members: A systematic literature review. Workplace Health & Safety; Workplace Health Saf. 2020;68(5):236-248. doi: 10.1177/2165079919888940.

5 Beseler CL, Stallones L, Hoppin JA, et al. Depression and pesticide exposures among private pesticide applicators enrolled in the agricultural health study. ENVIRON HEALTH PERSP. 2008;116(12):1713-1719. doi: 10.1289/ehp.11091.

6 van den Bosch & Meyer-Lindenberg (2019)

7 Freire C, Koifman S. Pesticides, depression and suicide: A systematic review of the epidemiological evidence. Int J Hyg Environ Health. 2013;216(4):445-460. https://www.sciencedirect.com/science/article/pii/S1438463912001393. doi: 10.1016/j.ijheh.2012.12.003.

8 Ibid.

9 Reed & Claunch (2020)

10 Beard JD, Umbach DM, Hoppin JA, et al. Pesticide exposure and depression among male private pesticide applicators in the agricultural health study. Environ Health Perspect. 2014;122(9):984-991. doi: 10.1289/ehp.1307450.

11 Bienkowski (2014)

12 Reed & Claunch (2020)

13 Ibid.

14 van den Bosch & Meyer-Lindenberg (2019)

15 Reed & Claunch (2020)

16 Jacobson MH, Ghassabian A, Gore AC, Trasande L. Exposure to environmental chemicals and perinatal psychopathology. Biochem Pharmacol. 2022;195:114835. https://www.sciencedirect.com/science/article/pii/S0006295221004512. doi: 10.1016/j.bcp.2021.114835.

17 van den Bosch & Meyer-Lindenberg (2019)

18 Perera F, Nolte ELR, Wang Y, et al. Bisphenol A exposure and symptoms of anxiety and depression among inner city children at 10-12 years of age. Environ Res. 2016;151:195-202. doi:10.1016/j.envres.2016.07.028

19 Mustieles V, Messerlian C, Reina I, Rodríguez-Carrillo A, Olea N, Fernández aMF. Is bisphenol A (BPA) a threat to children's behavior? Journal of Mental Health & Clinical Psychology. 2018;2(1). https://www.mentalhealthjournal.org/articles/is-bisphenol-a-bpa-a-threat-to-childrens-behavior.html. Accessed Mar 28, 2023.

20 Jacobsen et al. (2022)

21 Center for Disease Control (CDC). Polybrominated diphenyl ethers (PBDEs) and polybrominated biphenyls (PBBs) factsheet | national biomonitoring program | CDC. https://www.cdc.gov/biomonitoring/PBDEs_FactSheet.html. Updated 2021. Accessed Mar 28, 2023.

22 Jacobsen et al. (2022)

23 Ibid.

24 Mustieles et al. (2018)

25 Perera et al. (2016)

26 Ibid.

27 Bouchard MF, Bellinger DC, Weuve J, et al. Blood lead levels and major depressive disorder, panic disorder, and generalized anxiety disorder in US young adults. Arch Gen Psychiatry. 2009;66(12):1313-1319. doi:10.1001/archgenpsychiatry.2009.164

28 CDC (2021)

29 Bouchard et al. (2009)

30 Shute N. Lead exposure may cause depression and anxiety in children. National Public Radio (NPR) Web site. https://www.npr.org/sections/health-shots/2014/06/30/326940022/lead-exposure-causes-anxiety-and-depression-in-chinese-children. Updated 2014. Accessed March 15, 2023.

31 Mozes A. Https://Www.webmd.com/mental-health/news/20190123/childhood-lead-exposure-raies-mental-rises-later. Web MD Web site. https://www.webmd.com/mental-health/news/20190123/childhood-lead-exposure-raies-mental-rises-later. Updated 2019. Accessed March 15, 2023.

32 Harvard. Study finds link between childhood lead exposure and mental illness. News Web site. https://www.hsph.harvard.edu/news/hsph-in-the-news/childhood-lead-exposure-mental-illness/. Updated 2019. Accessed Mar 28, 2023.

33 Mozes (2019)

34 Cybulska AM, Grochans S, Kamińska MS, Bosiacki M, Skonieczna-Żydecka K, Grochans E. Are cadmium and lead levels linked to the development of anxiety and depression? - A systematic review of observational studies. Ecotoxicol Environ Saf. 2021;216:112211. https://www.sciencedirect.com/science/article/pii/S0147651321003225. doi: 10.1016/j.ecoenv.2021.112211.

35 Gaum PM, Gube M, Esser A, Schettgen T, Quinete N, Bertram J, Putschögl FM, Kraus T, Lang J. Depressive Symptoms After PCB Exposure: Hypotheses for Underlying Pathomechanisms via the Thyroid and Dopamine System. International Journal of Environmental Research and Public Health. 2019; 16(6):950. https://doi.org/10.3390/ijerph16060950

36 United States Environmental Protection Agency (EPA). Learn about polychlorinated biphenyls (PCBs). https://www.epa.gov/pcbs/learn-about-polychlorinated-biphenyls-pcbs. Updated 2022. Accessed Mar 28, 2023.

37 Gaum et al. (2019)

38 EPA (2022)

39 Saraei M, Golshan M, Aminian O. Association between solvent exposure and depression among industrial workers | SpringerLink. Journal of Public Health. 2022;30:953-958. https://link.springer.com/article/10.1007/s10389-020-01376-y#citeas. Accessed Mar 17, 2023. doi: https://doi.org/10.1007/s10389-020-01376-y.

40 Gaum et al. (2019)

41 Ibid.

42 Ibid.

43 EPA (2022)

44  Brown Jr. JS. Psychiatric effects of organic chemical exposure. In: Effects of persistent and bioactive organic pollutants on human health. ; 2013:514-531. https://doi.org/10.1002/9781118679654.ch19. 10.1002/9781118679654.ch19.

45 Brown (2013)

46 Saraei et al. (2022)

47 Ibid.

48 Brown (2013)

49 O’Mary L. Air pollution linked to depression in older adults: Study. WebMD Web site. https://www.webmd.com/depression/news/20230213/air-pollution-linked-depression-older-adults-study. Accessed Mar 28, 2023.

50 Qiu X, Shi L, Kubzansky LD, et al. Association of Long-term Exposure to Air Pollution With Late-Life Depression in Older Adults in the US. JAMA Netw Open. 2023;6(2):e2253668. doi:10.1001/jamanetworkopen.2022.53668

51 Ibid.

52 Ali NA, Khoja A. Growing Evidence for the Impact of Air Pollution on Depression. Ochsner J. 2019;19(1):4. doi:10.31486/toj.19.0011

53 Petkus AJ, Younan D, Widaman K, et al. Exposure to fine particulate matter and temporal dynamics of episodic memory and depressive symptoms in older women. Environ Int. 2020;135:105196. https://www.sciencedirect.com/science/article/pii/S0160412019313613. doi: 10.1016/j.envint.2019.105196.

54 Ibid.

55 American Psychological Association (APA). Air pollution linked to depressive symptoms in adolescents. American Psychological Association (APA) Web site. https://www.apa.org/news/press/releases/2022/03/air-pollution-adolescents. Updated 2022. Accessed Mar 28, 2023.

56 Manczak E, Miller J, Gotlib IH. Census tract ambient ozone predicts trajectories of depressive symptoms in adolescents. American Psychological Association. 2022. https://www.apa.org/pubs/journals/releases/dev-dev0001310.pdf. Accessed Mar 28, 2023.

57 APA (2022)

58 Borroni E, Pesatori AC, Bollati V, Buoli M, Carugno M. Air pollution exposure and depression: A comprehensive updated systematic review and meta-analysis. Environmental Pollution. 2022;292:118245. https://www.sciencedirect.com/science/article/pii/S0269749121018273. doi: 10.1016/j.envpol.2021.118245.

59 Ibid.

60 Szyszkowicz, M., Rowe, B. H., & Colman, I. (2009). Air pollution and daily emergency department visits for depression. International journal of occupational medicine and environmental health, 22(4), 355–362. https://doi.org/10.2478/v10001-009-0031-6

61 Ali & Khoja (2019)

62 van den Bosch & Meyer-Lindenberg (2019)

63 Ibid.

64  National Institute of Mental Health (NIMH). Depression. National Institute of Mental Health (NIMH) Web site. https://www.nimh.nih.gov/health/topics/depression. Updated 2022. Accessed Mar 28, 2023.

When Dreams Overpower Reality: Maladaptive Daydreaming

Maladaptive Daydreaming - What’s the Harm?

Daydreams can be a regular part of daily life—fleeting flights of fancy that come and go, often lasting no more than a few minutes at a time. However, sometimes daydreams can begin to get out of hand. They can stretch out for hours at a time, and become so detailed and realistic that a person feels intense, authentic emotions in response to them.[1] These daydreams can become  so overly involved that they bring the person to unconsciously speak or act out things that are occurring in their daydreams, and start to absorb more of a person’s attention and time than their real lives do.[2] At face value, maladaptive daydreaming may seem harmless. It’s easy to dismiss it as simply an “overactive imagination,” to expect the individual to simply control their wandering mind, and to undercut the potential consequences it carries. If daydreaming is common and natural - when does it become maladaptive?

The short, simple answer is that daydreams begin to become maladaptive when they begin to have a strong, negative impact on a person’s daily life. Poerio (2023) explains that those who experience maladaptive daydreaming cannot just turn off their daydreams, or shift their focus; the need to actively engage in, and be consumed by, their daydreams is a compulsion. As such, the act of daydreaming can overpower multiple facets of their day-to-day life. These individuals will, often entirely unintentionally, prioritize their daydreams over commitments to things such as school or work; they will let coursework, tests, and projects go undone in favor of focusing on their fantasies.[3] A study performed by Jayne Bigelsen and her colleagues (2015) reported that some maladaptive daydreamers spend at least half of their waking hours daydreaming and honing the intensely detailed plots they create.[4] 

Similarly, social lives of maladaptive daydreamers can also suffer as a result of this condition. They will fail to respond to their friends, be present in relationships or go on outings purely because they are so focused on their daydreams, which can take up several consecutive hours of their day.[5] The effect that maladaptive daydreaming has on an individual’s life is so great that, Soffer-Dudek (2022) concluded in a study that nearly half of the sample of maladaptive daydreamers were unemployed, and more than a fourth had attempted suicide at least once in their life.[6]

WHAT CAUSES MALADAPTIVE DAYDREAMING?

While one, definitive cause of maladaptive daydreaming has not been discovered, multiple factors may influence whether or not a person will develop this disorder. Some theories suggest that maladaptive daydreaming is a coping mechanism. If an individual’s life or experiences are intensely traumatic, they can develop the capability to create a different, safer, more preferable world to escape into—only to have that coping strategy get out of hand and become a dominant fixture in their life.[7] The appeal of their daydreams lies in just how rewarding they are compared to their daily lives. However, many without traumatic histories experience maladaptive daydreaming, with some reporting that their daydreams are actually more intense or stressful than their real lives are.[8]

Others point at the link between maladaptive daydreaming and other disorders, namely OCD, depression, and anxiety. Somer and his colleagues (2017) reported that over half of the participants who experienced maladaptive daydreaming also exhibited symptoms of OCD (though it’s not stated whether or not those participants were actually diagnosed with OCD).[9] As such, the same mechanisms in our brains that result in OCD may also influence the development of maladaptive daydreaming. With anxiety and depression, on the other hand, maladaptive daydreaming is viewed more as a reaction to the already existing disorders. Because the daydreams supposedly provide “an escape from intolerable feelings and conflicts, emptiness, stressful external conditions, and/or unresolved trauma,” the presence of depression and anxiety can spur a person into developing maladaptive daydreaming. However, while these daydreams may provide temporary relief, they are not a functional long-term solution; that brief comfort provided via daydreaming leads to feeling even more discomfort when the daydream ends—often driving the individual to daydream even more frequently in an effort to cognitively escape.[10]

At the present time, maladaptive daydreaming is not an officially recognized disorder, and thus, a person can’t technically be “diagnosed” with it. However, a physician or licensed, qualified mental health professional can still assess if a person is engaging in maladaptive daydreaming. One diagnostic tool, the Structured Clinical Interview for maladaptive daydreaming (SCIMD), is a 16-item test that asks an individual questions about their daydream triggers, how they feel while daydreaming, and how their daydreams affect their daily life.[11]

THE DAYDREAMERS’ PERSPECTIVE

Maladaptive daydreams can range from wild, fantastical storylines, to personal renditions of popular media, to stories that seem entirely grounded in reality. One individual might daydream about a world with hyper-advanced space travel, and all that entails.[12] Another might daydream about their own life, with only minor tweaks here and there. Another might daydream about being involved in an existing foreign conflict.[13] 

While maladaptive daydreaming can negatively impact a person’s life in a variety of ways, many people who experience it have a positive relationship with their condition, and would not sacrifice it if given the opportunity.

Lee (2019) describes a Canadian teenager named Maddie. By her own account, Maddie has been maladaptively daydreaming since she was a young child; as a little girl, she often paced in her driveway while daydreaming. She did this often enough and for long enough periods to wear through the grass and leave a strip of exposed dirt in her wake.[14] These vivid, consuming daydreams continued to be regular parts of her day through her teen years; by her estimate, she spends about four hours every single day daydreaming.[15] The time that her daydreams command has affected her schoolwork, social life, and her perception of her own identity, since she feels she knows the Maddie that exists in her daydreams better than the one that exists in real life. The extent of her daydreams even caused her to question her sanity in her early teen years, before learning about the concept of maladaptive daydreaming. But despite the confusion and distress it has caused her, and the impact it has on her outside life, Maddie considers her maladaptive daydreaming to be a part of her, and enjoys many parts of it.[16]

Karina Lopez, another individual who experiences maladaptive daydreaming, shares a similar fondness for her condition. That’s not to say that maladaptive daydreaming doesn’t complicate aspects of her life. Many times in the past, her daydreams have taken priority over necessary tasks, such as grocery shopping or studying for important exams.[17] In her college years, she would spend up to six hours a day daydreaming; she has since brought that number down to three. Much like Maddie, though, regardless of the negative impacts, Karina does (to some degree) love her condition. She enjoys the process of fine-tuning the daydreams, and looks forward to engaging with them, stating, “As soon as I wake up, I want to daydream.”[18]

However, this welcoming perspective isn’t universal. Unlike Maddie and Karina, both of whom report having experienced maladaptive daydreaming since their youth, Carol didn’t begin maladaptive daydreaming until she reached middle adulthood, and believes the daydreams were brought about by the hormonal shift that came with menopause.[19] While Maddie and Karina both view their daydreams as fascinating stories to explore and retreat into, Carol describes her daydreaming as being similar to, “being tied to a chair and forced to watch a film.” She also feels that her maladaptive daydreaming negatively impacts her creativity, since all of her creative energy is being funneled into her daydreams, whether she wants it to be or not.[20]

TREATMENT OPTIONS

Proposed treatment options for maladaptive daydreaming are limited, for two reasons. The first reason is maladaptive daydreaming is still a relatively new term and concept, having only been coined by Dr. Eli Somer in 2002.[21] Therefore, in the grand scheme, there has been limited time to research the condition or test the effectiveness of varying treatment options. Secondly, while maladaptive daydreaming is gaining more recognition among the medical and mental health communities, it is not yet recognized in the DSM-5 as a psychological disorder at this point in time.

Currently, the most recommended form of treatment for maladaptive daydreaming is cognitive behavioral therapy (CBT).[22] The goal of treatment with CBT is to help the individual understand why they have developed the tendency to daydream to such an excessive extent, and how best to manage their symptoms and ground themselves in reality.[23] Because of its believed link to conditions like anxiety, OCD and depression, therapies and treatment methods employed for those disorders may also be beneficial for those experiencing maladaptive daydreaming.[24]

If you think you may be experiencing maladaptive daydreaming, please reach out to a licensed mental health professional for guidance and treatment options.

Contributed by: Jordan Rich

Editor: Jennifer (Ghahari) Smith, Ph.D.

1 Jay, S. (2023). Maladaptive Daydreaming. Sleep Foundation.

https://www.sleepfoundation.org/mental-health/maladaptive-daydreaming

2 Ibid.

3 Poerio, G. (2023). When too much daydreaming becomes a disorder. CNN.

https://www.cnn.com/2023/01/09/health/maladaptive-daydreaming-disorder-wellness-partner/index.html

4 Ibid.

5 Ibid.

6 Soffer-Dudek, N. (2022). Why We Should Take “Maladaptive Daydreaming” Seriously. 

Psychology Today. 

https://www.psychologytoday.com/us/blog/consciousness-and-psychopathology/202205/why-we-should-take-maladaptive-daydreaming-seriously

7 Poerio (2023)

8 Robson, D. (2022). ‘I just go into my head and enjoy it’: the people who can’t stop 

daydreaming. The Guardian. 

https://www.theguardian.com/science/2022/aug/28/i-just-go-into-my-head-and-enjoy-it-the-people-who-cant-stop-daydreaming

9 Poerio (2023)

10 Laderer, A. (2022). Here’s What Maladaptive Daydreaming Really Feels Like. Wonder Mind. https://www.wondermind.com/article/maladaptive-daydreaming/

11 Cirino, E. (2021). Maladaptive Daydreaming. Health Line.

https://www.healthline.com/health/mental-health/maladaptive-daydreaming

12 Robson (2022)

13 Lee, J. (2019). Maladaptive Daydreaming — How this psychiatric condition can impact creativity. We Present. https://wepresent.wetransfer.com/stories/maladaptive-daydreaming

14 Ibid.

15 Ibid.

16 Ibid.

17 Robson (2022)

18 Ibid.

19 Lee (2019)

20 Ibid.

21 Laderer (2022)

22 Cleveland Clinic. (2022). Maladaptive Daydreaming. 

https://my.clevelandclinic.org/health/diseases/23336-maladaptive-daydreaming

23 Ibid. 

24 Laderer (2022)

Marginalized Groups & Telework: Transforming Workplace Culture

Covid-19:Working from Home

Three years into the pandemic, the average American’s workday has significantly changed. Remote work, which emerged for many companies as the needed response to the mounting cases of COVID-19, now appears to be here to stay. Pew Research Center found that prior to the pandemic, only 17% of Americans worked from home.[1] But their follow-up study found that by the end of the pandemic’s first year, over 71% of people were engaged in remote work; from 2021 to 2023 these numbers have remained steady and a 2022 study by Phillips noted 74% of surveyed workers expect remote work to endure.[2,3] In particular, marginalized groups are embracing the teleworking boom as minorities face a greater risk of microaggressions, pay gaps, and other forms of discrimination in office environments.

DIFFERENCES BETWEEN DEMOGRAPHICS IN WORKPLACE NAVIGATION

Remote work has created a new consideration: Even if I enjoy my job, do I enjoy being physically there? For the average person, the answer is “No.” Only 21% of White and 3% of Black Americans are interested in returning to the office full-time, favoring a hybrid or full-time remote schedule. Further, Latinx and Asian Americans report experiencing a higher sense of belonging within their work culture when they are able to work hybridly or remotely. In a 2021 survey of 100,000 workers conducted by the Future Forum, results showed that 80% of Black, 78% of Latinx, and 77% of Asian respondents wanted a flexible working experience, either through a hybrid or remote-only model.[4]

Much of the apprehension racial minorities feel towards returning to full-time office culture comes in response to many of the unwritten professional biases that favor White American values and can leave people of color to face discrimination and exclusion.[5] According to the Stanford Social Innovation Review, regardless of industry, American work spaces tend to promote certain cultural norms: speak in standard English, communicate without an accent and with little emotion, and adhere to Western standards of dress such as straight hair and heteronormative clothing.[6] For the straight, White American male, these expectations began in child-rearing and many felt a seamless transition into the workforce. However, rooting professionalism in the dominant Western culture compounds stress for minorities, many of whom find themselves code-switching in daily interactions with peers and at the brunt of frequent verbal or behavioral slights (e.g., “You speak so well” to a person of color, or “You’re very demanding” to a female leader).[7]

Commonly referred to as microinvalidations or microaggressions, these behaviors are aimed at racial, ethnic, and gender-nonconforming minorities; while they may be short-lived and even unintentional, they represent larger implicit biases and in the long-term they impact minorities’ self-image, sense of belonging within a space, physical and mental health.[8] In a study by Hall & Fields (2015) of American Indians, individuals who were victims of microaggressions reported feeling tension, anxiousness and digestive issues such as reflux disease and GI conditions.[9] A study conducted by Torres & Driscoll (2010) found that microaggressions are also extremely disruptive to one’s work: the energy a person expends deciding if comment was a slight against them takes away from other potentially important, work-related tasks.[10]

Remote work, then, can act as a protective barrier from microinvalidations or microaggressions, allowing for marginalized communities to work without the distractions that can be detrimental to both their health and productivity.  

Differences amongst demographics in managerial roles further explain why marginalized groups feel less attached to in-person work. 2021 Census data found that 67% of managers are White Americans; Hispanic, Asian, and Black Americans collectively hold less than 25% of managerial roles and only 10% of managers identify as LGBTQ+.[11] Further, minorities and female employees make up the majority of blue-collar and service jobs, both of which are often highly physical forms of employment that further limit these marginalized groups’ access to remote jobs.[12] With limited managerial roles, women, people of color, and other minorities have less representation in decisions within their companies, and as a result, they often feel less inclined to be physically present in the workspace. 

DIFFERING VIEWS ON TELEWORK AMONG LEADERS 

Nearly seven-in-ten employees (68 percent) said they would rather look for a new job than return to the office, according to a 2023 survey from Clarify Capital (a financial consultancy in New York City that surveyed more than 1,000 remote workers).[13] However, some CEOs and other business leaders of high profile companies have come out with arguments in favor of workers returning to the office. Disney’s Bob Iger, Starbucks’ Howard Schultz, and Goldman Sachs’ David Solomon are a few of the CEOs who spokehave come out in early 2023 requiring workers to spend a dedicated number of weekly hours in the workplace.[14] Cumulatively, their arguments in favor of on-site labor are a call to return to normalcy. Of the challenges COVID-19 has brought senior leadership, managers cite decentralized management, challenges to accountability, and the limitations that come alongside distance collaboration as major impediments to meeting their end-of-year goals.[15]

Conversely, some company leaders are coming forward as advocates for working from home. Facebook’s CEO Mark Zuckerburg explained midway through 2022 that he would spend at least half of his year working from home, attributing his ability to accomplish more on a daily basis and spend more time with his family to remote work.[16] Elsewhere, Twitter, Spotify, and Kaiser Permanente are also embracing remote work for its positive impact on work productivity and employee satisfaction. Working from home is a transformational change that can cause disagreements between employees and managers, but the managers that accommodate and adapt to workers’ needs are already seeing more success in employee retention and satisfaction.[17] 

CHANGING THE WORKSPACE FOR URBAN & RURAL WORKERS THROUGH TELEWORK

Remote work even has the potential to build a sense of community and lessen social isolation in rural communities and regions facing economic decline.[18] Between 10 to 25 percent of adults in rural areas experience anxiety and depression; in addition to limited local access to mental health treatment, the financial burdens of unemployment and limited job market often exacerbate their mental health issues. With the introduction of remote work comes employment opportunities for these individuals, who are no longer limited geographically and require little more than internet access and a space within their home, local library or coffee shop to work. Thus, rural remote workers gain comparable employee benefits to those of their commuting counterparts, but often without the added stressors of a high monthly gasoline bill, wear and tear on their vehicle (or comparable high public transportation costs), an extensive work wardrobe and extended time away from family.

Further, with remote workers remaining in their original communities, their salaries in-turn stimulate the local economy, often creating new jobs and encouraging economic growth. The phenomenon of the growing workforce in rural areas became so popular during the pandemic that it was coined “Zoom towns”, with cities like Moab, Utah and Jackson, Wyoming experiencing record migration and revenue.[19]

Remote work’s positive impact is also felt in the urban employee, whose access to remote jobs also becomes an opportunity to relocate from a heavily congested area, and evade stressors such as pollution, long commutes, and constant stimuli.[20] While racial and ethnic minorities make-up about 43% of the American population, they comprise only 22% of the rural population while 48% inhabit urban regions.[21] City living comes with a variety of mental and physical challenges, exposing its inhabitants to heightened risks of elevated stress levels, respiratory issues, cancer, and depression.[22] In the long term, leaving urban populations has the potential to extend an individual’s lifespan and quality of life, and telework offers a clear route to this healthier lifestyle.

WORK CULTURE IS ADJUSTING, AND FOR THE BETTER

Workplace dynamics provide a window into larger societal issues and are also a key space to identify solutions for these disparities. Embracing remote work is just one example of the opportunity to do so. Addressing the array of experiences workers of different backgrounds face is also a step in the direction of creating organizations that value diversity, equity, and inclusion, and in doing so company leaders prove to marginalized workers that they are valued team members. As society continues to embrace remote work as the new-normal, managers and workers alike will continue to revisit its impact on productivity, eliminating disparities, and building a better work culture.

Contributed by: Kate Campbell

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Parker, K., Horowitz, J.M., Minkin,R. How the Corona virus outbreak Has-And Hasn’t- Changed the Way Americans Work. Pew Research Center Website. 2020. https://www.pewresearch.org/social-trends/2020/12/09/how-the-coronavirus-outbreak-has-and-hasnt-changed-the-way-americans-work/. Accessed March 14, 2023.

2 Ibid.

3 Phillips, T. The Ultimate List of Remote Work Statistics. Code Summit Website. 2022. https://codesubmit.io/blog/remote-work-statistics/. Accessed March 21, 2023. 

4 United Nations. (2022). 3rd Meeting, 15th session of the Forum on Minority Issues. United Nations Website. https://media.un.org/en/asset/k1f/k1fx05gdea. Accessed March 17, 2023.

5 Gray, A. The Bias of “Professionalism Standards.” Stanford Social Innovation Review Website. 2019.  https://ssir.org/articles/entry/the_bias_of_professionalism_standards. Accessed March 21, 2023.

6 Ibid. 

7 Ibid.

8 Montoya, E. The Effects of Microaggressions on One’s Health. University of California, Irvine Medicine Website. 2021. https://sites.uci.edu/morningsignout/2021/03/09/the-effects-of-microaggressions-on-ones-health. Accessed March 14, 2023.

9 Hall, J.M., Fields, B.“It’s Killing Us!” Narratives of Black Adults About Microaggression Experiences and Related Health Stress. Global Qualitative Nursing Research. 2015;2. doi:10.1177/2333393615591569

10 Torres L., Driscoll M. W. (2010). Racial microaggressions and psychological functioning among highly achieving African-Americans: A mixed methods approach. Journal of Social and Clinical Psychology, 1074–1099.

11 Hall, J.M., Fields, B.“It’s Killing Us!” Narratives of Black Adults About Microaggression Experiences and Related Health Stress. Global Qualitative Nursing Research. 2015;2. doi:10.1177/2333393615591569

12 Ibid.

13 Mayer, K. Will Employees Quit if They are Forced Back into the Office? SHRM Website. 2023.https://www.shrm.org/resourcesandtools/hr-topics/benefits/pages/will-employees-quit-if-they-are-forced-back-into-the-office.aspx. Accessed March 18, 2023.

14 Ugincius, L. Is a return to the office inevitable? Should it be? Virginia Commonwealth University Website. 2023. https://news.vcu.edu/article/2023/01/is-a-return-to-the-office-inevitable-should-it-be

15 Ibid.

16 Stropoli, R. Are We Really More Productive Working from Home? Chicago Booth Review Website. 2021. https://www.chicagobooth.edu/review/are-we-really-more-productive-working-home. Accessed March 20, 2023. 

17 Mayer (2023)

18 Reynolds, B.W. The Mental Health Benefits of Remote and Flexible Work. Mental Health America Website. 2020. https://mhanational.org/blog/mental-health-benefits-remote-and-flexible-work. Accessed March 21, 2023.

19 Potter, L. (2020, October 14). The rise of ‘Zoom Towns’ in the rural west. The University of Utah Magazine.https://magazine.utah.edu/issues/summer-2021/zoom-towns/

20 Hoffman, E. Stress and the City: Is Your City Making You Sick? Life Intelligence Website.  (2020). https://www.lifeintelligence.io/blog/stress-and-the-city-is-your-city-making-you-sick. Accessed March 26, 2023.

21 United States Department of Agriculture. (2020). Racial and Ethnic Minorities made up about 22 percent of the rural population in 2018, compared to 43 percent in urban areas. 

https://www.ers.usda.gov/data-products/chart-gallery/gallery/chart-detail/

22 Hoffman (2020)

Improving Couple Dynamics Through Relationship Therapy

How Relationships and Therapy Met

Couples therapy originated in Germany in the 1930s, when three clinics opened to service married couples experiencing difficulties adhering to traditional gender roles.[1] The clinics were service- and education-oriented as the closest aspect to theory at this time were ideas borrowed from psychoanalysis. While most of this therapy was conducted as individual sessions, some therapists began experimenting with conjoint sessions in 1931.[2] Between 1963 and 1985, family therapy became popular, sparking theoretical ideas to explain couple and family dynamics. Notably, Bowen (1954) founded a multigenerational approach to family therapy to explain the differentiation, triangulation, and projection processes within a family.[3] Since 1986, couples therapy has been condensed, tested, refined, and retested by analyzing new theories such as Integrative Behavioral Couples Therapy, Emotionally Focused Therapy, and Solution-Focused Therapy. Presently, the theories utilized in couples therapy have shown empirical support for treating depression, anxiety, alcoholism, among other mental health issues.[4]

Common Conflict Dynamics

Each individual that makes up a romantic relationship has their own assumptions about what “being a couple” means. Tensions are likely to rise in a relationship as differences between each individual’s expectations occur. A common issue resolved in couples therapy is the feeling of a loss of autonomy for each person involved.[5] For some, monumental life experiences (e.g., moving in together, having a child, and pursuing new career opportunities), can magnify anxieties about losing one’s identity. Wachtel (2017) notes that to bridge the gap between different motivations and desires in a relationship, a balance must be established to accommodate each person’s identity in a relationship.[6] Gehrke (2022) underlines the importance of establishing ways to relate to one another in a relationship by recommending that, “Couples should have hobbies both individually and together to see where priorities lie in a relationship.”[7] Individuality in a relationship is important for maintaining a sense of self, however, it is also essential to understand and support one’s partner by showing an interest in their hobbies, as well.

Couples commonly experience issues regarding the lack of feeling loved and valued by one another. Additional conflict dynamics can be embedded in dissatisfactions or disappointments regarding the amount of quality time spent together in a relationship. As Wachtel explains, if one partner is unhappy with the amount of time their spouse spends working, it can lead to feelings of resentment and insecurity.[8] In certain cases, attachment issues and expressions of love can be side topics that surround the main, focal issues that bring couples to therapy. Significant issues such as extramarital affairs and volatile occurrences are among the more severe issues couples can work through in therapy, and typically require more work to unravel the basis for these troubles.[9]

A popular approach used in therapy for understanding and resolving conflict between couples is the Gottman Method. Gottman and Gottman (1980) determined four conflict styles that can predict the breakdown of a romantic relationship with 93% accuracy.[10] Known as the “Four Horsemen” of conflict, these styles include:[11]  

  • Criticism - Attacking one’s core character versus offering a critique or expressing a complaint. Due to the harmful nature of criticism, it can lead to feelings of contempt towards an overly critical partner.

  • Contempt - Occurs when one is disrespected, ridiculed, or mocked with sarcasm in a relationship with the goal of putting one down. Gottman and Gottman (2022) note that contempt is the single greatest predictor of divorce and must be eliminated when present in a relationship.

  • Defensiveness - A common response to criticism that reverses blame onto the partner who is asking a question or expressing concern. For example, a partner expresses their concern with their spouse not helping around the house and is met with a response that blames the expressor. Instead of blaming others, one should take responsibility for their actions and try to remedy the situation moving forward.

  • Stonewalling - A response to contempt that involves a hurt partner withdrawing from the interaction, shutting down, or simply ceasing all response to the other partner.

Theories and Modalities

Couples who seek out therapy have their own unique issues and situations that need to be worked through, and there are numerous approaches that can be utilized during couples therapy. Four well-known and effective methods include: psychodynamic; humanistic; behavioral; and integrative.[12,13] 

  • Psychodynamic - This counseling technique was developed from the research and findings of Sigmund Freud; it is used to understand one’s conscious and unconscious needs and desires. 

  • Humanistic - This approach is based on one’s response to life experiences, and aims to explore thoughts and feelings to reach solutions.

  • Behavioral - This method is based on the idea that one’s environment has a direct influence on one’s behavior. Behavioral counselors are taught that behavior is learned, and therefore, can be unlearned. 

  • Integrative - This approach uses methods from each of the afore-mentioned three types of approaches as a combination to resolve conflict.  

It is crucial for a therapist to become familiar with a couple’s unique situation and issues before choosing the best approach to utilize with them. 

What to Expect in Couples Therapy

When first meeting a therapist, a couple can expect to provide an oral history of the relationship such as how you met, memories of dating, and experiences of becoming parents (if applicable). An oral history helps the therapist to understand the journey that a couple has been through together so far.[14] Additionally, each individual will meet with the therapist separately to “vent” about issues without having to filter thoughts for the other partner. This practice is not done to keep secrets from one another, but to build a relationship with the therapist one-on-one as well as share worries and hopes for what therapy can accomplish.[15] 

A classic and well-researched activity to try in couples therapy involves “mutual eye-gazing”. A study at Clark University in Worcester, Massachusetts (1989) found a significant increase in feelings of mutual attraction and passion among 72 couples that engaged in eye-gazing for only 2 minutes.[16] Empirical research suggests that prolonged eye contact encourages one’s nervous system to release oxytocin which is associated with bonding and attachment. In addition, the neurotransmitter phenylethylamine was noted to increase feelings of interpersonal attraction after prolonged eye contact.[17] Relationship and sex therapists often recommend extended eye-gazing for couples that feel alienated from one another or those who hope to strengthen intimacy. 

Generally, couple’s can expect to gain various skills in therapy, including communication skills and coping skills to manage stress. Licensed marriage and family therapist, Moshe Ratson, found that couples therapy assisted himself and his wife to deal with fears, expectations, anger, and passive-aggressive behaviors.[18] Specifically, Ratson learned how to recognize triggers that brought up negative emotions and distressing memories. Moreover, couple’s therapy taught Ratson and his wife to replace blame with compassion and how to be proactive instead of reactive.[19] Coping skills like proactiveness and compassion help couples to understand one another instead of blaming each other when topics of conflict arise.

When couples experience long-term issues in relationship dynamics, steps should be taken to reduce such negative experiences by contacting a licensed mental health professional for further guidance.

Contributed by: Tori Steffen

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Niolon. (2011). The History of Marital Therapy. PsychPage.  http://www.psychpage.com/family/history_of_couples_therapy.html

2 Ibid. 

3 Ibid. 

4 Ibid. 

5 Wachtel, E. (2017). The Heart of Couple Therapy : Knowing What to Do and How to Do It. The Guilford Press.

6 Ibid.

7 Gehrke, G. (2022). Interview with Certified Personal Trainer and Wellness Coach on Relationship Therapy.

8 Wachtel (2017)

9 Ibid.

10 Moore, M. (2022, February 24). 4 relationship behaviors that often lead to divorce. Psych Central. https://psychcentral.com/blog/predicting-divorce-the-four-horsemen-of-the-apocalpyse#:~:text=John%20Gottman's%20Four%20Horsemen%20are,help%20you%20take%20proactive%20steps.

11 Gottman, J., & Gottman, J. (2022). Why Gottman Method Couples Therapy? The Gottman Institute. https://www.gottman.com/students/

12 BetterHelp. (2022). 6 common counseling approaches in couples therapy and how they can help your relationship. ReGain. https://www.regain.us/advice/counseling/6-common-counseling-approaches-in-couples-therapy-and-how-they-can-help-your-relationship/

13 Ibid.

14 McNeil, D. (2023). What to expect when you go to couples therapy. The Gottman Institute. https://www.gottman.com/blog/what-to-expect-when-you-go-to-couples-therapy/  

15 Ibid.

16 Lancaster, V. (2021). Why gazing into a partner's eyes boosts intimacy and sexual pleasure. Psychology Today. 

https://www.psychologytoday.com/us/blog/all-about-sex/202108/why-gazing-partner-s-eyes-boosts-intimacy-and-sexual-pleasure  

17 Ibid.

18 Ratson, M. (2017). 6 critical things marriage counseling taught me. HuffPost. https://www.huffpost.com/entry/6-critical-things-marriag_b_13134268  

19 Brenner, B. (2022). What to expect from Couples Counseling. Therapy Group of NYC. https://nyctherapy.com/therapists-nyc-blog/what-to-expect-from-couples-counseling/  

Understanding the Mental Health of Children on the Autism Spectrum

Signs of ASD in Children 

Autism Spectrum Disorder (ASD) is a developmental condition affecting a person's ability to socialize and communicate with others. It can also present with restricted and/or repetitive behavior patterns, interests, or activities. ASD is considered a “spectrum” because some people diagnosed with this disorder are mildly affected while others are severely disabled.[1] 

Approximately 1-in-100 people are on the autism spectrum[2] and the CDC reports that roughly 1-in-36 children has been identified with ASD.[3] People with ASD typically get diagnosed in their early years since symptoms of ASD often begin to appear during the first three years of life.[4] Some symptoms of ASD in children may include:[5,6]

  • Difficulty engaging in everyday human interactions

  • Intense specific interests

  • Different ways of interacting with others

  • Failing to make eye contact

  • Not responding to their name

  • Playing with toys in unusual, repetitive ways

  • Severe tantrums or non-compliance

  • Destructiveness

  • Self-injurious behavior

  • They may sleep less or are awake frequently during the night


Co-Morbid Mental Health Conditions in Children with ASD

Autism Spectrum Disorder is one of the most common disabilities affecting children and has drawn many researchers to investigate the well-being of children affected by ASD’s well-being. Studies show children with ASD are at higher risk of developing a mental health condition; Melissa (2021) notes that it is reported that more than three-quarters of children with ASD have at least one co-morbid mental health condition. Based on the statistic, children with ASD are likely to develop a mental health condition which is more than children with an intellectual disability, special health care needs, or the general population.[7]

The most common mental health conditions children with ASD experience, in order, are behavioral/conduct problems, attention-deficit/hyperactivity disorder (ADHD), anxiety, and depression.[8] Research has found certain factors have been tied to an increased likelihood of specific mental health conditions compared to others. For example: 

  • Females with ASD are more likely to have anxiety

  • Children with ASD and intellectual impairments are more likely to have behavioral problems;

  • Children with ASD who experience multiple adverse childhood experiences have greater odds of anxiety and ADHD.[9] 

Age is yet another factor that affects how mental health conditions present in children, as emotional, behavioral, and social difficulties can influence the timing of an autism diagnosis. Early childhood diagnoses usually present with greater emotional, conduct, hyperactivity, and social difficulties. Meanwhile, late-diagnosed children often have mental health and social difficulties before diagnosis that become more severe as they enter adolescence.[10]

Multiple reasons contribute to children with ASD's high risk of developing mental health conditions. The Mental Health Foundation (2022) notes that children with ASD may struggle in trying to fit into or make sense of the world, which can lead them to have feelings of depression and anxiety.[11] The act of camouflaging or strategizing to hide autistic traits also contributes to higher levels of depression, anxiety, and stress in adolescents and adults with ASD.[12] Children with ASD are more likely to face stigma and discrimination because of their disorder,[13] and those with internalizing problems (e.g., feelings of guilt, fear, worry, depression or anxiety) are more likely to be victimized by bullying.[14] Lastly, children with ASD may face difficulties receiving the proper care for their mental health conditions, including delays in diagnosis and lack of appropriate support available (e.g., therapists trained to work with autistic children).[15]


Co-Morbid Condition Effects 

Categorized as an internalizing behavior of ASD, anxiety is an excessive feeling of worry about a variety of events and activities over a long period. Perihan, et al., (2021) and Shea et al., (2018) found that internalizing problems may predict externalizing problems (e.g., aggression, conduct issues, and hyperactivity) in children with ASD.[16,17] Children with ASD and ADHD have been found to express a more substantial severity of autistic symptoms than patients with ASD alone; this increase in symptoms may result from inattention, impulsivity and hyperactivity.[18] Greene & Sherrel (2022) report that obsessive-compulsive disorder (OCD) is also found comorbidity with ASD.[19] Repetitive behaviors and hoarding are common in mild forms of autism, and Bejerot (2007) has shown that a combination of ASD and OCD results in a more severe and treatment-resistant form of OCD.[20]

Example of visualized language cards.

Mental health treatment options 

Treatment for mental health conditions in autistic children often has to be tailored to accommodate how they individually communicate and make sense of the world around them. For example, existing clinical anxiety programs for neurotypical children use communication and the relationship between clients and therapists to treat the condition. However, since children with ASD experience social and communication difficulties, they may experience difficulty interacting with their therapists and understanding the therapeutic social and emotional contexts that foster successful treatment. Research has found visualization to be one of the most effective treatment strategies in promoting effective social interaction and communication in children with ASD and utilizing visualized language significantly improves the success of anxiety treatment in children with ASD.[21] 

Cognitive behavioral therapy (CBT) is another treatment option for children with autism spectrum disorder and mental health conditions (e.g., anxiety, depression and ADHD) and works by teaching children how to alter their beliefs or behaviors to avoid negative emotions.[22] The cognitive component of the therapy helps children change how they think about a situation, while the behavioral component helps change how they react.[23] Modifications to CBT techniques are often needed to provide a more successful treatment to children with ASD and therapists may include concrete, repetitive, and visual tactics and focus on the child's unique interests to hold their focus. Additionally, a therapist may have to incorporate frequent movement breaks or sensory activities for children with attention or sensory under- or over-reactivity.[24]


The role of community 

The mental health of children with ASD has been shown to improve as a result of community support. Caregivers of children with autism should be aware that feeling tired or hungry can increase the severity of the child’s mental health condition(s).[25] Additionally, families should be aware that accommodating anxiety by removing the source of anxiety in response to a child's outburst is not as beneficial as one would imagine it should be. Storch et al. (2015) studied the effects of family accommodation on anxiety levels of children with ASD and found that lower levels of family accommodation can actually lead to lower levels of anxiety.[26] It is also important that caregivers take care of their own physical and psychological needs since raising a child with ASD can be difficult to navigate; this will benefit the caregiver as well as the child as levels of parental psychological stress have also been positively correlated to anxiety symptoms in children and adolescents with ASD.[27]

Further, O'Connor et al., (2022) note that young people with ASD who have more positive friendship features present with fewer signs of depression.[28] Supporting children with ASD to have healthy, positive relationships can improve their overall mental health. Additionally, O’Connor et al. recommend teaching non-autistic children how to be supportive friends to their autistic peers in order to help more autistic children experience the positive effects of friendship.[29]

If you are the parent or caregiver of a child with ASD and are experiencing signs of significant stress, anxiety and/or depression, please reach out to a licensed mental health provider who can help you navigate through the nuances of this disorder as well as any stressors you may be experiencing.

Contributed by: Maria Karla Bermudez

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Autism. NAMI. (n.d.). Retrieved February 27, 2023, from https://www.nami.org/Learn-More/Mental-Health-Conditions/Related-Conditions/Autism#:~:text=Children%20with%20autism%20can%20also,conditions%20than%20children%20without%20autism.  

2 Autism and mental health. Mental Health Foundation. (2022, February). Retrieved February 27, 2023, from https://www.mentalhealth.org.uk/explore-mental-health/a-z-topics/autism-and-mental-health  

3 Data & Statistics on Autism Spectrum Disorder. Centers for Disease Control and Prevention. (2023, April). Retrieved August 23, 2023, from https://www.cdc.gov/ncbddd/autism/data.html

4 NAMI

5 Ibid. 

6 Payakachat, N., Tilford, J. M., Kovacs, E., & Kuhlthau, K. (2012, August). Autism spectrum disorders: A review of measures for clinical, health services and cost-effectiveness applications. Expert review of pharmacoeconomics & outcomes research. Retrieved February 27, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3502071/  

7 Melissa J. (2021, March). Mental health conditions seen in 78% of children with autism. Retrieved February 27, 2023, from https://publications.aap.org/aapnews/news/11976?autologincheck=redirected  

8 Ibid. 

9 Ibid.

10 Mandy, W., Midouhas, E., Hosozawa, M., Cable, N., Sacker, A., & Flouri, E. (2022). Mental health and social difficulties of late-diagnosed autistic children, across childhood and adolescence. Journal of child psychology and psychiatry, and allied disciplines, 63(11), 1405–1414. https://doi.org/10.1111/jcpp.13587

11 Mental Health Foundation (2022)

12 Bernardin, C. J., Lewis, T., Bell, D., & Kanne, S. (2021). Associations between social camouflaging and internalizing symptoms in autistic and non-autistic adolescents. Autism : the international journal of research and practice, 25(6), 1580–1591. https://doi.org/10.1177/1362361321997284

13 Mental Health Foundation (2022)

14 Cappadocia, M. C., Weiss, J. A., & Pepler, D. (2012). Bullying experiences among children and youth with autism spectrum disorders. Journal of autism and developmental disorders, 42(2), 266–277. https://doi.org/10.1007/s10803-011-1241-x

15 Mental Health Foundation (2022)

16 Perihan, C., Bicer, A., & Bocanegra, J. (2022). Assessment and Treatment of Anxiety in Children with Autism Spectrum Disorder in School Settings: A Systematic Review and Meta-Analysis. School mental health, 14(1), 153–164. https://doi.org/10.1007/s12310-021-09461-7

17 Shea, N., Payne, E., & Russo, N. (2018). Brief Report: Social Functioning Predicts Externalizing Problem Behaviors in Autism Spectrum Disorder. Journal of autism and developmental disorders, 48(6), 2237–2242. https://doi.org/10.1007/s10803-017-3459-8

18 Banaschewski, T., Poustka, L., & Holtmann, M. (2011). Autismus und ADHS über die Lebensspanne. Differenzialdiagnosen oder Komorbidität? [Autism and ADHD across the life span. Differential diagnoses or comorbidity?]. Der Nervenarzt, 82(5), 573–580. https://doi.org/10.1007/s00115-010-3239-6

19 Greene N, Sherrell Z.(2022, March). ADHD vs. OCD: Differences, symptoms, treatment, and more. Medical News Today. Retrieved February 27, 2023, from https://www.medicalnewstoday.com/articles/adhd-vs-ocd  

20 Bejerot S. (2007). An autistic dimension: a proposed subtype of obsessive-compulsive disorder. Autism : the international journal of research and practice, 11(2), 101–110. https://doi.org/10.1177/1362361307075699

21 Perihan et al., (2022)

22 Cognitive behavioral therapy for autism spectrum disorder in children. Patient Care at NYU Langone Health. (n.d.). Retrieved February 27, 2023, from https://nyulangone.org/conditions/autism-spectrum-disorder-in-children/treatments/cognitive-behavioral-therapy-for-autism-spectrum-disorder-in-children#:~:text=Cognitive%20behavioral%20therapy%20may%20be,behaviors%20to%20avoid%20negative%20emotions  

23 Ibid. 

24 Schorr, B. (2021, April 28). Cognitive behavioral therapy for autism. Hidden Talents ABA. Retrieved February 27, 2023, from https://hiddentalentsaba.com/cognitive-behavioral-therapy-for-autism/  

25 Behavioral Innovations. (2023, January 5). Autism and impact on mental health. Behavioral Innovations - ABA Therapy for Kids with Autism. Retrieved February 27, 2023, from https://behavioral-innovations.com/blog/autism-and-impact-on-mental-health/

26 Storch, E. A., Zavrou, S., Collier, A. B., Ung, D., Arnold, E. B., Mutch, P. J., Lewin, A. B., & Murphy, T. K. (2015). Preliminary study of family accommodation in youth with autism spectrum disorders and anxiety: Incidence, clinical correlates, and behavioral treatment response. Journal of anxiety disorders, 34, 94–99. https://doi.org/10.1016/j.janxdis.2015.06.007

27 Guerrera, S., Pontillo, M., Tata, M. C., Di Vincenzo, C., Bellantoni, D., Napoli, E., Valeri, G., & Vicari, S. (2022). Anxiety in Autism Spectrum Disorder: Clinical Characteristics and the Role of the Family. Brain sciences, 12(12), 1597. https://doi.org/10.3390/brainsci12121597

28 O'Connor, R. A. G., van den Bedem, N., Blijd-Hoogewys, E. M. A., Stockmann, L., & Rieffe, C. (2022). Friendship quality among autistic and non-autistic (pre-) adolescents: Protective or risk factor for mental health?. Autism : the international journal of research and practice, 26(8), 2041–2051. https://doi.org/10.1177/13623613211073448

29 Ibid.