How Birth Order and Sibling Relationships Shape Our Personality

Typical Traits Related to Birth Order

Approximately 80% of children in the United States grow up with at least one sibling[1], which makes us consider: how does having a sibling affect a child’s social development and personality? 

Comprehensive MedPsych Systems (2023) built a very thorough description and explanation for the traits that are often associated with each birth order. While these will not be applicable to everyone and all families, they are commonalities found among a family’s oldest child, middle children, youngest child and children without siblings based on parenting style and familial structure.

For example, a family’s oldest child (i.e., firstborns) are often responsible, independent, perfectionistic, rule-followers, role models, and hard workers. These traits are often developed from the attention that firstborns receive due to being the only child, as well as the care that first-time parents generally have with their oldest children. Parenting can be extremely scary and difficult; therefore, first-time parents are typically stricter.  Further, because this is their only child, they are able to devote all of their attention to this child. As siblings are introduced into the family, older children tend to develop leadership skills and responsibility as they are deemed as role models, often helping with household tasks (e.g., babysitting, chores).[2]

Middle children are often diplomatic, adaptable, funny, creative, sociable, rebellious, and competitive. These children are often trying to compete for attention with their other siblings and tend to be typically very flexible and more comfortable “going with the flow”. Middle children also have the unique experience of being the youngest child for some time before another sibling is born, but then can experience a shift toward the character of an older sibling, especially if there is a large age gap between them and the first-born.[3,4]

Youngest children are often outgoing, dependent, easy-going, mischievous, and free-spirited. They are typically deemed “the baby of the family” because they are not only the youngest, but also receive more attention from their parents as their siblings get older. Additionally, they tend to receive a more lenient and laid-back parenting style as third-time parents become more comfortable parenting. Dr. Catherine Salmon, a professor of psychology at the University of Redlands and co-author of The Secret Power of Middle Children, explains that “In general, high agreeableness, extraversion (the social dimension) and openness are associated with youngest children, and sometimes low conscientiousness due to lack of responsibilities and parental indulgence over expectations.”[5]

An only child shares many traits with first borns such as independence and leadership, but they are also known to be mature, loyal, sensitive, and confident. They are typically raised with their parent’s full attention, and as an only child, may be raised with higher expectations and pressure.[6] Krynen (2011) notes that the intelligence and motivation achievement scores are significantly higher, and they typically complete more years of education as well as obtain more prestige than those with siblings. Only children are also known to be very creative and imaginative, as they often spend more time alone and therefore, are more likely to invent imaginary friends or scenarios.[7] 

The Effect of Siblings on a Child’s Social Development

Sibling relationships are often vastly underestimated in their importance. While research often evaluates the effects of parental behavior on children’s development, their sibling relationships are often overlooked. However, Dr. Shawn Sidhu from the University of New Mexico, explains that siblings are often consistent sources for support and aid in the development of positive emotional competence because we share more information and confide in our siblings more often than we do our parents, specifically regarding topics such as friendships, relationships, and school.[8] 

Siblings also appear to one another as consistent sources for support and help children learn how to manage conflict and various socio-emotional skills at a young age, while many children without siblings don’t learn these behaviors until preschool or kindergarten. McHale et al. (2012) explains, “Through their conflicts, for example, siblings can develop skills in perspective taking, emotion understanding, negotiation, persuasion, and problem solving. Notably, these competencies extend beyond the sibling relationship and are linked to later social competence, emotion understanding, and peer relationships. In adolescence, siblings also contribute to positive developmental outcomes, including prosocial behavior, empathy, and academic engagement.”[9] McHale also confirms that those with close sibling relationships often have better mental health, better psychological health, and better social relationships.[10] Furthermore, even if siblings struggle to get along as kids, psychologist Jill Suttie (2022) explains that sibling relationships do change throughout their lifetime and often siblings become closer as they reach and extend into adulthood.[11]

While there are many positive effects that siblings can have on a child’s development, there are also some negative effects that can occur depending on the circumstances. Because a child is often surrounded by their siblings more than almost anyone else, an unhealthy or toxic sibling relationship can have detrimental effects on a child’s social development. Since siblings are often seen as support systems and are consistent in a child’s life, bullying from a sibling can be more devastating than peer bullying, as their home is no longer an escape.[12] 

Furthermore, psychiatrist Shawn Sidhu explains that children are often compared to their siblings in academic or athletic settings by coaches, teachers, and peers, which can lead to children internalizing their incompetence in comparison. This causes lower self-esteem, and can drive a wedge in their sibling relationship.[13]

Lastly, since older siblings are often role models for their younger siblings, negative or unhealthy behavior by the older siblings can introduce and encourage bad behavior for younger siblings.[14] Suttie (2022) explains, “Research confirms that if siblings have hostile or conflicted relationships when young, it can increase their risks of suffering anxiety, depressive symptoms, and even risky or antisocial behavior later in adolescence.”[15]

While several debates remain regarding which situation is better for a child’s development, having siblings or being an only child both have their unique sets of pros and cons. Additionally, while research has found that a person’s birth order tends to predict specific traits in each child due to both different parenting techniques and sibling competition, these traits are also affected by a slew of environmental factors such as the child’s age, sibling age gap, and family income.[16]

If you or someone you know would like to learn more about or are struggling with their family dynamic, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for additional guidance and support.

Contributed by: Kendall Hewitt

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

References

1 Weir, K. (2022). Improving Sibling Relationships. American Psychological Association, 53(2). 

https://www.apa.org/monitor/2022/03/feature-sibling-relationships#:~:text=Sibling%20warmth%20and%20support%20in,review%20of%20sibling%20dynamics%20in

2 What Your Sibling Birth Order Reveals About Your Personality Traits (Even If You’re an Only Child). (2023). Comprehensive MedPsych Systems. https://www.medpsych.net/2021/08/19/what-your-sibling-birth-order-reveals-about-your-personality-traits-even-if-youre-an-only-child/

3 Ibid.

4 Shanley, S. (2015). What Happens When The Youngest Child Becomes the Middle Child. The Washington Post. https://www.washingtonpost.com/news/parenting/wp/2015/03/23/what-happens-when-the-youngest-child-becomes-the-middle-child/ 

5 Comprehensive MedPsych Systems (2023)

6 Ibid.

7 Krynen, C. (2011). The Rise of Single-Child Families: Psychologically Harming the Child?  Intuition: The BYU Undergraduate Journal of Psychology, 7(1)(3). https://scholarsarchive.byu.edu/cgi/viewcontent.cgi?article=1191&context=intuition

8 Sidhu, S. (2019). The Importance of Siblings. The University of New Mexico Health Sciences Newsroom. https://hsc.unm.edu/news/news/the-importance-of-siblings.html

9 McHale, SM., Updegraff, KA., & Whiteman, SD. (2012). Sibling Relationships and Influences in Childhood and Adolescence. J Marriage Fam, 74(5), 913-930. doi:10.1111/j.1741-3737.2012.01011.x

10 Suttie, J. (2022). How Your Siblings Can Make You Happier. The Greater Good Science Center at the University of California, Berkeley. https://greatergood.berkeley.edu/article/item/how_your_siblings_can_make_you_happier 

11 Ibid.

12 Sidhu (2019)

13 Ibid.

14 Ibid. 

15 Suttie (2022)

16 Comprehensive MedPsych Systems (2023)

Protecting our Most Vulnerable: The Suicidality Crisis in Black Children

A Call to Action

In April 2019 the Congressional Black Caucus (CBC) gathered to confront the pressing concern over Black children who were dying by suicide at an unprecedented rate in America.[1] After its meeting, the caucus determined that it was their responsibility to identify this crisis as a Black health emergency, and subsequently built a coalition that has since spent the past four years working towards solutions. 

The suicidality issue amongst young Black Americans initially came as a surprise to the CBC and other researchers within the mental health sector. Historically, the suicide rate within the overall Black community has been lower than that of the national average, particularly in comparison to White Americans.[2] Even between 2021 and 2022 the Center for Disease Control (CDC) recorded 48,183 suicides within the United States, with only 7% of the group identifying as Black American.[3] However, a closer look at suicide trends began to indicate a growing rate in Black children. Price & Khubchandani (2020) analyzed data between 2001 and 2017, discovering that the rate of suicides in young Black men and women increased by 60% and 182%, respectively.[4] They also found that suicide was the second highest cause of death for Black adolescents.[5]

Research conducted by the CDC in 2021 also drew similar conclusions: Black male children aged five to 11 are at risk to the point where they are twice as likely to die by suicide over their White counterparts.[6] Similarly, the Journal of the American Academy of Child & Adolescent Psychiatry analyzed data between 2003 to 2017 and found Black girls between the ages of 15 to 17 had the largest percentage in suicides of all race and gender-based demographics.[7]

Understanding the “Why” behind Black Youth Suicidality

With Black children dying by suicide at such an unprecedented rate, the CBC began to focus on the causes, supposing that each cause would later have an accompanying solution it could implement in order to address this crisis. While all children are vulnerable to bullying, issues with self-identity, and hormonal changes that can cause depression and suicidal ideations, the CBC found that the compounding impacts of trauma, cultural stigmas, and socioeconomic barriers are uniquely faced by Black children. Mathew et al. (2020) found that of children who attempt suicide, having a hostile family environment and perceiving a lack of care from family members within a household have been discovered as contributing factors to suicidal behavior among adolescents and young adults.[8] Black children have the highest likelihood of witnessing home violence, experiencing communal stigmas in response to mental crisis, and enduring distressing racism and discrimination, all of which have the potential to exacerbate their likelihood of not wanting to live.[9,10] In the face of these compounding factors, young Black men often feel a sense of hopeless that is further aggravated by the racism and discrimination they face within society.[11] Black girls also combat the complex intersectionality of race and gender-based discrimination, encountering racism while also having a higher likelihood than their male counterparts of being sexually assaulted. With race and gender-based pressures mounting, young Black women have a singular struggle in overcoming sexual harassment, misogyny, and racism - all of which make them more vulnerable to depression and suicidal ideations.[12]

The Necessity of Support

For all children, familial and community support play pivotal roles in mental health outcomes. A strong support system can serve as a protective factor against suicide, especially for Black children where familial support and communalism are heavily integrated in Black culture.[13] In the absence of a strong support system, children often feel isolated and have a higher likelihood of experiencing depression and/or suicidal ideation.[14] In a 2020 report conducted by the U.S. Department of Health and Human Services, researchers concluded that Black children had a high likelihood of experiencing crisis in the two weeks prior to their death by suicide.[15] Further, nearly 40% of Black youth had a crisis or dispute with a family member, romantic partner, or friend before their death by suicide; 30% of this group had an argument within 24 hours of their death.[16] Within the Black community, providing accessible resources to navigate relationship issues and familial trauma can provide useful support to save a child’s life.

The Trouble in Exhibiting Mental Health Issues

For all children suffering from depression and mental health struggles, early detection and timely treatment are essential to mitigating their symptoms. However, Black children are the most likely to be suspended, expelled, or labeled with “behavioral issues” when they are actually displaying mental health issues. A 2015 study conducted by Okonofua & Eberhart concluded that educators often perceive black students’ behaviors as more problematic and more punishable than those of their White counterparts.[17] This study not only exhibits racial disparities in disciplinary action, but it also points to the isolation Black children face in the midst of a crisis. 

The Lack of Mental Health Intervention

While intervention is key to preventing a child from getting to the point where they attempt suicide, mental health issues remain underdiagnosed and stigmatized within the Black community. In its 2020 report to Congress, the U.S. Department of Health and Human Services identified this contradiction: despite dying by suicide at a faster rate than any other racial/ethnic group, Black youth had lower reported rates of known mental health problems and documented histories of suicidal thoughts or plans. However, the lack of reported rates of mental health issues is not equivalent to these problems being nonexistent for Black children. On the contrary, the low rates of recorded mental health disorders that stand in contrast to the high rates of past suicide attempts suggest that Black youth are still experiencing depression, but they have limited access to mental healthcare and proper treatments. Not only do Black children face barriers to attaining effective mental health resources because of the high cost of therapy, but the American Psychological Association (APA) note the United States has a shortage of culturally-competent therapists across the country.[18] With over 88% of mental health providers identifying as white, young Black children continue to have more difficulty finding therapists that look like them and with whom they can identify.[19]

Mental Health Stigma Within the Black Community

Within the Black community, mental health conditions are not only misunderstood, but many Black adults view mental health conditions as a weakness.[20] As a result, people within this community may face embarrassment about their mental health condition and worry that they may be ostracized if they share how they are struggling with friends or family.[21] This perspective is not only damaging to Black adults, who will often mask their mental health disorders, but also to Black children who are the most vulnerable and often also the most susceptible to being silenced in a time of distress.[22] 

Further, another obstacle for this cohort is that many Black Americans turn to spirituality and a faith-based community rather than seeking a medical diagnosis.[23] While spirituality is a proven source of resiliency for many ethnic minorities and can provide healthy outlets and reduce isolation, it is not always effective or effective enough in crisis.[24] In contrast, children should be encouraged to seek out multiple treatment avenues to ensure the highest chance of recovery from mental illness.

Solutions to the Suicide Crisis 

The CBC concluded that addressing the issue of youth suicide within the Black community demanded a comprehensive approach that continues to consider the complex intersection of mental health, cultural, and socioeconomic factors. They note the following factors are essential to halting the trend of Black children ending their lives:

1. Schools stand at the forefront of community-based care and they can close the gap in mental-health access by offering all students access to affirming environments and well-trained professionals. Unlike mental health care provided by hospitals, mental health professionals in schools have the ability to provide resources and assistance to students without the barriers of insurance and financial security. Schools within a child’s community also have the potential to help a child overcome their mental health challenges with culturally-relevant care.

2. Expanding access to underprivileged communities has the potential to give Black children access to treatment that would otherwise be unavailable. As the American Psychological Association (APA) asserts, telehealth with expanded coverage via the assistance of insurance companies is an equity-based solution that may allow Black children to get the treatment they are seeking.[25]

3. Black researchers must also be given adequate funding and support in order to narrow the knowledge gap that leaves Black-specific illnesses underreported. Research topics proposed by Black scientists are less likely to be funded, leaving profound gaps in the level of understanding that is required to protect Black youths from the unique challenges they face.

In 2019, Congresswomen Coleman and Napolitano led the CBC in proposing the “Pursuing Equity in Mental Health Act.” The act has successfully passed the House of Representatives, and once it is officially enacted it will provide $750 million annually between fiscal years 2024 to 2029 for the National Institute on Minority Health and Health Disparities.[26] The future act will also authorize $150 million dollars to the National Institutes of Health (NIH) to build mental health facilities within Black communities, support clinical research, and work to end racial/ethnic disparities in healthcare.[27]

Ensuring Children Have Hope in their Future

Ultimately, Black children face the unique challenge of navigating their lives at the intersection of race, gender, and sexual orientation all while carrying the basic challenge of simply “being kids”. With societal pressures and feelings of isolation becoming prevalent within the current generation, it is essential for the adults within their lives to make sure that they are protected and supported. Children are a vulnerable population who are not fully capable of self-advocacy, and for this reason the rising suicide rates among Black children necessitates collective action. By addressing the mental health stigma within the Black community, systemic inequalities and cultural factors, American society will build a mental healthcare system where, regardless of their background, all children feel supported and capable of overcoming trauma.

If you or someone you know is struggling with depression, hopelessness and/or suicidal thoughts, please call 911, 988, or go to the closest emergency room. Individuals seeking non-crisis support can also reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and additional resources. 

Contributed by: Kate Campbell

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

References

1 Coleman, B.W. (2023). Emergency Task Force on Black Youth Suicide and Mental Health.https://watsoncoleman.house.gov/suicidetaskforce/

2 Kung, K. C., Liu, X., & Juon, H. S. (1998). Risk factors for suicide in Caucasians and in African-Americans: a matched case-control study. Social psychiatry and psychiatric epidemiology, 33(4), 155–161. https://doi.org/10.1007/s001270050038

3 Langston, L. & Truman, J.L. (2014). Socio-Emotional Impact of Violence. Bureau of Justice Statistics. https://bjs.ojp.gov/library/publications/socio-emotional-impact-violent-crime

4 Price, J. H., & Khubchandani, J. (2019). The Changing Characteristics of African-American Adolescent Suicides, 2001-2017. Journal of community health, 44(4), 756–763. https://doi.org/10.1007/s10900-019-00678-x

5 Ibid

6 Meza, J.L., Patel, K., Bath, E. (2022). Black Youth Suicide Crisis: Prevalence Rates, Review of Risk and Protective Factors, and Current Evidence-Based Practices. Focus: The Journal of Lifelong Learning in Psychiatry, 20(2), 197-203. https://doi.org/10.1176/appi.focus.20210034

7 Sheftall, A. H., Vakil, F., Ruch, D. A., Boyd, R. C., Lindsey, M. A., & Bridge, J. A. (2022). Black Youth Suicide: Investigation of Current Trends and Precipitating Circumstances. Journal of the American Academy of Child and Adolescent Psychiatry, 61(5), 662–675. https://doi.org/10.1016/j.jaac.2021.08.021

8 Mathew, A., Saradamma, R., Krishnapillai, V., & Muthubeevi, S. B. (2021). Exploring the Family factors associated with Suicide Attempts among Adolescents and Young Adults: A Qualitative Study. Indian journal of psychological medicine, 43(2), 113–118. https://doi.org/10.1177/0253717620957113

9 Chopra, S. (2022, September 9). Black girls are experiencing record rates of self-injury and death by suicide. https://youthtoday.org/2022/09/black-girls-are-experiencing-record-rates-of-self-injury-and-death-by-suicide/

10 Langston, L. & Truman J.L. (2014)

11 Meza, J.L., Patel, K., Bath, E. (2022)

12 American Academy on Child and Adolescent Psychiatry. (2022) AACAP Policy Statement on Increased Suicide Among Black Youth in the US. https://www.aacap.org/aacap/Policy_Statements/2022/AACAP_Policy_Statement_Increased_Suicide_Among_Black_Youth_US.aspx

13 Langston, L. & Truman, J.L. (2014)

14 Bethune, S. (2022). Increased need for mental health care strains capacity. American Psychological Association (APA). https://www.apa.org/news/press/releases/2022/11/mental-health-care-strains

15 Okonofua, J. A., & Eberhardt, J. L. (2015). Two Strikes: Race and the Disciplining of Young Students. Psychological Science, 26(5), 617–624. https://doi.org/10.1177/0956797615570365

16 Okoya, Wenimo. (2022, March 30). The fight for Black Lives needs to happen in schools. The Hechinger Report. https://hechingerreport.org/opinion-the-fight-for-black-lives-needs-to-happen-in-schools/

17 Okonofua, J.A., & Eberhardt, J.L. (2015)

18 Ward, E. C., Wiltshire, J. C., Detry, M. A., & Brown, R. L. (2013). African American men and women's attitude toward mental illness, perceptions of stigma, and preferred coping behaviors. Nursing research, 62(3), 185–194. https://doi.org/10.1097/NNR.0b013e31827bf533

19 Meza, J.L., Patel, K., Bath, E. (2022)

20 Ibid.

21 Okonofua, J. A., & Eberhardt, J. L. (2015) Nguyen A. W. (2020). 

22 Bethune (2022)

23 Religion and Mental Health in Racial and Ethnic Minority Populations: A Review of the Literature. Innovation in aging, 4(5), https://doi.org/10.1093/geroni/igaa035

24 Ibid.

25 The Mental Health Liaison Group.(2023).  MHLG Letter of Support - Pursuing Equity in Mental Health Act 118th Congress. https://adaa.org/MHLG098402

26 Ibid.

27 Ibid.

Developments in Art Therapy for Mental Health

What Words Can’t Express 

The process of making art, like literature, has long been shown to have mental and emotional health benefits. The APA describes art therapy as a type of psychotherapy that helps provide a way to express emotions and experiences not easily expressed in words.[1] The artist Georgia O’Keeffe said, “I found I could say things with color and shapes that I couldn’t say any other way – things I had no words for.” 

The American Art Therapy Association explains that art therapy includes active art-making, the creative process, and applied psychological theory - within a psychotherapeutic relationship - to enrich the lives of individuals, families, and communities.[2] Furthermore, art therapy is used to foster self-esteem and self-awareness, cultivate emotional resilience, promote insight, enhance social skills and reduce conflicts and distress. Although art therapy has been used to treat a range of mental health disorders including anxiety and depression, this type of therapy is particularly applicable to survivors of trauma because the nonverbal and experiential character of art therapy appears to be an appropriate approach to the often “wordless and visual nature of traumatic memories.”[3]

MechanismS of Art Therapy  

Art therapy engages the mind, body, and spirit in ways that are distinct from verbal communication. In an article published in the Journal of the American Art Therapy Association, Lusebrink 2010 differentiates art therapy from verbal therapies by the use of art media as a means of expression and communication, the multileveled meaning present in visual expressions, and the therapeutic effects of the creative process.[4] In a schematic framework known as the Expressive Therapies Continuum (ETC), three distinct levels (kinesthetic/sensory, perceptual/affective, and cognitive/symbolic) reflect different functions and structures in the brain that process visual and affective information.[5]  

This is particularly useful because the art therapist can first assess the client’s cognitive and emotional functioning through these different ETC levels in order to better address their strengths, challenges, and progress in art therapy. For example, Hendler et al. (2001) found that in individuals with post-traumatic stress disorder (PTSD), affectively-charged visual stimuli activate limbic regions and sensory areas of the cerebral cortex but not the prefrontal area. This is significant, as visual processing within non-PTSD individuals does include the prefrontal cortex which is critically involved in the emergence of conscious visual perception. On the other hand, client areas of strength would constitute a lack of difficulty in processing visual information on particular levels of the ETC. This framework is useful for helping art therapists determine where the “missing links'' are in terms of the sequence of visual information processing. 

These assessments can act as guidelines for starting points, pathways, and goals in art therapy.[6] The range of kinesthetic, sensory, perceptual, and symbolic opportunities also allow clients to practice and create alternative modes of expressive communication, which can help circumvent the limitations of language.[7] 

Art Therapy Sessions 

Though one can always choose to pursue the arts on their own time to calm and relax the mind, formal art therapy sessions are typically carried out by licensed clinicians, master's-level or higher degree holders trained in art and therapy work. Art therapists work with diverse populations in a variety of settings including hospitals, schools, veterans’ clinics, private practice and psychiatric and rehabilitation facilities.[8] One may choose to engage in a private art therapy session or a group setting with other individuals. 

Before beginning, it is important for the therapist to emphasize that the client does not need to be artistically or creatively inclined to benefit from this process. During a typical session, clients will engage in both art-making and meaningful conversation with the therapist.[9] The therapist's main goal is to describe the goal of art therapy, help the client choose an appropriate medium for expression (e.g., collage, painting, sculpture, drawing), and prompt the client with questions which will shape and guide the art making session. At the conclusion of the session, the therapist and client will debrief. To make sense of the process, they may collaboratively discuss any emotions and feelings that arose during the art making process, the work of art itself and its potential meanings, as well as plans for future sessions.[10] 

Applications for Addressing Trauma 

Art therapy has historically been used to address and treat trauma for a variety of reasons. Art is an effective means of expressing past trauma from a safe environment; it provides emotional distance from the actual event and provides an alternative outlet to confront unresolved trauma memories through the use of symbols and visual media. Additionally, PTSD UK notes how new research has found that art therapy fosters a mind-body connectedness and allows the brain to use mental and visual imagery.[11]

In 2016, Campbell et al. (2016) conducted research to examine the impact of art therapy on those with combat-related PTSD. They administered a series of art therapy sessions in which participants engaged in creating a visual trauma narrative, mapping representations of their emotions, making images of the self before and after the trauma and creating final reflective art pieces. Results from a depression scale score showed that although not statistically significantly different, a trend toward greater reduction in depression symptoms for the test group compared to the control was noted.[12] Although these quantitative measures did not show statistical significance, a more recent study by Berberian et al. (2019) examined the qualitative outcomes of art therapy, or more specifically, montage painting, for active-duty military service members with traumatic brain injuries or PTSD. They found that group art therapy elicited improvement in interpersonal relatedness, as well as the expression of hopefulness and gratification. Art therapy allowed the individuals to work toward creating an individual trauma narrative which is a key component for recovery and healing.[13]

Aside from veterans and active-duty military service members, PTSD within children and early relational trauma has also been addressed through art therapy. Individuals who have experienced trauma at a young age show increased levels of suicide, alcohol addiction, and/or drug addiction later in life, thus art therapy is especially valuable as an early intervention for children who have been exposed to trauma in a variety of contexts and in different forms (e.g., witnessed or experienced gang violence, bullying, loss and grief, domestic abuse, suicide, homelessness, and drug abuse).[14] A study conducted by Woollett et al. (2020) invited school-aged children and their mothers in domestic violence shelters to participate in a pilot study aiming to integrate trauma-informed art and play therapy with traditional cognitive behavioral therapy (CBT). From baseline levels, children's depressive symptoms showed significant reduction and improvement in PTSD symptoms.[15] 

Another specific context which art therapy has been applied to is early relational trauma. This type of trauma is distinct from post-traumatic stress disorder in its emphasis on childhood abuse, various forms of neglect, and other neurological effects that occur during a specific time period when the developing brain was exposed to prolonged trauma.[16] Art therapy can be particularly helpful for early relational trauma clients who exhibit anger and frustration as they struggle to confront and articulate their emotions. The art they make is a non-verbal activity that reflects, mirrors and amplifies expression of the client's internal state of affects. A study by Chong (2015) presented a collection of clinical vignettes in which she notes that school-aged children with early relational trauma showed improvement in dimensions such as confidence, attention span, and the formation of positive relationships in school settings.[17]

Within communities of all ages and backgrounds, art therapy is a flexible, effective and low-intensity intervention for individuals dealing with trauma which can cultivate a greater sense of creativity, empowerment, and independence while fostering a healthy psychosocial relationship with themselves and others.[18] 

If you or someone you know would like to learn more about art therapy and how to incorporate it into your own life, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for additional guidance and support.  

Contributed by: Kaylin Ong

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

References 

1 (2020, January 30). Healing Through Art - APA Blogs - Patients and Families. American Psychiatric Association. https://www.psychiatry.org/news-room/apa-blogs/healing-through-art#:~:text=Art%20therapy%2C%20a%20type%20of,the%20process%20of%20making%20art 

2 American Art Therapy Association. (2014). American Art Therapy Association. https://arttherapy.org/ 

3 Schouten, K. A., van Hooren, S., Knipscheer, J. W., Kleber, R. J., & Hutschemaekers, G. J. M. (2018). Trauma-Focused Art Therapy in the Treatment of Posttraumatic Stress Disorder: A Pilot Study. Journal of Trauma & Dissociation, 20(1), 114–130. https://doi.org/10.1080/15299732.2018.1502712 

4 Lusebrink, V. B. (2010). Assessment and Therapeutic Application of the Expressive Therapies Continuum: Implications for Brain Structures and Functions. Art Therapy, 27(4), 168–177. https://doi.org/10.1080/07421656.2010.10129380

5 Expressive Therapies Continuum: Three-Part Healing Harmony | Psychology Today. (December 30, 2018). Www.psychologytoday.com. https://www.psychologytoday.com/us/blog/arts-and-health/201812/expressive-therapies-continuum-three-part-healing-harmony 

6 Lusebrink (2010) 

7 American Art Therapy Association 

8 Ibid. 

9 Homepage - The British Association Of Art Therapists. (2022, September 26). The British Association of Art Therapists; BAAT. https://baat.org/ 

10 What Is Art Therapy? | Psychology.org. (2022, February 15). Www.psychology.org. https://www.psychology.org/resources/what-is-art-therapy/#:~:text=During%20a%20session%2C%20an%20art 

11 How art therapy has helped those with PTSD – PTSD UK. (n.d.). https://www.ptsduk.org/how-art-therapy-has-helped-those-with-ptsd/ 

12 Campbell, M., Decker, K. P., Kruk, K., & Deaver, S. P. (2016). Art Therapy and Cognitive Processing Therapy for Combat-Related PTSD: A Randomized Controlled Trial. Art Therapy, 33(4), 169–177. https://doi.org/10.1080/07421656.2016.1226643 

13 Berberian, M., Walker, M. S., & Kaimal, G. (2018). “Master My Demons”: art therapy montage paintings by active-duty military service members with traumatic brain injury and post-traumatic stress. Medical Humanities, 45(4), 353–360. https://doi.org/10.1136/medhum-2018-011493 

14 Helping Kids Cope with Trauma. (October 20, 2017). Cedars-Sinai. https://www.cedars-sinai.org/blog/art-therapy-helps-children-cope-with-trauma.html#:~:text=Art%20therapy%20teaches%20kids%20how 

15 Woollett, N., Bandeira, M., & Hatcher, A. (2020). Trauma-informed art and play therapy: Pilot study outcomes for children and mothers in domestic violence shelters in the United States and South Africa. Child Abuse & Neglect, 107(1), 104564. https://doi.org/10.1016/j.chiabu.2020.104564 

16 Terradas, M. M., Poulin-Latulippe, D., Paradis, D., & Didier, O. (2020). Impact of early relational trauma on children’s mentalizing capacity and play: A clinical illustration. European Journal of Trauma & Dissociation, 100160. https://doi.org/10.1016/j.ejtd.2020.100160 

17 Chong, C. Y. J. (2015). Why art psychotherapy? Through the lens of interpersonal neurobiology: The distinctive role of art psychotherapy intervention for clients with early relational trauma. International Journal of Art Therapy, 20(3), 118–126. https://doi.org/10.1080/17454832.2015.1079727 

18 Boyadjis, A. (2019). Healing the Child Through Expressive Arts Therapy. https://minds.wisconsin.edu/bitstream/handle/1793/79197/Boyadjis%2C%20Andrea%20Thesis%202019%20compiled.pdf?sequence=1&isAllowed=y 

Perceived Social Support in School Environments During Adolescence

Nurturing Growth

Adolescence is one of the most formative periods of human development, a stage wherein many long-term habits and lifestyles are developed. It is marked by significant physical, cognitive, and socio-emotional changes.[1] Hellström & Beckman (2021) explain how understanding the needs and special challenges of this stage of life will bring about great benefits for solving and preventing unique problems in society.[2] As the majority of changes in adolescence come about through a combination of social, hormonal, cognitive circumstances (most of which occur in the environment of middle-high schools) Verhoeven et al. (2019) note this is an ideal time period to examine when looking for answers for questions about brain-behavior development.[3] 

As we increasingly concern ourselves with improving child educational environments and outcomes, Zhao et al. (2021) note that one of the biggest risk factors for adolescents’ academic motivation and achievement is the environment in their academic setting.[4] As Wang et al. found in 2020, positive classroom climate has been essential to many school reform efforts hoping to promote youth’s academic and psychological well-being.[5] Especially, the role of teacher support as a moderator for academic achievements among various types of learner is highlighted in importance. Supportive student-teacher relationships can help improve students’ self-schema and sense of belonging, and therefore enable them to productively achieve their personal goals.[6] So, how can we best support students and provide significant developmental opportunities?

Adolescent Social Support 

Farmer & Farmer (1996) explain how social support is the “processes of social exchange that contribute to the development of individuals’ behavioral patterns, social cognitions, and values”.[7] Hogan et al. (2002) have theorized two forms of social support, natural and formal, in which a natural social support network would consist of family and friends, while formal networks would include health professionals, religious or other social communities.[8] Specifically within an academic setting, social support refers to the perception of belonging and feeling cared for within a  support network of peers and teachers.[9] 

Perceived social support includes an individual's feeling of the availability and adequacy of support from their social network. Further, perceived social support is dependent on how individuals gauge the amount of emotional, informational, or tangible assistance they receive from their community.[10] Feeling a sense of social support is critical for promoting positive social, psychological, academic outcomes for students, and especially during adolescence with multiple transitions happening at once.[11] In an academic setting, where adolescents tend to spend much of their time (learning, socializing) this sense of perceived social support is especially important to find and be encouraged. According to Allen and Gregory (2018), social support is a significant buffer against negative experiences in life and stressors in the school environment, thus crucial in helping students cope with challenges, fostering a positive school climate, and ultimately promoting their academic and emotional well-being.[12] Danielsen et al. (2008) suggested that indirect support from teachers, classmates and parents can lead to student life satisfaction, and school-related support from teachers, classmates, parents have a direct effect on school satisfaction and scholastic competence in students.[13] 

Similar to social support, teacher’s confirmation positively predicts and has a noticeable influence on students’ emotional outcome. When teachers engage more, students seem less likely to exert unnecessary emotional efforts in the classroom; in contrast, if teachers display less or no interest or engagement in the classroom, students have a greater likelihood to expend emotional work, which bodes negatively for students achievement, motivation and other learning outcomes.[14] Specifically, emotion work is draining for students as it describes the extent to which students must expend emotional energy and perform emotional labor (i.e., faking or feigning emotions). In the context of the classroom, this can mean suppressing authentic emotions (e.g., anger, frustration, boredom) and displaying more socially acceptable ones.[15] Similarly, Spera (2005) found that parent support provides adolescents with a positive learning environment and instills a sense of responsibility and motivation. Peers can also provide emotional support, help with academic tasks, and serve as role models for positive behavior and achievement.[16]

However, there are multiple factors that mediate or moderate perceived social support and its outcomes in an academic environment beyond the student-teacher interactions; such factors include: 

• Self-Esteem - Lau et al. (2018) conducted a study on the link between self-esteem and social support in first-year university students in Hong Kong and discovered that positive adjustments during the transition to college life increase when self-esteem is supported by peer and family social support. In particular, it offers a sense of security and represents an individual's importance to their social circle, in turn improving their self-esteem. Moreover, students with higher self-esteem may have higher aspirations and more resilience than those with lower self-esteem, therefore contributing to differing adjustment abilities.[17] These findings support those by Roman et al. in 2008, who found that self-esteem is positively correlated with effort and deep processing, which is the encoding of information in a meaningful and elaborate manner, facilitating long-term retention and retrieval. Vice versa, self-esteem is negatively related to shallow processing. It also has the strongest indirect positive effect on academic achievement through deep processing and effort.[18] 

• Personality Traits - Personality traits play a significant role in shaping individuals' perceptions and experiences within their social environments.[19,20] A commonly used construct for analysis is the Big Five model of personality. The Big Five personality traits, (i.e., the five-factor model of personality) is a suggested personality taxonomy for personality traits developed in 1992 which postulates that there are five universal dimensions: Extraversion, Agreeableness, Conscientiousness, Neuroticism, and Openness to Experience.[21] According to Swickert (2009), various personality dimensions are related to social support, including all of the Big Five personality traits. For example, agreeableness and extraversion seem to be most strongly positively correlated, while neuroticism (anger, irritability, self-doubt) has a strong negative correlation, with the perceived availability of social support.[22] Those with higher life satisfaction are also more extraverted, more sociable and more likely to experience pleasant moods.[23,24] 

• Educational Goals - Hernandez et al. (2016) found that while social support has a positive and direct effect on academic performance, its influence also depends on the manner with which they treat this social support, like their personal goals and representation of this support.[25] In adolescents who mainly pursue social goals and neglect academic achievements, social support can influence inattention and lack of class participation. Additionally, social support predicts students’ investment and interest in work and success, but only if they are pursuing academic achievement.[26] This means that students’ effort in their school performance is in fact motivated by what they expect to get out of school, and attaching values to school for its emotional and relational opportunities detach students from academic expectations and demands. Therefore, in this way, social support can actually hinder them from achieving academic success. It is also important to note that elementary students report higher academic engagement and more social support from both family and school faculty than junior high school students.[27] It is therefore important that researchers and educators focus on the pleasures and importance of gaining knowledge throughout adolescence in order to redirect students’ motivation and achievement efforts in educational settings. 

• Socioeconomic Status (SES) - Regarding the relationship between SES and academic achievements, Malecki & Demaray (2006) found that adolescents with lower SES tend to have corresponding lower GPA than those with higher SES.[28] However as a mitigating factor, students with lower SES have a significant positive relationship between GPA and social support - especially the social support of teacher.[29] To support this finding, a study conducted on low-income students by Wen & Li (2022) concluded that despite additional difficulties and risk factors these students face, higher levels of social support improved their academic performance by increasing dispositional optimism, which reflects positive perception of disadvantaged situations and the tendency to expect positive outcomes.[30] This “learned hopefulness” therefore underlines that individuals with higher perceived social support have more positive self-perceptions, including positive evaluations of their environment and more optimistic expectations of success.[31] 

Negative effects of negating social support

Even though there has been limited research done on the direct influence of the lack of social support and academic achievements in adolescents, studies have been conducted that may clue us into the nature of this relationship. For instance, Orban et al. (2020) studied the effects of social deprivation on adolescents’ development through the animal model of adolescent rodents.[32] They discovered that at the behavioral level, even a short period of isolation (e.g., 24 hours) in adolescent rodents can lead to heightened anxiety, increased hyperactivity, and a heightened sensitivity to social rewards, which extends to seeking food or drug rewards, making them more susceptible to developing addictions. Rodents that are chronically isolated throughout their entire adolescent period display abnormal behaviors such as hyper-reactivity to stressful situations and increased aggression. Moreover, isolation-induced changes also affect cognitive processes, such as learning and attention, resulting in reduced performance on tasks involving these processes. Specifically, isolation during adolescence leads to deficits in cognitive flexibility, impairing reward learning, reversal learning, and attention shifting.[33] Even though these results do not replicate exactly to human adolescents, they still inform us of the possible consequences of social isolation in adolescents’ mental wellbeing and cognitive development, which both influence their academic outcomes.[34] 

On a less extreme level of social support deprivation, findings from an experimental study on adult humans by Tomova et al. (2022) also suggest that social isolation results in increased feelings of loneliness, craving for social contact, and decreased happiness.[35] This is further supported by Glozah and Pevalin in 2014, who found that teenagers experiencing low psychological and physical wellbeing tend to resort to unhealthy coping mechanisms, such as absenteeism, truancy, and a general lack of motivation towards their studies.[36] Additionally, compromised health and psychological well being can contribute to attention issues, subsequently affecting academic performance and making it challenging for students to cope with academic pressures.[37]

Considering these findings, it is possible that without a strong network of social support in school, adolescents may be negatively affected not only academically, but also in terms of cognitive development and mental well-being. Given the current gap in knowledge, however, further studies on the potential effects of social support deprivation in adolescents are imperative. 

Potential interventions 

It is thus crucial for us as individuals and institutions to focus on creating an academic space in which social support is optimally available to adolescents. 

In 2007, the World Health Organization (WHO) listed efforts that have been implemented globally to improve social support and help-seeking behaviors in adolescents in an international literature review and program consultation.[38] Some schools have reported a strategy for improving students’ health and attracting them to existing services by experimenting with making local services more “adolescent-friendly” by offering more suitable hours and hiring training staff in adolescent-specific needs.[39] Another way of offering more convenience for adolescents is by locating/relocating health services to attract them, such as building more school-based health clinics. In addition to this, some countries offer adult outreach or community health promoters, who have been employed to bring health services and information to adolescents at home or at school.[40] However, they point out that in already overburdened public education systems, it can be difficult to aid adolescents’ use of public health resources.[41] 

The report also noted the use of peer promoters, which includes the training and supervising of adolescents or young adults to introduce health-related information to their peers to promote help-seeking.[42] Dougherty & Sharkey (2017) has also provided literature in favor of these peer programs and peer support groups for those with specific health needs, such as substance use or violence.[43] Along this line, information campaigns, hotlines and information centers have also long been carried out to increase awareness on support resources for adolescents and can provide youth with information on existing local resources, services, job training, and recreational activities.[44] 

In several countries, service integration also exists, which is the formal or informal networks among existing services, as a strategy for promoting help-seeking by adolescents with the goal of casting a broader net for social support.[45] However, this service is often built upon the premise that infrastructure exists and can be integrated to increase access. The underlying framework is that through collaboration, this social support network can become larger than the sum of its parts, thus in theory more effective.[46] 

In support of this, a study conducted by Lee et al. (1999) in Chicago found that when seeking to improve students’ academic performance, school systems should not ignore social support as a pertinent factor that contributes to students' success.[47] For those who may receive especially little support from their local community, peers, and at home, it is even more important that school staff create academic environments that are supportive for learning. Similarly, looking to improve students’ achievements by fostering supportive environments alone is insufficient. The report found that without academic press in school, social support alone may not lead to meaningful improvements in academic performance.[48] 

Specifically for social support, some schools within the Chicago Annenberg Research Project have created smaller, more personalized classrooms (e.g., school-within-schools, teachers teaching the same cohort for multiple grades, supplemental one-on-one tutoring with teacher assistants). Some schools provide teachers with professional development opportunities to encourage supportive relationships with students, others strengthen support through parent education programs, engaging parents in classroom activities and one-on-one student mentorships. Several schools have given students the opportunities to develop relationships with local community members who can support and guide them as role models, or increase peer relationships through extracurricular activities.[49] 

For academic purposes, schools have turned to communicating high learning expectations and clear responsibilities for students. This has also been accomplished by professional development for teachers aiming at improving quality of instruction and guiding students towards more challenging work and critical thinking. Some schools have developed incentive systems to reward students for high academic achievements or student assessments that have a double-pronged purpose: student-teacher accountability and the teacher’s own examination of their teaching style for improvements.[50] 

While these options can offer increased social support for students, they do not come without substantial challenges and school systems may not have the time and resources currently available to enact these changes.[51,52] 

Therefore, more research should be done to bring awareness to these approaches and develop more easily applicable and less costly methodologies. The WHO notes that these efforts, whether it be research or application, should also involve meaningful participation of adolescents, as junior researchers.[53,54] As the Kellogg Foundation cited in 1998, some of the key needs when it comes to initiatives promoting support-seeking from adolescents include the need to:[55] 

• Identify service barriers 

• Have detailed written agreements and plans to services 

• Consider culturally appropriate models of support 

• Work with existing community resources.

Through increased awareness and opportunities, social support within school environments can help adolescents’ mental health and educational opportunities.

If you or your loved ones are looking for ways to provide additional support for your child, or if they seem to be struggling in school, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance. 

Contributed by: Mai Tran

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

References

1 National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Division of Behavioral and Social Sciences and Education; Board on Children, Youth, and Families; Committee on the Neurobiological and Socio-behavioral Science of Adolescent Development and Its Applications. The Promise of Adolescence: Realizing Opportunity for All Youth. Backes EP, Bonnie RJ, editors. Washington (DC): National Academies Press (US); 2019 May 16. PMID: 31449373.

2 Hellström L, Beckman L. Life Challenges and Barriers to Help Seeking: Adolescents' and Young Adults' Voices of Mental Health. Int J Environ Res Public Health. 2021 Dec 12;18(24):13101. doi: 10.3390/ijerph182413101. PMID: 34948711; PMCID: PMC8700979.

3 Verhoeven, M., Poorthuis, A.M.G. & Volman, M. The Role of School in Adolescents’ Identity Development. A Literature Review. Educ Psychol Rev 31, 35–63 (2019). https://doi.org/10.1007/s10648-018-9457-3

4 Zhao, K., Chen, N., Liu, G., Lun, Z., & Wang, X. (2023). School climate and left-behind children’s achievement motivation: The mediating role of learning adaptability and the moderating role of teacher support. Frontiers in Psychology, 14. https://www.frontiersin.org/articles/10.3389/fpsyg.2023.1040214

5 Wang, M.-T., L. Degol, J., Amemiya, J., Parr, A., & Guo, J. (2020). Classroom climate and children’s academic and psychological wellbeing: A systematic review and meta-analysis. Developmental Review, 57, 100912. https://doi.org/10.1016/j.dr.2020.100912

6 Zhao et al. (2023)

7 Farmer, T. W., & Farmer, E. (1996). Social relationships of students with exceptionalities in mainstream classrooms: Social networks and homophily. Exceptional Children, 62, 431-450.

8 Hogan, B. E., Linden, W., & Najarian, B. (2002). Social support interventions: Do they work? Clinical Psychology Review, 22(3), 381–440. https://doi.org/10.1016/S0272-7358(01)00102-7

9 Grapin, S.L., Sulkowski, M.L. & Lazarus, P.J. A Multilevel Framework for Increasing Social Support in Schools. Contemp School Psychol 20, 93–106 (2016). https://doi.org/10.1007/s40688-015-0051-0

10 Farmer, A. & Farmer, S. (1996). Motivational Influences on Social Cognition and Aggressive Behavior. In D.J. Pepler & K.H. Rubin (Eds.), The Development and Treatment of Childhood Aggression (pp. 433-455). Hillsdale, NJ: Lawrence Erlbaum Associates.

11 Bauer A, Stevens M, Purtscheller D, Knapp M, Fonagy P, Evans-Lacko S, Paul J. Mobilising social support to improve mental health for children and adolescents: A systematic review using principles of realist synthesis. PLoS One. 2021 May 20;16(5):e0251750. doi: 10.1371/journal.pone.0251750. PMID: 34015021; PMCID: PMC8136658.

12 Allen, J. P., & Gregory, A. (2018). Social support as a buffer for perceived racial discrimination stress among African American youth. Journal of Research on Adolescence, 28(4), 1015-1030. doi:10.1111/jora.12385

13 Danielsen, A. G., Samdal, O., Hetland, J., & Wold, B. (2009). School-related social support and students' perceived life satisfaction. The Journal of Educational Research, 102(4), 303–318. https://doi.org/10.3200/JOER.102.4.303-320

14 Goldman, Z. W., & Goodboy, A. K. (2014). Making students feel better: Examining the relationships between teacher confirmation and college students' emotional outcomes. Communication Education, 63(3), 259–277. https://doi.org/10.1080/03634523.2014.920091

15 Titsworth, S., Quinlan, M. M., & Mazer, J. P. (2010). Emotion in teaching and learning: Development and validation of the Classroom Emotions Scale. Communication Education, 59, 431–452. doi:10.1080/03634521003746156

16 Spera, C. (2005). A review of the relationship among parenting practices, parenting styles, and adolescent school achievement. Educational Psychology Review, 17(2), 125-146. doi:10.1007/s10648-005-3950-1

17 Lau, E.Y.H., Chan, K.K.S., & Lam, C.B. (2018). Social Support and Adjustment Outcomes of First-Year University Students in Hong Kong: Self-Esteem as a Mediator. Journal of College Student Development 59(1), 129-134. doi:10.1353/csd.2018.0011.

18 Román, S., Cuestas Díaz, P., & Fenollar, P. (2008). An examination of the interrelationships between self-esteem, others’ expectations, family support, learning approaches and academic achievement. Studies in Higher Education, 33, 127–138. https://doi.org/10.1080/03075070801915882

19 Ali, I. (2019). Personality traits, individual innovativeness and satisfaction with life. Journal of Innovation & Knowledge, 4(1), 38–46. https://doi.org/10.1016/j.jik.2017.11.002

20 The Importance of Personality Traits in Students' Perceptions of Metacognitive Awareness. (2016). Procedia - Social and Behavioral Sciences, 232, 655–667. https://doi.org/10.1016/j.sbspro.2016.10.090

21 Costa, P T. & McCrae, R. (1992) Revised NEO Personality Inventory (NEO-PI-R) and NEO Five Factor Model (NEO-FFI) Professional manual. Odesa, FL; Psychological Assessment Center.

22 Swickert, R. (2009). Personality and social support. In P. Corr & G. Matthews (Eds.), Cambridge handbook of personality (pp. 524–540). Cambridge, England: Cambridge University Press.

23 Potash M.. Noppe 1. and Noppe L. (1981) The relationship of personality factors to life satisfaction among the elderly. Paper presented at the Annual Meeting of the Gerontological Society of America, Toronto.

24 Emmons R. A. and Diener E. (1986) Influence of impulsivity and sociability on subjective well-being. J. Person. sot. PsJchol. 50, 121 I-1215. family environment generalized to new social relationships? Cognitive Therapy and Research, 18, 39–53.

25 Hernandez, L., Oubrayrie-Roussel, N. & Prêteur, Y. Educational goals and motives as possible mediators in the relationship between social support and academic achievement. Eur J Psychol Educ 31, 193–207 (2016). https://doi.org/10.1007/s10212-015-0252-y

26 Ibid.

27 Rueger SY, Malecki CK, Demaray MK. Relationship between multiple sources of perceived social support and psychological and academic adjustment in early adolescence: comparisons across gender. J Youth Adolesc. 2010 Jan;39(1):47-61. doi: 10.1007/s10964-008-9368-6. Epub 2008 Dec 9. PMID: 20091216.

28 Malecki, C. K., & Demaray, M. K. (2006). Social support as a buffer in the relationship between socioeconomic status and academic performance. School Psychology Quarterly, 21(4), 375–395. https://doi.org/10.1037/h0084129

29 Ibid.

30 Wen, X., & Li, Z. (2022). Impact of Social Support Ecosystem on Academic Performance of Children From Low-Income Families: A Moderated Mediation Model. Frontiers in Psychology, 13. https://www.frontiersin.org/articles/10.3389/fpsyg.2022.710441

31 Ibid.

32 Orben A, Tomova L, Blakemore SJ. The effects of social deprivation on adolescent development and mental health. Lancet Child Adolesc Health. 2020 Aug;4(8):634-640. doi: 10.1016/S2352-4642(20)30186-3. Epub 2020 Jun 12. PMID: 32540024; PMCID: PMC7292584.

33 Ibid.

34 Ibid.

35 Tomova L, Wang KL, Thompson T, Matthews GA, Takahashi A, Tye KM, Saxe R. Acute social isolation evokes midbrain craving responses similar to hunger. Nat Neurosci. 2020 Dec;23(12):1597-1605. doi: 10.1038/s41593-020-00742-z. Epub 2020 Nov 23. Erratum in: Nat Neurosci. 2022 Mar;25(3):399. PMID: 33230328; PMCID: PMC8580014.

36 Glozah, F. N., & Pevalin, D. J. (2014). Social support, stress, health, and academic success in Ghanaian adolescents: A path analysis. Journal of Adolescence, 37(4), 451–460. https://doi.org/10.1016/j.adolescence.2014.03.010

37 Barriga, A., Doran, J., Newell, S., Morrison, E., Barbetti, V., & Robbins, B. (2002). Relationships Between Problem Behaviors and Academic Achievement in AdolescentsThe Unique Role of Attention Problems. Journal of Emotional and Behavioral Disorders - J EMOTIONAL BEHAV DISORD, 10, 233–240. https://doi.org/10.1177/10634266020100040501

38 Barker, Gary. (‎2007)‎. Adolescents, social support and help-seeking behaviour : an international literature review and programme consultation with recommendations for action / Gary Barker. World Health Organization. https://apps.who.int/iris/handle/10665/43778

39 Ibid.

40 Ibid.

41 Ibid.

42 Ibid.

43 Dougherty, D., & Sharkey, J. (2017). Reconnecting Youth: Promoting emotional competence and social support to improve academic achievement. Children and Youth Services Review, 74, 28–34. https://doi.org/10.1016/j.childyouth.2017.01.021

44 Barker (2007)

45 Ibid.

46 Costello J, Pickens L & Fenton J (2001). Social supports for children and families: A matter of connections.Chicago, Chapin Hall Centre for Children at the University of Chicago (Draft manuscript).

47 Lee, V. E., Smith, J. B., Perry, T. E., & Smylie, M. A. (1999). Social Support, Academic Press, and Student Achievement: A View from the Middle Grades in Chicago. Improving Chicago’s Schools. A Report of the Chicago Annenberg Research Project. Consortium on Chicago School Research, 1313 E. https://eric.ed.gov/?id=ED439213

48 Ibid.

49 Ibid.

50 Ibid.

51 Griffith, M. (2018). What is the cost of providing students with adequate psychological support. National Association of School Psychologists (NASP). https://www.nasponline.org/research-and-policy/policy-matters-blog/what-is-the-cost-of-providing-students-with-adequate-psychological-support  

52 Barker (2007)

53 Ibid.

54 Bauer, A., Stevens, M., Purtscheller, D., Knapp, M., Fonagy, P., Evans-Lacko, S., & Paul, J. (2021). Mobilising social support to improve mental health for children and adolescents: A systematic review using principles of realist synthesis. PLOS ONE, 16(5). https://doi.org/10.1371/journal.pone.0251750  

55 Kellogg Foundation (1998). Safe Passages through Adolescence: Communities Protecting the Health and Hopes of Youth. In Lessons Learned from WK Kellogg Foundation Programming. Battle Creek,MI, USA.

Autism Diagnosis & Treatment: Understanding Racial Disparities

Diagnostic Symptoms & Patterns 

Autism Spectrum Disorder (ASD) is a neurological developmental disability that causes individuals to have lifelong difficulties in communication, interpretation and behavior. ASD is most commonly referred to as a developmental disorder because symptoms first appear within the first two years of a person’s life.[1] Commonly observed ASD symptoms within a child’s first 24 months include:[2]

- Limited social interaction (avoiding eye contact, disinterest in interactive games)

- Repetitive behaviors (playing with the same toy, having obsessive interests) 

-Delayed language and/mobility 

-Mood or emotional reactions that deviate from the norm

-High comorbidity with anxiety, depression, and attention-deficit hyperactivity disorder (ADHD)

As a spectrum disorder, it is common to see different combinations and severities of ASD symptoms in each diagnosed person. Regardless of which symptoms manifest in a person, treatment typically still has the potential to effectively mitigate some of ASD’s long-term challenges. With proper intervention and therapy, adults with ASD are often capable of achieving significant autonomy and social integration.[3] But, early detection is crucial. The American Academy of Pediatrics recommends that all children receive “well-child visits” (including screening for autism) at 18 and 24 month appointments; the sooner a child with symptoms receives an accurate screening, the sooner they are able to begin effective intervention and treatment.[4] Through assessment methods such as observation, blood tests and interactive tests, the accuracy of ASD assessments continues to improve - thus improving the odds of developmental and social progress in children with ASD.[5] 

In 2023, there was a groundbreaking shift in autism diagnosis statistics: for the first year in U.S. history, Black and Hispanic youth were diagnosed at a higher rate than their White counterparts.[6] This comes after decades of underrepresentation of autism in minority populations. However, understanding racial differences in access, culture and environment among marginalized communities provides insight into the progress required to see continual improvements in ASD disparities.

Early Assumptions 

When Leo Kanner first published his observations in 1943, he referred to this condition as “early infantile autism” and asserted that it occurred most often in children belonging to White middle and upper-class families.[7] Unfortunately, Kanner overlooked the reality that the parents who could typically seek help regarding their child’s developmental problems were likely those with resources, privilege and access to appropriate healthcare. In the 1940s those parents were almost exclusively White, and decades later White children continue to have disproportionate access to autism treatment and resources.[8,9] Research from the Center for Disease Control (CDC) has since established that ASD has no disposition toward a particular ethnic group, so factors other than biological differences contribute to White American children receiving the quickest and most frequent ASD diagnosis of all socioeconomic groups.[10] 

ASD in Black Children

According to a 2017 study conducted by the American Journal of Public Health, Black children are 19 percent less likely than their White counterparts to receive an autism diagnosis.[11] Similarly to other health disparities in America, high poverty rates and limited access to treatment facilities contribute to autism’s underdiagnosis in Black Americans. Research continues to identify racism as one of the greatest determinants in a person’s long-term health.[12] It is estimated that Black Americans live four years less than their White counterparts from compounding issues that contribute to a poorer quality of life (e.g., Black Americans are under-represented in higher income jobs and have a disproportionately high rate of chronic diseases in comparison to their White counterparts).[13] 

Addressing this socioeconomic gap is crucial to improving Black Americans’ ASD diagnosis. Research conducted between 2002 and 2010 on the prevalence of autism in White, Black and Hispanic children found autism diagnosis was higher in high socioeconomic Black Americans than their counterparts. Therefore, diminishing socioeconomic differences is key to improving ASD diagnosis for all Black Americans, who remain the demographic with the lowest average annual income in America.[14,15] 

Diagnosis issues also tend to arise when Black families seek autism treatment facilities with concerns. The majority of school documentation of ASD children identifies the child’s history as “bad behavior” instead of a developmental disorder.[16] A 2007 study conducted at the University of Pennsylvania found that Black children with ASD are 5.1 times more likely to be misdiagnosed with behavior disorders before they are correctly diagnosed with autism.[17] Another 2007 study found that African-American children were 5.1 times more likely than White children to receive a diagnosis of adjustment disorder, and 2.4 times more likely to receive a diagnosis of conduct disorder.[18] 

Racist stigmas labeling Black children as rude, unruly, and aggressive also extends to teachers. A 2020 American Psychological Association study on 178 prospective teachers across universities in southeastern states revealed that the majority of teachers within the study inaccurately observed anger in both genders of Black children at higher rates than of White children. The implications of this study extend to autism: teachers and other school administrators (e.g., school psychologists) play an instrumental role in referring children for further behavioral assessments.[19]

ASD in Hispanic Children

In past decades, Hispanic children were diagnosed at an average 65% lower rate than their White counterparts.[20] Recent strides in autism awareness within the Hispanic community have contributed to their improvements in ASD diagnosis, but there are still improvements to make in resources, treatment accessibility and awareness. Similarly to Black children, Latino children often have delayed diagnoses caused by low socioeconomic standings and limited accessibility to treatment and resources.

Spanish is also the second highest primary language spoken in the U.S, and is a factor that has been identified as both a barrier to identifying ASD and a communication challenge between parents and healthcare providers. In a 2004 study by Shapiro et al. 16 young, low-income Hispanic mothers described feelings of “alienation” in their interactions with healthcare providers.[21] The mothers described how information was not always explained enough and if a translator is not present, they felt as though they missed a lot of information.[22] Another study conducted in 2016 by Steinberg et al. found that Spanish-speaking parents are often asked less about their developmental concerns even if their child is known to be at risk, and have reported trouble connecting with providers because they are treated as though they lack knowledge.[23] These experiences not only dissuade parents from asking questions, but also intensify a caregiver’s skepticism, as families with limited English proficiency report less trust in providers compared to English proficient families.[24]

Emerging solutions to disparities in ASD diagnosis/treatment

There are growing resources available to help families from underrepresented communities better understand and identify ASD in their children, aiding in diagnosis and treatment and help close these racial disparities. 

• The Autism Society of Los Angeles (ASLA) runs a hotline at (424) 299-1531 to help parents navigate the diagnosis and healthcare landscape. This organization also offers services in English and Spanish, providing families the resources they need without a financial burden.[25]

• The Children's Hospital, Los Angeles employs liaisons to connect families to further assessment, locate other treatment facilities and gain general support. This hospital is physically located in Los Angeles, and it also provides a virtual autism assessment that can be accessed at: https://chla.purview.net/patient/start.

• “Autism in Black” is a non-profit that aims to provide support to black parents who have a child on the spectrum, through educational and advocacy services like podcasts, free consultations and  hosting outreach events to better educate local communities. Managed by licensed mental health providers, “Autism in Black” is grounded in a mission to improve awareness of and reduce the stigma associated with ASD in the Black community.[26]

• The Center for Disease Control (CDC) has a “Learn the Signs. Act Early.” program that provides free resources in English and Spanish to monitor children’s development starting at 2 months of age. Additionally, by downloading the CDC’s free Milestone Tracker mobile app, caregivers can log and monitor their child’s behavior to later share with healthcare providers.[27]

Community-based Intervention for ASD

JAMA Pediatrics (2022) conducted analysis of decades of autism studies and found that compounding factors increase the likelihood of early morbidity for individuals with autism in comparison to the general population as well as for minorities in comparison to their White counterparts.[28] Under this consideration, marginalized individuals with ASD are uniquely vulnerable to compounding issues related to how they must navigate the world due to their racial identity and neurodivergence (e.g., non-verbal communication, self-harming, and dependence on a caretaker).[29]

 People of color have a higher likelihood of limited availability of treatment centers, fewer services provided by Medicare providers, and of belonging to a lower socioeconomic group.[30] Equal access to healthcare is the foundation for children with mental disabilities to find the resources and treatment plans that will enable them to not only survive but also reach their full. With Hispanic people comprising both the largest minority population in the United States and the majority of the 25 million people in the United States with limited English proficiency, healthcare must continue to make adjustments in order to ensure that ASD is not only diagnosed accurately for this population, but healthcare providers also need to ensure that this demographic continues to feel supported as they navigate this complex condition.[31] Similarly, Black Americans continue to face the greatest discrimination of any group in America, and improving access to timely quality ASD treatment is crucial.[32]

As a growing pediatric concern, ASD was found to occur in 1-in-125 children in 2018 only to triple to 1-in-36 in 2023.[33] As the ASD population increases and the conversation shifts towards finding the resources to assist individuals on the spectrum better integrate into their communities, understanding the health disparities that affect progress is paramount. By diminishing the barriers to affordable and accessible care for marginalized communities, autism advocates will continue to become better equipped to serve the diverse population of individuals with ASD.

Help and support are available: If you or someone you know is struggling to obtain an ASD diagnosis and/or treatment, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Kate Campbell

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

References

1 National Institutes of Health. Autism Spectrum Disorder. National Institute of Health Website. Updated 2023. Accessed June 12, 2023.  https://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd

2 Centers for Disease Control and Prevention. Signs and Symptoms of Autism of Spectrum Disorder. Centers for Disease Control and Prevention Website. Updated March 28, 2022. Accessed June 12, 2023. https://www.cdc.gov/ncbddd/autism/signs.html

3 Whiteley, P., Carr, K., & Shattock, P. (2019). Is Autism Inborn And Lifelong For Everyone?. Neuropsychiatric disease and treatment, 15, 2885–2891. https://doi.org/10.2147/NDT.S221901

4 Durkin, M. S., Maenner, M. J., Baio, J., Christensen, D., Daniels, J., Fitzgerald, R., Imm, P., Lee, L. C., Schieve, L. A., Van Naarden Braun, K., Wingate, M. S., & Yeargin-Allsopp, M. (2017). Autism Spectrum Disorder Among US Children (2002-2010): Socioeconomic, Racial, and Ethnic Disparities. American journal of public health, 107(11), 1818–1826. https://doi.org/10.2105/AJPH.2017.304032

5 Ibid.

6 Centers for Disease Control and Prevention. Autism Prevalence Higher, According to Data from 11 ADDM Communities. Centers for Disease Control and Prevention Website Updated March 23, 2023. Accessed June 10, 2023. 

7 Rosen, N. E., Lord, C., & Volkmar, F. R. (2021). The Diagnosis of Autism: From Kanner to DSM-III to DSM-5 and Beyond. Journal of autism and developmental disorders, 51(12), 4253–4270. https://doi.org/10.1007/s10803-021-04904-1

8 American Psychiatric Association. (2023). New Research Points to Disparities in Autism Prevalence and Access to Care. Last updated April 23, 2023. Accessed June 20, 2023. https://www.psychiatry.org/news-room/apa-blogs/disparities-in-autism-prevalence-and-access

9 Mandell, D.S., Listerud, J., Levy, S.E., Pinto-Martin, J.A. (2002). Race Differences in the Age at Diagnosis Among Medicaid-Eligible Children with Autism. Journal of Child & Adolescent Psychiatry, 41(12), 1447-1453. https://doi.org/10.1097/00004583-200212000-00016.

10 Centers for Disease Control and Prevention. Spotlight on Closing the Racial and Ethnic Gaps in the Identification of Autism Spectrum Disorder among 8-year-old-Children. Centers for Disease Control and Prevention Website. Last updated March 23, 2023. Accessed June 23, 2023. https://www.cdc.gov/ncbddd/autism/addm-community-report/spotlight-on-closing-racial-gaps.html

11 Ibid.

12 Paradies, Y., Ben, J., Denson, N., Elias, A., Priest, N., Pieterse, A., Gupta, A., Kelaher, M., & Gee, G. (2015). Racism as a Determinant of Health: A Systematic Review and Meta-Analysis. PloS one, 10(9), e0138511. https://doi.org/10.1371/journal.pone.0138511

13 Price, J. H., Khubchandani, J., McKinney, M., & Braun, R. (2013). Racial/ethnic disparities in chronic diseases of youths and access to healthcare in the United States. BioMed research international, 2013, 787616. https://doi.org/10.1155/2013/787616

14 Mehta, N. K., Lee, H., & Ylitalo, K. R. (2013). Child health in the United States: recent trends in racial/ethnic disparities. Social science & medicine (1982), 95, 6–15. https://doi.org/10.1016/j.socscimed.2012.09.011

15 The Urban Institute.(2009). Racial and Ethnic Disparities among Low-Income Families [Fact sheet]. https://www.urban.org/sites/default/files/publication/32976/411936-racial-and-ethnic-disparities-among-low-income-families.pdf

16 Mandell, D. S., Ittenbach, R. F., Levy, S. E., & Pinto-Martin, J. A. (2007). Disparities in diagnoses received prior to a diagnosis of autism spectrum disorder. Journal of autism and developmental disorders, 37(9), 1795–1802. https://doi.org/10.1007/s10803-006-0314-8

17 Halberstadt, A. G., Cooke, A. N., Garner, P. W., Hughes, S. A., Oertwig, D., & Neupert, S. D. (2022). Racialized emotion recognition accuracy and anger bias of children’s faces. Emotion, 22(3), 403–417. https://doi.org/10.1037/emo0000756

18 Ibid.

19 Centers for Disease Control and Prevention. Spotlight on Closing the Racial and Ethnic Gaps in the Identification of Autism Spectrum Disorder among 8-year-old-Children. Centers for Disease Control and Prevention Website. Last updated March 23, 2023. Accessed June 23, 2023. https://www.cdc.gov/ncbddd/autism/addm-community-report/spotlight-on-closing-racial-gaps.html

20 Shapiro, J., Monzó, L. D., Rueda, R., Gomez, J. A., & Blacher, J. (2004). Alienated advocacy: perspectives of Latina mothers of young adults with developmental disabilities on service systems. Mental retardation, 42(1), 37–54. https://doi.org/10.1352/0047-6765(2004)42<37:AAPOLM>2.0.CO;2

21 Ibid.

22 Steinberg, E. M., Valenzuela-Araujo, D., Zickafoose, J. S., Kieffer, E., & DeCamp, L. R. (2016). The "Battle" of Managing Language Barriers in Health Care. Clinical pediatrics, 55(14), 1318–1327. https://doi.org/10.1177/0009922816629760

23 Ibid.

24 Warm Line. (2021). Autism Society of Los Angeles. https://www.autismla.org/1/program/speaker-series/

25 Advocacy, Education, and Support. (2023). Autism in Black. https://www.autisminblack.org/

26 About CDC’s Learn the Signs. Act Early. Program. (2023). Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/wicguide/about-cdcs-learn-the-signs-act-early-program.html

27 Ferrán, C. L., Hutton, B., Page, M.L., Driver, J.A., Ridao, M., Arroyo, A.A., Valencia, A., Saint-Gerons, D.M.,Tabarés-Seisdedos, R. (2022). Mortality in Persons With Autism Spectrum Disorder or Attention-Deficit/Hyperactivity Disorder. JAMA Pediatr, 176(4), e216401. https://doi.org/10.1001/jamapediatrics.2021.6401

28 Ibid.

29 Ibid.

30 Steinberg, E. M., Valenzuela-Araujo, D., Zickafoose, J. S., Kieffer, E., & DeCamp, L. R. (2016). The "Battle" of Managing Language Barriers in Health Care. Clinical pediatrics, 55(14), 1318–1327. https://doi.org/10.1177/0009922816629760

31 Dietrich, S., Hernandez, E. (2022). What Languages Do We Speak in the United States? United States Census Bureau Website. Last updated December 06, 2022. Accessed June 27, 2023.

32 The Texas Politics Project. Most Discriminated Group (April 2022). The Texas Politics Project at the University of Texas at Austin Website. https://texaspolitics.utexas.edu/set/most-discriminated-group-april-2022

33 Centers for Disease Control and Prevention. Data and Statistics on Autism Spectrum Disorder, Centers for Disease Control and Prevention Website. Last updated April 4, 2023. Accessed June 25, 2023.

Exploring the Mechanisms, Popularity & Health Implications of Vaping

How Does Vaping Work?

Vaping imitates the act of smoking by utilizing battery-powered devices that produce an aerosol resembling water vapor. However, this aerosol contains not only nicotine but also flavorings and over 30 additional chemicals. When inhaled, the aerosol enters the lungs, allowing the nicotine and chemicals to enter the bloodstream. A single vape pod contains the same amount of addictive nicotine as 20 cigarettes. Vaping conditions the brain to anticipate higher nicotine levels, leading to a stronger desire to vape.[1]

Initially, vape devices resembled traditional cigarettes, but more recent models have taken on different forms, such as resembling a USB flash drive or a compact pod. Vaping devices vary in their appearances, yet they share fundamental components, including a battery, sensor and atomizer/flavor cartridge.[2]

Targeted Age Group

As numbers for cigarette smoking have been on the decline for the past year, the popularity of vapes, a type of e-cigarette, has exploded in the United States, especially in younger generations. Johns Hopkins Medicine conveyed that over two million middle and high school students admitted to the use of vapes in 2022, with 80% of them using flavored e-cigarettes.[3] The Texas Health and Human Services notes that the teenage brain is particularly vulnerable to the impact of nicotine, making it more challenging to quit vaping and raising the likelihood of teens transitioning to smoking tobacco cigarettes due to nicotine addiction.[4]

Vaping devices have gained immense popularity among teenagers, becoming the most prevalent form of nicotine used among youth in the United States. A 2020 report from the National Institute on Drug Abuse indicates that many teens are unaware that vaping cartridges contain nicotine and mistakenly believe they only contain flavoring.[5] The widespread availability of these devices, captivating advertisements, a wide range of e-liquid flavors, and the perception that they are safer than traditional cigarettes contribute to their appeal among this age group. Moreover, their concealable nature, lacking the distinct odor of tobacco cigarettes, and their ability to be disguised as flash drives make them easier for teens to hide from teachers and parents.[6]

Why do People Vape?

The idea that vaping is less harmful than smoking has made it especially popular to young audiences, who do not see negative repercussions from the devices and often do not even know they contain nicotine.[7] According to the CDC, some vaping devices advertise themselves as not even containing any nicotine despite being found to have it.[8] The popularity of vaping makes it extremely accessible to young people, and teenagers are especially susceptible to the idea of doing something because those around them choose to participate. The CDC adds that one of the most common reasons provided for beginning to vape by middle and high school students in the United States was that they had a friend who used vapes. Further, most participants added they continued to vape due to feelings of stress, depression and anxiety.[9]

Negative Health Effects

While there is a belief that vaping is significantly better for health than smoking cigarettes, this is not necessarily true. Vaping can be linked to a number of lung injuries and even deaths as a large number of harmful chemicals have been identified in these devices. Nicotine, found in both traditional cigarettes and e-cigarettes, serves as the main active component and possesses a strong addictive nature. It generates a desire for smoking and can lead to withdrawal symptoms if the craving is ignored. Johns Hopkins Medicine notes that nicotine is considered a toxic substance, capable of elevating blood pressure, triggering a surge in adrenaline levels, accelerating heart rate, and augmenting the risk of experiencing a heart attack.[10]

effects on the brain

Additionally, the use of nicotine during adolescence can pose risks to the developing brain, which continues to mature until approximately the age of 25. Nicotine consumption during this stage can potentially harm the regions of the brain responsible for attention, learning, mood regulation and impulse control.[11] In the process of forming memories or acquiring new skills, the brain establishes stronger connections (synapses) between its cells, and the adolescent brain constructs synapses at a faster rate compared to adult brains. However, nicotine alters the normal formation of these synapses. Furthermore, the use of nicotine during adolescence may also heighten the likelihood of future addiction to other substances.[12]

easing Anxiety?

The CDC found that when asked why they vape, one of the most common responses youth will provide is that it, “helps ease their feelings of stress, anxiety or depression”. However, continuous use of an e-cigarette can actually exacerbate these feelings.[13] Nicotine-containing e-cigarettes exert an impact on various major systems within the body. For instance, vaping stimulates increased dopamine activity in the brain's reward pathway, elevates heart rate and blood pressure, and potentially disrupts the functioning of the hypothalamic-pituitary-adrenal (HPA) axis. These physiological changes, in turn, have psychological implications for addiction, cognition, mood and anxiety.[14]

The use of nicotine salts in e-cigarettes enhances the efficiency of nicotine delivery, potentially increasing their addictive nature. Vaping may also result in short-term enhancements in cognitive performance, as nicotine has the ability to improve memory and attention. Users of e-cigarettes often report mood-enhancing and anxiety-reducing effects, although Tattan-Birch & Shahab (2020) note these may be actually attributed to the relief of withdrawal symptoms.[15] Symptoms of nicotine withdrawal encompass irritability, restlessness, feelings of anxiety or depression, sleep difficulties, impaired concentration, and intense cravings for nicotine. In an attempt to alleviate these symptoms, individuals may continue using tobacco products and associate their feelings of relief with the act of vaping rather than withdrawal. Teenagers may resort to vaping as a means to cope with stress or anxiety, inadvertently perpetuating a cycle of nicotine dependency.[16]

If you or someone you know is struggling with anxiety and/or nicotine addiction, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support. Click here to see our interview on the role of social anxiety in addiction as well as how Cognitive Behavioral Therapy (CBT) and Exposure and Response Prevention (ERP) can be effective methods at overcoming substance abuse.

Contributed by: Ananya Kumar

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

References

1 Texas Health and Human Services. (2023). What is Vaping? Texas Department of State Health Services. https://www.dshs.texas.gov/vaping/what-is-vaping#:~:text=Vaping%20simulates%20smoking.,cross%20over%20into%20the%20bloodstream.

2 Ibid.

3 Blaha, M. J. (2022). 5 Vaping Facts You Need to Know. Johns Hopkins Medicine.  https://www.hopkinsmedicine.org/health/wellness-and-prevention/5-truths-you-need-to-know-about-vaping

4 Texas Health and Human Services

5 NIDA. 2020, January 8. Vaping Devices (Electronic Cigarettes) DrugFacts. Retrieved from https://nida.nih.gov/publications/drugfacts/vaping-devices-electronic-cigarettes

6 Ibid.

7 Johns Hopkins Medicine

8 Centers for Disease Control and Prevention. (2022). Quick Facts on the Risks of E-cigarettes for Kids, Teens, and Young Adults. CDC. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/Quick-Facts-on-the-Risks-of-E-cigarettes-for-Kids-Teens-and-Young-Adults.html

9 Ibid.

10 Johns Hopkins Medicine

11 CDC

12 Ibid.

13 Ibid.

14 Tattan-Birch, H., & Shahab, L. (2020). The Psychobiology of Nicotine Vaping. In Psychobiological Issues in Substance Use and Misuse (1st Edition). Routledge. 

15 Ibid.

16 CDC

To Diagnose or Not to Diagnose: The Debate on Personality Disorders in Adolescence

The Intersectionality of PD in Adolescence 

The presentation of a personality disorder in adolescence is complicated by the ongoing debate of whether personality disorders should be diagnosed. Some licensed health professionals are hesitant to provide a diagnosis due to the belief that adolescence is a period of changing personality,[1] thus, it is not appropriate to judge if a personality is disordered. However, other health professionals argue for the benefits of early detection and treatment, leading to better health outcomes.[2] The impacts of the home environment, genetics and consequences of a diagnosis further complicate this debate.

Effects of Home Environment 

Childhood maltreatment (e.g., neglect, physical abuse) substantially increases the risk of developing a personality disorder.[3] The Minnesota Project by Sroufe et al. (2005) followed a group of high-risk children into adulthood and found that insecure attachment during childhood is strongly associated with the later development of personality disorders in adolescence.[4] Later studies on Borderline Personality Disorders (BPD) further supported the association of adverse childhood experiences as a risk factor for personality disorders. Marchetti et al. (2022) found that a history of childhood maltreatment was associated with higher levels of BPD in adolescents (average age 16).[5] Furthermore, studies by Xiao et al. (2023) found that adolescents with BPD had higher rates of all the assessed childhood traumas when compared to adolescents with non-disordered personalities; this was especially true for emotional neglect (the most commonly seen childhood trauma).[6]

Effects of Biological Factors

Adolescence is a time of biological change, including those that regulate one’s personality. Throughout adolescence, the brain continues to develop in term of myelination and the formation of synaptic networks; thus, the neural basis for many psychological regulatory systems are still in development.[7] Furthermore, the frontal, temporal and occipital lobes of the brain (which are responsible for response inhibition, emotion regulation, planning and organization) are still developing during adolescence, which may account for the increased impulsivity sometimes seen during this period.[8] The increased levels of sex hormones adolescents are exposed to during puberty also affect mood regulation.[9] Therefore, the developmental changes of adolescence can bring forth impulsivity and mood changes, similar to the changes brought by a personality disorder. 

However, studies by Xiao et al. (2023) have found that there are also biological differences in adolescents with personality disorders compared to non-disordered peers.[10] They found that adolescents with Borderline Personality Disorder showed increased Amplitude Low-Frequency Fluctuations in the limbic system (a measure of spontaneous neuronal activity related to the mood swings associated with BPD).[11] Thus, biological factors can also account for differences in the mood swings of adolescents with disordered personalities compared to non-disordered adolescents.

Arguments in favor of a diagnosis

The argument in favor of a diagnosis appeals to the benefits of early diagnosis, specifically: better health outcomes. Paris et al. (2013) report that conditions such as antisocial personality disorders begin in childhood, and as a result of the early onset, psychopathology is more likely to continue.[12] An analysis of personality trait dimensions also supports the early establishment of personality. Studies by Shiner et al. (2009) suggest a continuity from child to adult personality based on findings that certain personality traits (e.g., openness, conscientiousness, extroversion, agreeableness, neuroticism) in childhood predicted later behaviors.[13] Klimstra et al. (2009) distinguish that personality traits change considerably at the ages of 10-15 years old and then stabilize at the ages of 16-21 years.[14] However, according to Cicchetti et al. (2009), since personality disorders (PD) do not begin in adulthood, early investigation is necessary to develop a lifespan model for treatment.[15] Schmeck (2022) further supports the need for early intervention in personality disorders, arguing that early diagnosis rids the stigma associated with PD and lessens the possibility of long-lasting impairments and disability by facilitating the transition into adulthood.[16] 

These benefits of early diagnosis may have been considered by the Diagnostic and Statistical Manual of Mental Disorders (DSM) since the most recent version of the guide to diagnosing mental disorders has changed its age requirements for diagnosing PD. While earlier versions of the DSM did not allow someone under 18 to be diagnosed, the DSM-5 (the most recent version) allows the diagnosis of a personality disorder in someone under 18 if symptoms are present for at least one year.[17] 

Arguments against diagnosis

A study by Laurenssen et al. (2013) found that 57.8% of psychologists working with adolescents acknowledged the existence of personality disorders in this age group; however, only 8.7% of them actually made formal PD diagnoses in the adolescents.[18] The majority of psychologists are reluctant to diagnose adolescents based on the idea that personality is fluid and still developing.[19] Dijk et al. (2021) argue that while personality traits (e.g., openness, conscientiousness, extroversion, agreeableness, neuroticism) are structurally similar between adolescents and adults, there are developmental differences; for example, adolescents appear to be less conscientious.[20] Some psychologists also argue that an early diagnosis is stigmatizing since personality pathology can often be viewed as being unmodifiable.[21,22] Furthermore, according to Adshead et al. (2012), a misdiagnosis of a personality disorder in adolescence can focus attention away from interventions to improve the caregiving environment, particularly if neglect or abuse are present.[23] Perhaps taking the drawbacks of diagnosis into account, the American Psychiatric Association webpage, as of now, states that diagnosis of personality disorders is only applicable to individuals 18 and older (It is important to note that the American Psychiatric Association oversees the DSM-5).[24]

Treatment of PD in adolescence

Personality disorders vary in the ways they impact an individual’s thoughts and ways of expressing themselves, however, they align in their need for treatment to go away.[25] In adults certain psychotherapies (e.g., Dialectical Behavior Therapy (DBT), Cognitive Behavioral Therapy (CBT), Group Therapy, Psychoanalytic) have shown to be effective for treating personality disorder.[26] If an adolescent is diagnosed with a personality disorder, their treatment plans may differ slightly from adults. Adolescent treatment plans are complex due to a current need for more evidence if adult interventions also work for adolescents.[27] Furthermore, these treatment plans are unique as they often incorporate the adolescent’s school and parents.[28]

If you believe you or your child may have a personality disorder, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Maria Karla Bermudez

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

References

1 Adshead, G., Brodrick, P., Preston, J., & Deshpande, M. (2012). Personality disorder in adolescence. Advances in Psychiatric Treatment, 18(2), 109-118. doi:10.1192/apt.bp.110.008623

2 Cicchetti, D., & Crick, N. R. (2009). Precursors and diverse pathways to personality disorder in children and adolescents. Development and Psychopathology, 21(3), 683-685. doi:https://doi.org/10.1017/S0954579409000388

3 Adshead et al. (2012)

4 Sroufe, A, Egeland, B, Carlson, E et al (2005) The Development of the Person: The Minnesota Study of Risk and Adaptation from Birth to Adulthood. Guilford Press

5 Marchetti, D., Musso, P., Verrocchio, M., Manna, G., Kopala-Sibley, D., De Berardis, D., . . . Falgares, G. (2022). Childhood maltreatment, personality vulnerability profiles, and borderline personality disorder symptoms in adolescents. Development and Psychopathology, 34(3), 1163-1176. doi:10.1017/S0954579420002151

6 Xiao, Q., Yi, X., Fu, Y., Jiang, F., Zhang, Z., Huang, Q., Han, Z., & Chen, B. T. (2023). Altered brain activity and childhood trauma in Chinese adolescents with borderline personality disorder. Journal of affective disorders, 323, 435–443. https://doi.org/10.1016/j.jad.2022.12.003

7 Adshead et al. (2012)

8 Ibid. 

9 Ibid. 

10 Xiao et al. (2023)

11 Ibid. 

12 Paris, Joel. “Personality disorders begin in adolescence.” Journal of the Canadian Academy of Child and Adolescent Psychiatry = Journal de l'Academie canadienne de psychiatrie de l'enfant et de l'adolescent vol. 22,3 (2013): 195-6. doi:10.1007/s00787-013-0389-7

13 Shiner, R (2009) The development of personality disorders: perspectives from normal development. Development and Psychopathology 4: 715–34

14 Klimstra, TA, Hale, WW, Raaijmoken, QA (2009) Maturation of personality in adolescence. Journal of Personality, Society & Psychology 96: 898–912

15 Cicchetti et al. (2009)

16 Schmeck, K. (2022, March 17). Debate: Should CAMHS professionals be diagnosing ... - wiley online library. ACAMH. https://acamh.onlinelibrary.wiley.com/doi/10.1111/camh.12553

17 Personality disorders: Diagnosis. CAMH. (n.d.). https://www.camh.ca/en/professionals/treating-conditions-and-disorders/personality-disorders/personality-disorders---diagnosis#:~:text=According%20to%20DSM%2D5%2C%20features,for%20at%20least%20one%20year.

18 Laurenssen, E. M., Hutsebaut, J., Feenstra, D. J., Van Busschbach, J. J., & Luyten, P. (2013). Diagnosis of personality disorders in adolescents: a study among psychologists. Child and adolescent psychiatry and mental health, 7(1), 3. https://doi.org/10.1186/1753-2000-7-3

19 Paris (2013)

20 van Dijk, I., Krueger, R. F., & Laceulle, O. M. (2021). DSM-5 alternative personality disorder model traits as extreme variants of five-factor model traits in adolescents. Personality disorders, 12(1), 59–69. https://doi.org/10.1037/per0000409

21 Cicchetti et al. (2009)

22 Adshead et al. (2012)

23 Ibid. 

24 What are personality disorders?. Psychiatry.org - What are Personality Disorders? (2022, September). https://www.psychiatry.org/patients-families/personality-disorders/what-are-personality-disorders#:~:text=Diagnosis%20of%20a%20personality%20disorder,their%20personalities%20are%20still%20developing.

25 Ibid.

26 Ibid.

27 Adshead et al. (2012)

28 Ibid.

Inherited Memories: Current Research & Popular Misunderstandings

Memory Transmission & Monarch Butterflies

Carl Jung (1875-1961)[1] used the term “collective unconscious” to describe inherited wisdom and intuition from the past.[2] Evidence of the intergenerational effects of trauma have been found in populations affected by subjugation, genocide, racism and war.[3] This raises the question of how these memories are transmitted and whether there are biological mechanisms that enable the transmission of this information beyond environmental upbringing.

In nature, an example of inherited memory might be seen in monarch butterflies who take three generations to return from Mexico to Canada; the last generation knowing the route without any living members having previously been there.[4] Whether the inherited memories that have been demonstrated in cells, worms and butterflies can be extended to mammals has become a growing area of interest to researchers in recent decades.[5] In 2013, researchers at Emory University showed that mice are capable of passing the fear of a specific scent (a smell similar to a cherry blossom) down to future generations, via their sperm.[6] This process (which takes place through a mechanism referred to as “transgenerational epigenetic inheritance,”)  has led many scientists to jump to exciting conclusions as to how this research might be applied to the transmission of memories between generations of humans.[7] Yet researchers are still working to understand the intertwined relationship between epigenetics and genetics.[8]

Transgenerational Epigenetic Inheritance

There are a growing number of studies indicating that trauma may be able to be passed down through epigenetics,[9] which is the study of how the environment and people’s behavior can change the way genes work.[10] In genetic research, however, the environment is used as a general term to refer to anything other than genetics (which may include a person’s actions, the actions of others and the general, physical world).[11]

The term epigenetics is commonly used to refer to two concepts:[12]

1) The ways that packaging or modification of DNA results in the transmission of information within a group of cells (a theory widely accepted by science).

2) The ways that packaging or modifications of DNA might result in transmitting information from one generation to the next (a newer theory not as well established).

Epigenetic changes are reversible (unlike genetic changes) and they do not change a DNA sequence, but rather how the body reads the DNA sequence.[13] In epigenetics, the gene is not changed or damaged, instead the mechanisms of expression (when a gene is converted into functioning proteins) is altered.[14] These changes can affect gene expression by turning genes “on” and “off.”[15] Such molecular pathways with the potential to act epigenetically include histone modifications, DNA methylation, small RNAs and protein-protein interactions.[16]

It is believed that modifications to genetic expression may help an organism to respond to a changing environment and also help its descendants increase their likelihood of surviving.[17] When discussing how information is passed through generations, intergenerational change refers to changes that take place in one generation, whereas transgenerational changes are inherited from two or more generations.[18] Epigenetic transgenerational inheritance therefore refers to inheritance from an environmental exposure (e.g., the effects of an endocrine disruptor such as BPA or DDT) that alters the genetic programming of the germline with the changes transmitted between generations in the absence of direct exposure.[19]

Nonhuman Examples

In nonhuman species, research supports the notion that memories may be transmitted through multiple generations. Erickson (2020) found that the eggs of chickens originally domesticated in the red jungle fowl of Southeast Asia over 4,000 years ago (that later biologically adapted to the higher elevations of Tibet 1,200 years ago) were able hatch eggs when incubated in the lowland environment of their ancestral past unlike a control group of eggs that did not show the same adaptability.[20] Research on worms has also shown specific genes called the Modified Transgenerational Epigenetic Kinetics (MOTEK) are involved with turning epigenetic transmissions through RNA on or off.[21] Similarly, plants also appear to be particularly prone to transgenerational epigenetic inheritance through heritable changes in DNA methylation.[22] These findings raise the question as to whether comparable results can be found in mammals.

Lessons from Mice

In mice, studies have shown that a traumatic event could alter sperm that may affect the behavior of future generations.[23] Dias & Ressler (2014) found that by exposing mice to an odor and associating it with fear before conceiving the next generation of mice, the following two generations showed increased behavioral sensitivity to the same odor.[24] Similar initial research conducted by Gapp (2018) indicated that inheritance of specific trauma symptoms can be transmitted through alterations to long RNA in sperm through several generations in mice.[25] Mukherjee et al. (2018) evaluated five immediate-early genes in mice after memories were stored of either a positive or negative experience and found that the expressions were so unique for each that they could predict which experience the mouse had undergone by simply looking at the gene expression; suggesting the activation profile for each gene can contain information about experiences they have undergone.[26] These examples provide a framework of how environmental information could potentially be passed down through generations at the epigenetic, behavioral and neuroanatomical levels.[27]

To evaluate whether epigenetic changes resulting from environmental exposures could be reversed, Aoued et al. (2019) established fear in mice through olfactory cue-based fear conditioning and then sought to reverse the effects.[28] They did this by training the first generation of mice to associate the odors of either acetone or Lyral with mild foot shocks. They then extinguished this fear by providing odor-only exposure without the presentation of electric shocks. The results showed that first generation offspring did not show behavior sensitivity to the two odors. These findings provide hope for potential therapies in the future that may provide methods for reversing the influence of parental stress in both offspring and the parental germline.[29]

Human Applications

Though environmentally-induced changes passed from one generation to the next are observed relatively often in plants, it has remained elusive in mammals and even more difficult to find in humans.[30] The working memory that human beings, jumping spiders, archerfish and honeybees all possess involve similar genes that are believed to be inherited from the last common ancestor over 600 million years ago.[31] However, the study of transgenerational epigenetic inheritance in humans is difficult to isolate due to the confounding of ecological, genetic and cultural inheritance.[32] Since parental trauma is sometimes linked to childhood emotional abuse, it can be difficult for researchers to disentangle whether the experiences of parents are transferred to offspring as a result of genetics or through lived experiences.[33] With a newly sparked interest on whether epigenetics explains generational trauma, research has been conducted on descendants of abused prisoners from the American Civil War, children in the womb during the Dutch Hunger Winter, and Holocaust survivors.[34] However, within any traumatic situation, the effects may depend on the severity of the trauma, the age of an individual during the event, and whether the trauma was an isolated event or a reoccurring one.[35]

When discussing intergenerational memories in humans, it is important to differentiate between the concepts of transgenerational epigenetically inherited memories and collective memories. Collective memories are the shared remembrance or interpretation of facts about social groups which a person belongs (such as the person’s ethnic group or country) and may range from a national to a global level.[36] However, collective memories have been shown to change with time based on societal perception (e.g., older Americans alive during World War II remember the bombing of Hiroshima as a positive event that ended the war whereas younger Americans view it as a negative event because thousands of innocent civilians were killed).[37] Epigenetic transgenerational memories would be affected by different mechanisms and would not necessarily reflect the same changes as collective memories.

Lessons From Survivors and Their Descendants

To determine whether the epigenetic mechanisms of intergenerational transmission of stress effects can be found in humans, Yehuda et al. (2015) analyzed a specific gene encoding (epigenetic changes in FKBP5 methylation) in Holocaust survivors and their offspring with comparable parent/offspring control groups.[38] Their work found epigenetic alterations in both the exposed parent and offspring that were associated with preconception parental trauma. These findings were believed to be the first evidence in humans of an association between preconception stress effects and epigenetic changes in exposed parents and their adult offspring. Researchers believe these findings may contribute to an increased risk for psychopathology in the offspring of highly traumatized individuals.[39]

Alterations to the sperm of adult men has already been found to take place due to diet, alcohol, smoking, age and toxic exposure.[40] Costa et al. (2018) conducted research looking at children born after the Civil War who survived to age 45, comparing those whose fathers were POWs compared to those whose fathers were non POW veterans of the war. They also compared children born before and after the war in the same family by paternal ex-POW status. Though they did not find any impact of POW status on daughters, they found that sons of ex-POWs who experienced the camps during the harshest conditions were 1.11 times more likely to die than the sons of non POWs even after accounting for family structure, socioeconomic status, quality of marriage, maternal effects, and father-specific survival traits concluding that the findings were most consistent with an epigenetic explanation. However, they were not able to disentangle whether these epigenetic results were due to the stress of captivity or the effects of starvation.[41]

Future Research and Challenges

The University of Zurich’s Laboratory for Neuroepigenetics, run by Professor Isabel Mansuy, conducts research focused on determining molecular and cellular processes underlying how life experiences may influence physical and mental health across generations.[42] The laboratory not only conducts original research pioneering an understanding of transgenerational epigenetic inheritance in mice, but also conducts collaborative studies with clinicians in Europe and Asia to research the relevance as it relates to trauma patients in humans.[43] Professor Mansuy explains that trauma not only affects a person’s brain but also their reproductive system, which could cause depression or borderline personality disorder to be a trait inherited from parents.[44]

Challenges to studying environmentally-induced inheritance in humans include the nonexistence of four generations of human epidemiological cohorts and the ethical considerations of human experimentation.[45] A female fetus growing in the mother’s womb already contains the full complement of eggs, which means the DNA of future grandchildren is already present in a pregnant mother, so that it could take up to four generations to study true trans-generational inheritance in females.[46] In males, these changes could be seen in the next generation, since sperm is continually being produced.[47]

In terms of evolution, the transmission of epigenetic information in a fast-producing animal population could assist that species in rapidly adapting to a new environment, but this could become a maladaptive practice if the actual environment does not match that which was anticipated.[48] This may be one reason that the trait is not observed as much in humans who may come across multiple environments in their lifetimes.[49]

Research Riddled With Controversy

While the implications of epigenetic research have been met with enthusiasm by the press and public, there are scientists who heavily contest both the findings and their presentation. The research conducted by Yahuda et al. on Holocaust survivors was heavily criticized by Professor Ewan Birney, Director of the EMBL-European Bioinformatics Institute, for its small sample size (32 people and 8 controls), the tiny subset of genes used and the possibility of other potential causes for the findings.[50]

Similarly, Kevin Mitchell, a neurogeneticist known for speaking up against “neuro-bollocks,” in an interview with Claire McKenna (2020) explained his belief that there will never be accurate biomarkers (e.g., bloodwork, brain scans) for psychiatric or neurological conditions because the conditions are defined at the level of human behavior explaining, “Even if there’s a dynamic neural state that underpins some aspects of psychosis that we both share, the way that state looks in your brain may be very different from the way it looks in my brain…”[51] Mitchell does not find the transmission of trauma through epigenetic mechanisms plausible because it overly simplifies the relationship between psychological traits and genes explaining that a person’s experiences are expressed through changes in neuroanatomy instead of gene expression.[52]

In his blog, Wiring the Brain, Mithell also wrote an entry on May 29, 2018, reviewing what he believed to be the most prominent research on this topic at the time, and provided detailed information on each study as to why he believed them to be invalid (often small sample sizes and lack of predefined hypotheses).[53] In response, Jill Esher (a research philanthropist who funds pilot studies on exposure-induced nongenetic inheritance) posted a rebuttal on Germline Exposure’s website stating, among other things, that Mitchell cherry-picked the human studies he cited and then countered his argument by citing eleven studies illustrating transgenerational effects in humans and over 30 studies of intergenerational nongenetic inheritance in mammals.[54]

Mosche Szys, a professor of pharmacology at McGill University, similarly supported published findings on epigenetic research in mice telling the New York Times (2018) that dismissals of epigenetic theory are premature by explaining that, “The effects we’ve found have been small, but remarkably consistent and significant….This is the way science works. It is imperfect at first and gets stronger the more research you do.”[55]

Yehuda et al. (2018) (authors of the holocaust research criticized above) sought to clarify misconceptions by explaining that sensational media was oversimplifying their findings, obscuring the boundaries between fact and hypothesis and making inferences with implications far beyond the original findings; citing an example from Teen Vogue that cited their study and warned “You can get PTSD from your ancestors.”[56] They also warn that often articles claiming to debunk the notion that trauma is inherited are citing limitations written into the original research paper by the research team and are in fact debunking an over-interpretation of earlier journalists as opposed to the research itself. This led to an additional warning of inaccurately teaching the public that scientists are debunking one another rather than collaborating through the process of critique and correction.[57]

Potential Applications

Professor Mansuy explained during an interview with Jean Mary Zarate (2023), a senior editor at the journal Nature Neuroscience, that modifications to reproductive cells from traumatic experiences may transmit some of the effects of the exposure to children and research in this field could further our understanding of how inheritance can potentially affect psychiatric disorders including depression, anxiety and borderline personality disorder.[58] She explains there is a lot of work to be done in this field before it can be used to help people directly, but understanding that complex diseases like depression may be inherited from parents directly, instead of being related to something a person has done, would be important for psychiatrists and medical practitioners to know.[59]

This field is a budding new area of research and while the potential implications may excite the public, and at times become exaggerated in the media, the science is not yet understood well enough to be applied in the therapeutic setting. Though in the future, as more research emerges, it may be possible to incorporate these findings into techniques such as cognitive behavior therapy (CBT) or acceptance and commitment therapy (ACT) as a multi-pronged approach for addressing the root cause.

While progress in this field may be slow to produce answers, the current lack of understanding of epigenetic transgenerational inheritance does not minimize the reality of generational trauma and collective memories that can be passed down through a variety of other pathways. In addition to the potential for traumatic events that occur through transgenerational epigenetic inheritance, descendants of traumatized individuals may also be affected by the prenatal state of an anxious/symptomatic mother, or trauma affecting a parent’s behavior.[60] If you or someone you know is struggling to process generational trauma, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support. 

Contributed by: Theresa Nair

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

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4 Treffert (2015)

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7 Ibid.

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11 Birney E. Why I'm sceptical about the idea of genetically inherited trauma. The Guardian Web site. https://www.theguardian.com/science/blog/2015/sep/11/why-im-sceptical-about-the-idea-of-genetically-inherited-trauma-epigenetics. Updated 2015. Accessed June 1, 2023.

12 Ibid.

13 CDC (2022)

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18 Sarkies (2020)

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20 Erickson J. Past is prologue: Genetic ‘memory’ of ancestral environments helps organisms readapt. University Wire. 2020. Available from: https://www.proquest.com/docview/2405486117?pq-origsite=primo#. Accessed May 14, 2023.

21 Javelosa J. Scientists have discovered how memories are inherited. World Economic Forum Web site. https://www.weforum.org/agenda/2018/12/memories-can-be-inherited-and-scientists-may-have-just-figured-out-how/. Updated 2018. Accessed May 11, 2023.

22 Quadrana L, Colot V. Plant transgenerational epigenetics. Annu Rev Genet. 2016;50:467-491. doi: 10.1146/annurev-genet-120215-035254.

23 Gallagher (2013)

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27 Dias & Ressler (2014)

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29 Ibid.

30 Birney (2015)

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33 Yehuda R, Daskalakis NP, Bierer LM, et al. Holocaust exposure induced intergenerational effects on FKBP5 methylation. Biol Psychiatry. 2015;80(5):372-380. doi: 10.1016/j.biopsych.2015.08.005.

34 Benedict (2018)

35 Byrne D. How trauma’s effects can pass from generation to generation. Nature. 2023. https://www.nature.com/articles/d41586-023-01433-y. Accessed May 30, 2023.

36 Roediger H, DeSoto K. The power of collective memory. Scientific American Web site. https://www.scientificamerican.com/article/the-power-of-collective-memory/. Updated 2016. Accessed May 24, 2023.

37 Ibid.

38 Yehuda et al. (2015)

39 Ibid.

40 Costa DL, Yetter N, DeSomer H. Intergenerational transmission of paternal trauma among US civil war ex-POWs. Proc Natl Acad Sci U S A. 2018;115(44):11215-11220. doi: 10.1073/pnas.1803630115.

41 Ibid.

42 University of Zurich (UZ). Laboratory of neuroepigenetics | isabelle mansuy. University of Zurich Web site. http://www.hifo.uzh.ch/en/research/mansuy.html. Accessed May 30, 2023.

43 Ibid.

44 Byrne (2023)

45 Escher J. No convincing evidence? A response to kevin mitchell’s reckless attack on epigenetic inheritance. Germline Exposures Web site. http://www.germlineexposures.org/1/post/2018/07/no-convincing-evidence-a-response-to-kevin-mitchells-reckless-attack-on-epigenetic-inheritance.html. Updated 2018. Accessed Jun 2, 2023.

46 Birney (2015)

47 Ibid.

48 Horsthemke (2018)

49 Ibid.

50 Birney (2015)

51 McKenna C. Kevin mitchell. BJPsych Bull. 2020;44(2):81-83. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7283122/. doi: 10.1192/bjb.2020.18.

52 Ibid.

53 Mitchell K. Grandma’s trauma – a critical appraisal of the evidence for transgenerational epigenetic inheritance in humans. . 2018. http://www.wiringthebrain.com/2018/05/grandmas-trauma-critical-appraisal-of.html. Accessed Jun 5, 2023.

54 Escher (2018)

55 Benedict (2018)

56 Yehuda et al. (2018)

57 Ibid.

58 Byrne (2023)

59 Ibid.

60 Yehuda et al. (2018)