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Managing OCD and ADHD Medications for Kids

Are children being over-medicated for mental health issues? We spoke to DR ADRIAN LOH, Senior Consultant Psychiatrist at Promises Healthcare, who explained how doctors balance the use of drugs like or ODC or ADHD medication for kids with a duty of care in diagnostics and treatment.

Dr Loh’s general observation around healthcare in Singapore is that both parents and doctors remain cautious in the use of medication in children and adolescents being treated for mental health issues.

Yet, while it’s appropriate to exercise due diligence before starting medication – especially in view of possible side effects – there is a flip side when they’re withheld without good reason.

adhd medication for kids

“This may be due to insufficient understanding of the medication,” says Dr Loh. “There may be unfounded fear of ‘addiction’ or concerns about costs of treatment, for example, or it could be because of the persistent underlying social and cultural stigma around mental illness.”

What to take into account when considering medication

The decision to use medication, he says, should be a carefully considered one, taking into account a few key areas.

  1. In making a diagnosis, a good practitioner should also identify relevant factors that influence a child’s mental health condition, including their age and education level, the presence of other medical conditions, underlying temperament and personality traits, family and interpersonal relationships, as well as socio-cultural norms.
  2. There should be an assessment of the severity of the child’s symptoms and the level of distress caused to the child – and in some cases, to those around him.
  3. The practitioner should be able to confidently assess the impact of the condition across different areas of the child’s life.

For parents, stress around children’s mental health can be significant. For many of us, the tendency is to observe a child for signs of mental distress, but then wait to act. When we finally cannot intervene to help anymore as the child becomes a teen and even more inaccessible, we then realise it’s time to get professional help from therapists and psychiatrists.

From there, it can be an extended journey, according to Dr Loh. A patient may need months of therapy to unpack and get to the root of their fears, mood swings or erratic behaviour. Depending on the considerations mentioned earlier, the doctor will consider the use of medication to try to alleviate some of their symptoms at a suitable juncture.

“For example, a child could be diagnosed with mild ADHD (Attention Deficit Hyperactivity Disorder), but if there is a significant impact on their friendships or their ability to cope with schoolwork, and if other attempts at helping, such as classroom management, have been unsuccessful, it may be timely to introduce the use of ADHD medication for kids.”

adhd medication for kids ocd

Patient and parent responses

Dr Loh also notes that not all medication is going to “work” the way we want it to. Every patient responds to therapeutic drugs in a different way. “Some drugs that are used to treat mental health conditions may not have the intended effect and the doctor may then have to cycle through several different types to land on the right one. This can be distressing for the patient as well as parents, who can feel that the child is ‘over-medicated’.”

It’s a conundrum that requires patience from all involved, as not trying medication altogether may cause more harm, he says.

“Another illustrative case is with OCD (Obsessive-Compulsive Disorder). This is a condition that local and international studies have shown to be often characterised by a prolonged duration of untreated illness, extending even past a decade for some individuals. In many of the young people I’ve treated, my personal experience is that it would have been beneficial for them to have been started on medication much earlier in the course of their illness.”

At the same time, there are some instances where antidepressants may not be the most helpful solution. “Inappropriate use of medication is another valid concern,” says Dr Loh. “One example would be to ignore the underlying factors contributing to a child’s depressive symptoms. These could include unresolved grief after a death in the family, or feelings of helplessness or guilt about parents’ marital conflicts. In these situations, it’s wise not to offer antidepressants as a cure-all. Instead, offer counselling or other forms of therapies alongside the judicious use of medication to help the child in a holistic manner.”

In instances where parents describe “over-medication”, Dr Loh says that it could be possible that some children may have been offered medication without considering other alternatives. “When experiences of this kind are shared with other parents, it can lead to a perception that medication is overused.” He adds that if medication at a particular dose has been tried for a certain period and doesn’t result in an improvement of symptoms, this too can lead to an unwarranted generalisation that medication is ineffective.

Final word

It’s about taking the time to come to the right solution – because making or sticking to an inaccurate diagnosis can lead to the inappropriate use of medication. “If a teenager has symptoms of what we call hypomania (a less dramatic state of elevated mood) and those symptoms are missed and they are treated only with antidepressants, it can lead to a poor treatment response or even a worsening of what eventually can turn out to be a bipolar disorder.”

Mental health hangs in a delicate balance for both children and adults. It needs much more attention than we tend to give it, says Dr Loh – it’s all too easy to ignore the symptoms of unease and distress and block them with screen distractions. If you have concerns, he suggests speaking to a therapist as a key part of your self-care regimen.

About the doctor

Dr Loh is an experienced psychiatrist with a subspecialty focus in child and adolescent Psychiatry. He has a special interest in Obsessive-Compulsive Disorder and anxiety disorders, expertise in military and aviation psychiatry and a strong appreciation for the cross-cultural aspects of mental wellbeing.

This article was first published on the Expat Living Website on 30th March 2023 and written by Anna Murphy.

Preventing Suicide in Children: A Guide

The Samaritans of Singapore (SOS) reports that the number of suicides in Singapore rose 10 per cent in 2018, with suicides among boys aged 10 to 19 at a record high. Suicide mortality among youths and males is a “significant societal concern”, SOS said, highlighting that for every 10 suicides in 2018, at least 7 involved males. Among boys aged between 10 and 19 years old, there were 19 suicides last year – the highest since records began in 1991 and almost triple the seven cases recorded in 2017.

Suicide does affect children and adolescents, and avoiding the topic does nobody any favours – burying your head in the sand won’t help them learn how to get help if they find themselves needing it. One common misconception about the discussion of suicide is that talking about it plants the idea in people’s heads, causing children and adolescents to think about it. The simple truth is that parents won’t ever know if their child harbours suicidal thinking if they are too afraid to broach the topic. Suicidal behavior in children is complicated. It can be impulsive and associated with feelings of confusion, sadness, or anger. The so-called “red flags” people are cautioned to look for can be subtle in young children. While a young adult might say something along the lines of, “You’ll be better off when I’m gone,” in contrast, a child might say some something similar to, “No one cares if I’m here.”

Warning Signs

While the warning signs in children can be subtle, learning to identify potential red flags plays a crucial role in intervention.

Changes in baseline behaviour:

Take note of behavioural changes that aren’t short-lived.  While suicidal behaviour is often associated with symptoms of depression, you might also notice the following changes in your child:

  • Changes in sleeping habits (too much, too little, insomnia)
  • Changes in eating habits (overeating or eating too little)
  • Withdrawing from family and friends (social isolation)
  • Psychosomatic symptoms: headaches, stomach-aches, other aches and pains that can’t be explained

Changes at school:

It’s perfectly normal for children to experience ups and downs during the learning process, but a pattern of negative change can be a red flag that a child needs help. Make a note of the following:

  • Drop in academic performance
  • Decreased interaction with teachers and kids at school
  • Lack of interest in school
  • Refusal to attend school
  • Loss of interest in normal daily activities (playing, sports, co-curricular activities)

Preoccupation with death:

It’s natural for children to think about death at times, particularly when they are coping with loss or hear about tragic events in the news. Preoccupation with death, researching ways to die, and/or talking about their own death can be red flags. Watch for the following warning signs that involve thoughts about death:

  • Frequent questions about or looking up ways to die
  • Statements about dying or what will happen if the child dies (Examples: “You won’t miss me when I die, I wish I was dead, I won’t bother you anymore when I’m gone.”)

Feelings of hopelessness:

Children who have suicidal thoughts might communicate feelings of hopelessness for the future. They might also make statements about helplessness. These kinds of statements indicate that the child feels as if there is nothing to be done to improve their outcome, and no one can help.

Child-sized wills:

Some children give away their favourite possessions or tell parents, siblings, or friends who should get their favourite possessions. While talk of dividing up possessions might seem like fantasy play to parents, it can signal thoughts of suicide when combined with other changes in behaviour.

Writing or drawing about death or suicide:

Young children often struggle to verbalize intense emotions, but they are likely to take to the diary or drawing block to explore these emotions. Poems, stories, or artwork depicting suicide or, frequent writings and drawings about death should be evaluated.

Significant changes in mood:

Kids experience changes in mood as they grow and work through stressors, but significant changes in mood signal a problem. If your child suddenly shifts from calm and relatively happy to aggressive, completely withdrawn, or very anxious, it’s important to get help.

In addition to the warning signs that a child might experience suicidal ideation, there are also certain factors that can elevate the risk.

  • Previous suicide attempt (regardless of how serious)
  • Experiencing a loss (this can include grief and the loss of a relationship due to divorce or family discord or break-up)
  • Chronic bullying
  • Family history of suicide or suicide attempts
  • Violence or witnessing violence
  • Impulsivity
  • Acute rejection
  • Feelings of hopelessness
  • Feeling like a burden

Communication Tips with your Child 

Any signs of suicidal ideation or behaviour should be taken seriously.

Parents should ask specific, direct questions about suicidal thoughts – “Are you thinking about hurting or killing yourself?”

Parents should also talk openly about depression by asking questions like, “Are you feeling depressed or very sad lately?” These questions show your child that you understand and that you care. Conveying empathy in a time of emotional crisis is crucial. You may be concerned about saying the “right” thing. But the truth is that just having an open and honest discussion with your child can provide them with much-needed support.

Keep the Talk Age-Appropriate

  • Make sure that your child understands what you are saying and is not confused or bored by the discussion.
  • Use words that your child can understand. Words such as “depression” or “emotional reaction” are probably too complex for a younger child but may be appropriate for an older child or adolescent.
  • Try comparing your child’s depression to something that your child is already familiar with like a physical illness such as the flu or an ear infection.

Keep the Conversation Positive

  • Depression is a serious illness that causes emotional and physical pain, but try to keep the conversation focused on the positive.
  • By maintaining a positive and hopeful outlook in your discussions, you will avoid unnecessarily alarming your child.

Prioritize the Positive

Another important way to prevent suicidal behaviour is to prioritize interacting with your child in positive ways. Sometimes we get into a sort of vicious cycle with a child. The child does something concerning; the parent gets critical; the kid does something more concerning; the parents get more upset. All interactions turn contentious. Interacting in positive ways means doing fun things together, hanging out and chatting about things that aren’t controversial, that aren’t difficult.

Be Honest

  • Don’t make promises you cannot keep.
  • Don’t go into detail about topics that you are not certain of.
  • Do tell your child what you do know.
  • Make a list of questions to discuss with your child’s mental health professional.

Be Compassionate

  • Your child needs to know that you recognize and respect their feelings.
  • Even if you do not quite understand their thoughts, don’t dismiss their feelings.
  • Avoid comments like “What do you have to be depressed about?” or “Don’t be ridiculous.”
  • Dismissive comments can cause a child to hide their feelings or become defensive.

It may seem obvious to you that you love your children, and that they know you love them. But when they’re having a hard time, children need to hear over and over again from you how much you love them, and how much you care about them. It’s not good enough to just say, “You know I love you.” You need to convey that in small and big ways. These days, we all have so many things we’re juggling that our children can end up unsure of where they fit in, and whether you really have time for them. Let them know how important they are to you.

Be a Good Listener

  • Allow your child to talk openly and express their opinions and thoughts.
  • Avoid interrupting, judging or punishing them for their feelings.
  • Listening demonstrates that they have someone they can confide in help to sort out their feelings.

If there are any safety concerns, do not provide judgment or discipline; simply remove your child from immediate danger, do not leave them alone, and get them immediate help.

Never dismiss suicidal thoughts in a child and any suicidal thought or behaviour should be brought to the attention of your mental health provider immediately. If needed, bring the child to an emergency room or call an ambulance.

If for some reason the above options are not available, make a referral to the Samaritans of Singapore (SOS) by writing to pat@sos.org.sg, or calling its 24-hour hotline at 1800-221 4444.

The author hopes that the suicide prevention/awareness workshops he conducts at schools and corporations are doing some good.

Bibliography

https://www.channelnewsasia.com/news/singapore/suicides-number-2018-teenagers-boys-highest-11761480

https://www.health.ny.gov/prevention/injury_prevention/children/fact_sheets/10-19_years/suicide_prevention_10-19_years.htm

https://www.psycom.net/children-and-suicide

https://www.verywellmind.com/suicidal-thoughts-and-depression-in-children-1066661

https://childmind.org/article/youre-worried-suicide/

https://www.sos.org.sg/get-help/helping-someone-in-crisis

Psychological Testing: What You Should Know

Psychological evaluation is often helpful in understanding the strengths and challenges an individual may have in their cognitive, behavioural, learning and socio-emotional functioning.

At Promises Healthcare, we believe that “one size fits all” is not an approach that is applicable to the treatment of psychological disorders and challenges. We provide tailored recommendations for parents, teachers, and therapists so that interventions and accommodations allow each child to reach their potential.

IQ and academic testings can provide important information about a child’s cognitive strengths and weaknesses, academic needs, and preferred learning style. These can assist parents and children in making educational choices and implementing strategies to ensure that the child’s learning is appropriately supported.

Specific reasons for testing include:

  • Learning difficulties or delays (e.g. difficulties with spelling, writing, maths and/or reading)
  • Giftedness
  • Underachievement
  • Emotional and/or behavioural problems presenting in the classroom and/or at home
  • Admission to special educational programs
  • Increasing understanding of a child’s learning style
  • Concerns regarding possible attentional difficulties

What is IQ testing?

Intelligence testing is a method used by psychologists to measure a child’s intellectual capabilities. Intellectual assessment is a good indicator of a child’s potential. We use the Wechsler Intelligence Scale for Children, fifth edition (WISC- V). This is an individually administered instrument for assessing the cognitive ability of children aged 6 years to 16 years.

The WISC V is one of the most reliable and valid IQ testing instruments available and is the most widely used measure of IQ. The WISC V provided scores that represent intellectual functioning in four specified cognitive domains: Verbal Comprehension, Perceptual Reasoning, Processing Speed and Working memory.  During the testing session, a child is asked to solve problems and puzzles and to answer a range of questions. Generally, most children enjoy the testing session as it is an engaging process involving novel and fun tasks. Should parents have worries about their child’s emotional wellbeing during the assessment, raise it with us and, we can explore a workable collaborative plan to support you and your child during the testing process.

What is Academic Testing?

Academic Testing provided an overview of a child’s current performance across a range of academic domains. We use the Wechsler Individual Achievement Test (WIAT-III) with subtests including:

  • Oral Expression
  • Listening Comprehension
  • Written Expression
  • Spelling
  • Pseudoword Decoding
  • Word Reading
  • Reading Comprehension
  • Numerical Operations
  • Maths Reasoning

The assessment provides a rich source of information about a child’s achievement skills. Information obtained can then be utilized for intervention decisions.

The Assessment Process

The assessment is conducted in several stages:

  • An initial assessment with parent(s) is an integral part of our assessment procedure.
  • A time is set to administer the WISC 5 and the WIAT-III and other relevant tests. Usually, you may have to set aside about two or more sessions for approximately 6 to 12 hrs (excluding initial consult session) for testing, depending on the capacity and the needs of the child/person. Spacing out testing over several days can help some children overcome fatigue and stress.
  • A comprehensive written report will be prepared after all the testings are completed, based on the outcome of the assessment and testing process. The report will highlight relative areas of strengths and difficulties, with recommendations for home and school settings.
  • A feedback session will be provided to parents after the completion of the report. During this session, parents can be given an opportunity to clarify and discuss any concerns regarding the report.

Fees for assessments

  • The Psychologist conducting the tests will inform parents of the charges involved during the initial consultation session, based on the needs of the child/person and the different tests required.

Payment Plans

  • Payment plans are available for our testing procedures. Clients may choose to pay the full amount for testing at the end of the initial consultation or they may elect to pay in two payments. Like most of the private practices, reports will not be released prior to receipt of full payment.

Referrals/ For Information

Please do not hesitate to speak to our friendly reception staff at (+65) 6397 7309 if you wish to make an initial appointment. Alternatively, should you wish to clarify matters with me personally, you can leave your name and contact details with the reception at clinic@promises.com.sg

Understanding Childhood Emotional Neglect

As a child, how did adults around you react whenever you expressed your feelings? Did you grow up receiving that subtle message to wall up your emotions so they don’t get the better of you, or become anyone else’s burden? Childhood Emotional Neglect (CEN) is a topic often overlooked, and many fail to realise that it can eventually manifest into mood disorders or anxiety disorders if not dealt with appropriately.

Childhood Emotional Neglect occurs when our caretakers or parental figures fail to respond to our affectional needs suitably during critical stages in our development. An individual who grows up experiencing emotional neglect may experience a pattern of having his or her emotions being disregarded, invalidated or downplayed by others. While many of us may wonder, “What kind of parent doesn’t pay attention to a child’s emotional needs?” In reality, some parents may not actually realise that they have been shutting their child(ren) out emotionally. In Asian societies in particular, some parents are commonly labelled as “authoritarian” or “tiger parents”. These people may in fact perceive themselves to be giving the absolute best to their child, enforcing strict discipline and ensuring that their offsprings are well-equipped with the best skills to succeed in life. However, young children and teenagers may instead be overwhelmed by such demands, and feel as if their feelings were never considered or understood. Whilst we mentioned its prevalence in Asian societies, it is key to note that it is not merely limited to these children – many worldwide experience it too, making it an exceptionally important subject. With emotional neglect being a common feature in the childhood of many, it can become an undesirable shadow that follows us throughout our lives – eventually leading to undermined happiness and the lack of an authentic sense of self.

Delving into the matter at hand, Childhood Emotional Neglect (CEN) can come in two forms – active and passive CEN. Active CEN is when parents or caregivers actively act in a way that dismisses or denies the child’s emotions. For instance, a boy is sent to his room for crying over the death of his pet fish, and his parents complain of having an overly-dramatic son. When the child is being denied of his sadness and is receiving the message that his behaviour is unreasonable, this forces the child to grow up hiding his feelings, and at times struggling with fear and shame of his own emotions. On the other hand, passive CEN occurs when parents show a lack of care or validation regarding the child’s emotional needs. When parents fail to notice when the child is angry, upset, hurt or anxious, this gives off a subliminal message to the child that his feelings are irrelevant or not worthy of note. In any case, both forms of CEN are clearly detrimental towards one’s mental health.

Albeit not having a test or questionnaire that can help with a diagnosis for CEN, there are certain “symptoms” of CEN that may surface, be it in the later parts of one’s teenage years or adulthood.\

For one, individuals who have experienced CEN may find it difficult to prioritise their wants and needs, even if it’s something that would bring them great joy. It is innate for us to have desires and to just be aware of what we want and need. However, for someone who grows up having his feelings invalidated and cast aside, it could become a natural thing for him to keep his desires to himself. As such, even if opportunities do come along, these people would often fall through the cracks, most probably due to their inability to request for it upfront, or by allowing others to seize it instead.

CEN also causes one to start projecting any feelings inward, regardless of whether they are negative or positive ones. People who have experienced CEN are particularly predisposed to turning feelings of anger inwards, as they never learnt how to be comfortable with their emotions, nor how to handle them in a healthy manner. It is often said that nothing good comes from bottled-up feelings, and that is absolutely true.

Having pent-up feelings also mean that these individuals are not likely to seek help or lean into their support systems whenever things get tough, making them feel all the more isolated and vulnerable. Even at times when they are feeling deeply challenged by certain life events, they find themselves trying to cope all on their own, leading to unhealthy stress levels and anxiety. Unsurprisingly, the constant feelings of shame and inability to get in touch with one’s emotions will eventually lead to one losing sight of his or her strengths as well. As a result, poor self-esteem is sometimes a consequence of CEN.

While many individuals, including adults, fail to recognise the impacts of childhood emotional neglect on their lives due to its subtle nature, it is important that they get themselves back on track – to regain true happiness and greater self-esteem. You might have grown up devoid of your own emotions, but you need to recognise that facing them head-on will ultimately help you to cope with life events and for you to regain your sense of self.

Learn to start getting in touch with and embracing what you feel – both the good and bad. Identifying what you feel in certain situations will be a good step towards helping yourself cope with your environment and daily life. When challenges seem overwhelming, don’t feel afraid or ashamed of reaching out to your friends and family for help either. Even more so, if you ever feel like you’re losing control of your life and are derailing emotionally, seek professional help as soon as possible. While not everyone who grows up with emotional neglect ends up with mood disorders such as depression or anxiety disorders, there are certainly people who do. Don’t deny yourself of your emotions any longer, therapy might just be the solution to helping you learn the vital life-coping skills you never learnt as a child.  

References:

https://www.straitstimes.com/singapore/how-emotional-neglect-during-childhood-affects-ones-mental-health (Accessed 07/10)

https://blogs.psychcentral.com/childhood-neglect/2018/09/the-2-types-of-childhood-emotional-neglect-active-and-passive/  (Accessed 07/10)

Protecting Mental Health During COVID-19

Amidst the COVID-19 pandemic, there is evidently a growing sense of distress amongst the public – from panic-buying at supermarkets to wearing several layers of masks for fear of being infected. While ensuring our physical well-being is of great importance, we cannot deny that our mental health is also equally important – especially during the stress of a pandemic. The ever-changing situation can cast a shadow of uncertainty over us, creating feelings of vulnerability and helplessness.

However, allowing coronavirus related fear to overcome us certainly isn’t the way to go. Let’s take a look at how we can help ourselves by avoiding the pitfalls of anxiety and depression.

CNN recently published an article on how to keep coronavirus fears from placing an undue burden on our mental well-being. In the same vein, we would like to emphasise the utmost importance of self-care during these trying times.

In the context of this pandemic, what does self-care entail? By keeping our minds from straying into muddled uncertainty, we can avoid the toxicity of excessive worry – with the world already so volatile, it’s in our best interest to try to stay cool-headed to better make decisions. There’s no point expending precious processing power on unwarranted concerns. With the influx of information and ease of access to social media, it can be mentally exhausting if we choose to hang on every update. If you feel the urge to check your phones for up-to-date news constantly, learn to walk away. Know when to put away your phones if necessary.

Depending on the individual, the idea of self-care may vary, but ultimately, it is still a means of managing our stress and anxiety levels.

During this period, some of you may well experience higher levels of mental stress. Worry over your own health and your loved ones’ may consume your mind, in turn leading to knock on effects such as – changes in sleep and eating habits; worsening of chronic illnesses; and increased substance usage. Needless to say, we would do well to guard against the deterioration of our mental health, to better cope with our negative emotions appropriately.

Connecting with our own feelings is a great place to start. It’s important to stay in touch with our feelings, taking care to identify our worries and concerns. Try naming your emotions. It sounds simple enough, but you’ll soon learn that there are nuances that set apart sensations, emotions and feelings.

Is there anything specific about the situation that is heightening your stress level? Emotional awareness is often neglected, with some studies showing that only 1-in-3 people have the ability to correctly identify them. If you have reached a state of panic or hysteria regarding the virus, you might want to start considering how realistic your concerns are. There is a high chance that we often over-magnify our fears and underestimate our capacity to handle the situation.

As mentioned, there is a need for us to remain cool-headed and not plagued by excessive worry in these trying times. Here are some tips that may help you to get through this difficult time, if you ever find yourself feeling overwhelmed with anxiety or fear.

Firstly, it is of great importance to consider if your worry is solvable. Is the problem within your control? In the case of the COVID-19, you may be constantly worrying about contracting the virus. However, if you are certain that you have done your part, such as washing your hands occasionally and not touching your face unnecessarily, does worrying excessively help in any way?

In some cases, excessive anxiety may cause one to hyperventilate – and this is where proper breathing techniques will come to your rescue. The 7/11 breathing technique is an exercise where one breathes in for a count of 7 seconds and exhales for a subsequent count of 11 seconds. This exercise is very simple, yet proven to be extremely effective in helping one regain his or her composure. Try this for approximately 5 minutes (or whatever duration that is best for you), and you’ll eventually feel calmer and be able to think more clearly.

Remember, while you may not have power over what happens to you, you are able to control how you react to it hence your state of mind. 

Avoidance and escapism from acknowledging the root of our uneasiness is not a healthy method of coping. Coming to terms with and recognising our concerns can in fact help us to better seek social support. Stay connected and start talking to the people you trust. Talk to them about your feelings and worries. Get them to share theirs too, and by the end of it, you’ll realise that you are not alone. Understanding others’ perspectives on the situation and recognising that they are most probably experiencing the same concerns will surely help to calm your nerves and help you feel less lonely and vulnerable.

It is also important that we spend more time with our families and friends. Taking a break from our busy lifestyles and hectic work schedules will benefit your mental health. Make sure to take time off to unwind, and to do activities that you enjoy. This could mean exercising, socialising, or some form of recreation in your spare time.

Although socialising may be slightly more of a challenge due to the increased need for social distancing, it is still largely possible, especially with technological advancements. Now and then, you can opt to organise your own get-together through ‘Zoom’ or ‘Skype’, and perhaps have lunch with your friends over video-calls. Do you have something you’ve always wanted to learn, but could never find time for? Well, this might just be the right time for it too. In addition, some places of interest have started providing virtual tours. With this, one can explore and discover new areas whilst staying in the comforts of his/her home. With countless things to do on the internet, one can easily find various means to unwind and to de-stress.

Doing things you love will help to ease the burden on your shoulders and distract you from your fears and concerns. Life goes on even with the COVID-19 situation, and constant worrying is in nobody’s interests.

One crucial thing to note is that you should never feel guilty or ashamed of your fears, and neither should you blame yourself for worrying. It is completely normal to worry, especially with uncertainty at every turn. After all, evolutionary biology dictates that it’s perfectly natural to feel threatened and afraid during a pandemic.

Do not hesitate to seek help and support when the going gets tough. If you ever find yourself barely treading water, there’s absolutely no shame in reaching for a helping hand. Stay safe!

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Bibliography

https://edition.cnn.com/2020/03/14/health/coronavirus-fears-mental-health-wellness-trnd/index.html  (Retrieved 18/3/20)

https://www.cdc.gov/coronavirus/2019-ncov/prepare/managing-stress-anxiety.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fabout%2Fcoping.html (Retrieved 18/3/20)

https://www.apa.org/practice/programs/dmhi/research-information/pandemics?utm_source=linkedin&utm_medium=social&utm_campaign=apa-pandemics&utm_content=pandemics-resources (Retrieved 18/3/20)

Reducing Stigma and Overcoming Shame

As we celebrate World Mental Health Day (10/10), I pause to remember the patients/clients whom I have worked with in the past 17 years. I want to recognize and honour their courage, resilience and grit in continue living even though it is so hard.

I am heartened that there are more open conversations on mental health compared to a decade ago. Earlier this year there was even the inaugural Singapore Mental Health Film Festival. More sufferers are willing to step forward courageously to share their stories to encourage and inspire fellow sufferers. All of these efforts are pointing in the right direction and we should persist.

What makes mental illness so painful is the shame that individuals feel; the fact that they are less than, inadequate, weak and worthless. Society has not arrived at a place where we can talk about it as openly as our physical health. At least, no one is hesitant to get a medical certificate from a general practitioner but one from Institute of Mental Health, no way!

How can we reduce the stigma of mental illness?

I have one suggestion that I like to propose and it is as follows:

we need to start sharing our “failure” or “screwed up” stories.

Every person undergoes challenges in life and experiences deep pain for various reasons. For someone who suffers from mental illness, the natural thought is that “I am alone in this. Everyone but I can deal with life.” He/she looks around and sees “successful” people who seem to have it all and feel demoralised.

We, the supposed “successful” people have in some way perpetuate the stigma of mental illness by keeping silent and not share our pain openly.

Recently, I shared with a client of my struggle with anxiety and she was surprised because outwardly I appear mostly calm and confident. I believe my story gave her hope that if my therapist can overcome and learn to manage her anxiety, so can I.

The challenge that I want to extend to everyone is this: share your struggles, not just your victory.

When something painful is a common experience, there isn’t a need to hide the secret any longer and we can better support one another. Truthfully, all of us has some form of dysfunction; it is only a matter of degree and how well we manage it.

I shall walk the talk and share the times when I felt like a failure.

After getting a scholarship to come to study at a top Junior College, I did so poorly for my promo exam that I was put on probation. That was my first taste of failure as I had been an excellent student up until that point. My self-esteem took a hit and I seriously considered quitting school and return to my hometown. I persisted.

Being diagnosed with Moya Moya Disease and suffering stroke where I lost the ability to read and write and my right visual field.

The first year of my marriage was really tough. It caught me by surprise as we had a wonderful courtship and seemed to get along really well. We went through several challenges, including my brain surgeries and stroke. I was left confused and disillusioned. The upside of it is that I started to learn more about what makes relationship work and I ended up discovering my call and passion.

Infertility. As we looked forward to expanding our family, we received bad news after bad news with each visit to different specialists. I seriously felt that perhaps something was wrong with me that I was not good enough to be a mother. After 4 years, we had wanted to give up when our miracle baby came along.

The years that I was a trailing wife, I lost my sense of identity and I watched my peers moving ahead in their career and life while I was trying to figure out what I wanted to do with my life at age 32. I couldn’t let go of the narrow definition of success. I was a nobody. It took me 3 years to re-calibrate and find my voice and I started my blog- Winifred & You, Flourishing Together.

The above wasn’t easy to write; it’s not what we usually do and it feels risky and uncomfortable.

That’s the challenge; are we ready to share and reveal the pain that we too keep in our hearts?

To de-stigmatize mental illness, we need to acknowledge and embrace authenticity and vulnerability. As long as we breathe, we hurt. We fall and we rise.

Let’s share our resilient stories so that everyone else will be inspired to do the same. In so doing, we kill shame because it no longer has a hold on us.

Will you join me? #killshame #resilientstory

COVID-19 Easing and Mental Health in Singapore

The COVID-19 pandemic is unprecedented. The ubiquitous influence of the pandemic has been—and continues to be— felt by individuals globally. Many experiences the fear of being infected or infecting others, disruptions in their daily routines, social isolation, the likelihood of unemployment, financial hardship and the looming economic uncertainty (Ministry of Health Singapore, 2020). As such, there is a detrimental impact on the mental health and wellbeing of individuals, including an increased risk of suicidal behaviour.

Globally, the prevalence rates for depression and anxiety in the COVID-19 pandemic were 28.0% and 26.9% respectively (Nochaiwong et al., 2021). Factors contributing to depression and anxiety include suffering, fear or potential death, grief and financial stressors (World Health Organization, WHO 2022).

Young people have been identified as at increased risk for suicidal and self-harming behaviours (WHO, 2022). Women’s mental health, compared to men’s, has been more adversely impacted by the pandemic (WHO, 2022). In addition, people with existing medical conditions such as asthma, cancer and heart diseases, have been found to be at higher risk for developing mental health disorders (WHO, 2022).

In Singapore, a study conducted by the Institute of Mental Health (IMH) (Ministry of Health Singapore, 2020) found that 8.7% of Singapore residents reported having clinical depression, 9.4% reported having clinical anxiety and 9.3% reported mild to severe stress levels.  Older adults were identified as a vulnerable group, particularly, those who lived alone. Similar to the findings from WHO (2022), youths in Singapore were also identified as vulnerable to experiencing poor mental health in response to the pandemic. There is an urgency for countries to boost their mental health and psychosocial support services as part of the pandemic response plan.

According to the COVID-19 mental wellness task force, initiatives in Singapore include providing psychological support via helplines such as the National CARE hotline and a mental health help bot (‘Belle’), incorporating mental health materials in the school curriculum, fostering family resilience and supporting parents with parenting skills.

Here are some recommendations for mental health support during this pandemic:

  • Parents are encouraged to have conversations with their children about their children’s worries and responses to the pandemic. Parents have been found to underestimate such responses (Pfefferbaum & North, 2020). Such “talk time” can also help in trust and bond-building
  • Seniors can be equipped with digital skills and also expand their options for help and support i.e. the provision of telehealth counselling and support services (Brydon et al., 2022).
  • Health care workers can monitor their stress responses and seek assistance in relation to both their work and personal lives from a mental health professional (Pfefferbaum & North, 2020).
  • People can be encouraged to limit their consumption of news related to COVID-19 to once a day and to focus solely on credible news sources.
  • Having social interactions with family and friends and offering to help support one another during this difficult period can also be particularly beneficial.
  • Being outdoors and exercising are good habits for maintaining healthy wellbeing.

As restrictions are slowly easing around the world, it can also be challenging for most people to adjust back to when restrictions were first introduced (during lockdowns). With new changes and uncertainty, being mindful of one’s mental health and well-being is crucial. For example, larger social gatherings (e.g. group of 10) may seem overwhelming at first, therefore it is important for people to recognise their anxiety levels related to social gatherings.

Here are some suggestions that might help regulate your emotions as you enter this new season of Singapore opening up amidst the COVID-19 Pandemic (Black Dog Institute, 2022):

  • Gradually, increase your time spent in a larger social gathering at your own pace.
  • You can also start to focus on things that are within your ability and control. For instance, you can engage in different relaxation techniques such as deep breathing and focusing on being in the present in order to better cope with your stress levels (American Psychological Association, 2021).
  • it can be useful to discuss reasonable adjustments back to work with your managers such as flexible working arrangements and other training opportunities in order to increase work efficacy
  • Seek professional help if there are concerns regarding stress levels related to the easing of restrictions.

It is particularly evident that the COVID-19 pandemic has taken a toll on the well-being of Singaporeans and the rest of the world. The pandemic has highlighted the importance of mental health and wellbeing and there is an urgent call for countries worldwide to provide people with mental health and psychosocial support to help them maintain psychological wellness.

Some Local Helplines and support:

Raising Emotionally Healthy Children

What Is Circular Causality?: Understanding Your Child’s Reactions

The American Psychological Association defines ‘Circular Causality’ as a sequence of causes and effects that leads back to the original cause and either alters or confirms it, thus producing a new sequence, as in a feedback loop.

This is an important concept that helps to explain certain interactions within relationships better. Relational patterns and rules between family members within the family system dominate how individuals interact and engage with one another. These rules are often silent, unconscious or multi-generational in nature. Within this system, the family operates according to some ‘thermostat’ which sets the ‘desired setting’ for how each member is expected or required to function. The functioning applies to how situations or people are viewed, how much self-disclosure is welcomed or permitted, how personal or interpersonal difficulties are addressed or not, how disagreements or secrets are to be dealt with, or what relational values are being promoted. Families in different cultures may operate with certain predictable rules or patterns, eg. within families sensitive to shame, avoidance or non-verbal disclosure, communication is often practised. Tapping into the honest emotions of members over time tends to reveal the ‘temperature’ within the family system.

Families nurture the psychological ‘birth’ of the sense of self within children during their childhood. In the process, parents shape within their children how young children will engage themselves (intra-personal relationship) to function in later childhood and adulthood (inter-personal relationships). Healthy relational patterns and appropriate rules are important to foster healthy emotional development towards an important psychological milestone for children: healthy identity formation. Because these patterns and rules are so fundamental in the shaping process, it is important for parents to understand how they can shape their children towards this healthy identity. If not, the child could begin a life-long struggle from having accepted an identity that is diffused, confused or distorted in nature. This is usually accompanied by secondary effects of this outcome, eg. a pattern of difficult or troubled relationships with others. This usually adds additional distress to the sufferer and to those who relate to them.

Instead of understanding interactions within relationships along a linear continuum where there is a definitive start and end, circular causality opens up to appreciating the relational context where interactions can be examined between two events in more useful detail. With an understanding of circular causality, understanding the interactions between two or more individuals can better reveal where an interaction can get stuck. This pattern occurs in all relationships but it is especially within ongoing relationships where being stuck in a negative cycle can lead to particular disappointments, hurt and pain. For children, unhealthy patterns and rules within families can undermine the child’s emotional development over time.

Circular causality is particularly useful to explain conflicts between family members which can become persistent and damaging. Persistent hurts can undermine relationships and lead to how negative expectations of each person are viewed and engaged with over time. They are a concern because of the prospect of children’s sense-of-self being hurt or damaged within certain family systems. Therefore, careful attention is usually necessary in understanding the attribution of cause-and-effect of what is problematic between family members.

Individuals attribute cause and effect or causation in situations and within relationships. Linear cause and effect of A 🡪 B 🡪 C are defined by a specific start and end point. Individuals who operate from understanding relationships based on linear causality tend to assume that problems are caused and maintained by the other individual’s beliefs, biology, emotions or other abnormal factors within the individual, i.e., they are self-generated. Therefore, solutions are found when the individual in question changes their beliefs or emotions within them to respond differently to the situation.

In contrast, circular causality refers to the reciprocal relationship between two events. Family members influence each other in a continuous process within a feedback loop. A vicious cycle is often present when two or more family members have relied on unchecked assumptions to carry out their attributions of cause-and-effect in the situation. The perspective of reciprocal relationships stems from the foundations of cybernetics, which refers to the regulatory action where one part of the system impacts another. Events usually do not happen in isolation. There is a feedback loop which tend to result in a new equilibrium. It is more that A 🡪 B 🡪 A.

Case Studies

Case 1:

Susan refuses to go to school and goes into her room. Mom and Dad raise their voices and lecture her. When they raise their voices, Susan isolates. Mom and Dad’s frustrations or anger heighten Susan’s need for isolation, and Susan’s isolation heighten Mom and Dad’s anxiety, and therefore their escalation.

For parents who operate on assumptions of linear causality, their perception can easily overlook other reasons to explain the child’s original presenting problem, eg. Susan may be bullied at school, she has an unhappy relationship with her teacher, or she may be afraid of facing exams but is afraid to tell anyone. Parents who operate based on linear causality tend to see their child as the source of the problem, and to overlook their contribution or other reasons leading to the child’s presenting problem.

Instead of being quick to judge the situation as the child choosing to misbehave, parents should focus first on establishing a safe, trusting relationship with their daughter before their intervention.  They can raise concerns about what their child may be fearful of with empathy. The following statement could be as follows, “Hey Susan. You usually would enjoy attending school. But something unpleasant or uncomfortable may have happened to make you afraid of returning to school. I remember that when I went to school, I have at times been uncomfortable going to school because I was afraid of meeting someone I did not like, or having to face an exam I was not prepared for, or having to face a teacher who was mean. Can you tell me what is going on for you at school that you are uncomfortable facing? I will like to help you.”

Case 2: 

John struggles in completing his homework and his poor grades. The father Mr. Lim responds to him with harsh criticism. Hurt and demoralized by his father’s criticism, John does not put in his best effort at school. His father’s criticism then intensifies and John puts in even less effort to learn. 

Family difficulties are often not rooted by a simple mistake made by the child (mistakes are common for children and instrumental for how they learn).  In this scenario, the father’s response to John may be reflective of how Mr. Lim was regarded as a child himself by his own parents when he was growing up. Criticism then is an extension of how he was treated as problematic as a child (to regard himself as stupid, inadequate, irresponsible) so as to repeat the cycle here. Without knowing all this history, John becomes hurt and angry against his father’s accusation. He can try to defend himself and retaliate with, “I am not useless. You are.” Mr. Lim who is outraged by John’s apparently disrespectful reply can bear down on John for what he considers to be John’s defiance to intensify his attack: “You are not only useless but disrespectful.”  This pattern can then set up a loop that becomes self-perpetuating or self-reinforcing based on their view of each other. John is seen by his father not only as stupid or irresponsible, he is also viewed as disrespectful and defiant. In turn, John sees his father as unloving and hurtful whom he needs to distance himself from. If they had a positive relationship earlier in John’s life, this relationship can deteriorate over time if the underlying issues are not addressed.

In reciprocal relationships, circular causality is often revealed in the course of the interplay between emotional experiences, false or valid expectations and eventually how we experience each other. It often reveals how one or both parties perceive and interpret their individual world, and there is usually a historical reason  behind their perception. Our current experiences, perspectives and approach to relationships are often already influenced or shaped by our previous significant relationships with our family-or-origin and culture.

[ In this situation, Mr. Lim should be advised to consult a child clinical psychologist when he sees no improvement with his son’s behavior. He needs to be alerted to the importance and quality of the parent-child relationship in impacting the child’s self-esteem, emotional conditions for what children need to thrive and the nature of the unconscious. If Mr. Lim was armed with the appropriate knowledge and possibly obtain personal help to address his relationship with himself as defective or inadequate, he could approach his son with, “Hey son. Studying in Singapore can be challenging or difficult. The workload can be heavy and the material can be difficult. I struggled with it too when I was a student. What struggles are you facing at the moment?” ]

Case 3

In the midst of ongoing conflicts between parents, their child Ben develops anxiety because the two people he loves appear to be hurting each other. Ben acts out with anxiety and/or depression, eg. temper tantrums, excessive withdrawal from school or play, trouble at school. This draws the attention of his parents who attend to him. In the process, their own conflict decreases. From this, Ben learns that he can influence his parents’ conflict through his anxiety. 

Circular causality helps to explain why family members may be stuck arguing about the same subject every time through communication traps or failures. Understanding cause & effect on a linear perspective in relationships can result in an artificial understanding: one cause & one effect or multiple causes & the same effect. In this scenario, Ben’s parents may wish to see Ben as having difficulties coping with school. Their solution may be to improve Ben’s responses to become more resilient. But if Ben attempted to communicate his difficulties with his parents’ conflict, they may not wish to believe that they contribute to his struggles. In so doing, they fail to capture the root of the problem for what it is. A child’s struggles may be defined by their parents because the child’s limitations reflects the parents’ limited emotional insights on themselves or their children. This lack of emotional insight and understanding is often expressed through circular causality to reveal that children can be misunderstood often and that the parent-child relationships can often be negatively impacted.  The parents’ own limitations are often overlooked in the situation.

Repeated over time, the negative rituals expressed in circular causality can be locked in place by ignorance, emotional hypersensitivity, defensiveness, contempt for one or more family members, hopelessness, hurt, anger, blame, fear and avoidance or stonewalling. Emotional cut-offs may be used frequently. If this happens, the effects of circular causality in an unhealthy family system can be experienced as intolerable. If there was previously a positive bond that bound the relationship, it can now be worn down by pain and the relationship may become damaged.

In this situation, the parents should consult a clinical psychologist familiar with children and family issues when they notice their child struggling with school or presents with anxiety in the midst of their conflict.

How To Break The Cycle

Raising healthy children require establishing healthy relationships and healthy boundaries. Because the goal of raising healthy children is so worthwhile and essential to their future growth and success, parents need to be concerned that their relationship with their children are not defined by misunderstandings and conflict which are painful. To foster family unity and raise healthy children, three important values and practices are essential to promote certain patterns and rules in the family system:

  1. Parents need to learn about child development. They should also remember that children function at a disadvantage because they tend to lack the emotional insight to explain their fears, their confusion, and what they need. Subsequently, children often have difficulty articulating what they feel or need. They need parental help to develop their emotional insight and offer them a broad emotional vocabulary to learn to express and communicate themselves clearly and honestly. When this is offered by parents who are emotionally mature and aware, intentional to raise children in their best interests, and when these parents are trusted by their children, the groundwork is being laid for the healthy formation and development of the child’s emerging identity.
  2. Parents need to develop the courage to have honest conversations with each other and their children. This courage needs to be accompanied by the believe that each member has important value so that each person is treated with respect. With courage and respect, each person can be approached with caution about making inaccurate or false assumptions of each other, and engaging in a self-serving bias. Being honest and courageous is important to clarify if inaccurate attributions are being made. Being ready to listen without judgment prior to making honest inquiries would further help to avoid misunderstandings or address misunderstandings when they occur.
  3. The willingness to develop healthy emotional intimacy promotes the value of sharing for each family member to know one another and to being known by the others in the family. This offers the basis for bonding and closeness. When communication is constructive, affirming and respectful, it can establish the sense of security within children and trust between family members. For children, this is particularly important since secure attachments contribute significantly to the child’s emotional development and mental health. This in turn offers a basis for them to acquire a healthy approach to future relationships and healthy functioning.To promote relationships which are safe and nurturing, words are powerful to convey that each family member is highly valued. They should be deliberately selected to promote each other’s well-being. Having a pattern of honest and constructive communication with healthy rules where individuals are affirmed and supported help to promote a family system where each member can safely practice saying what they mean and mean what they say. Misunderstandings are not left to stay but are promptly corrected. This offers the most fertile ground for healthy personal and interpersonal growth to happen. When parents notice they have difficulty delivering these practices, they should consult a clinical psychologist.

References:

American Psychological Association. (n.d.). Apa Dictionary of Psychology. American Psychological
Association. Retrieved October 22, 2022, from https://dictionary.apa.org/circular-causality

Kerr, M. E., & Bowen, M. (1988). Family evaluation: An approach based on Bowen theory. W W Norton & Co.

Understanding Body Dysmorphic Disorder

Body Dysmorphic Disorder (BDD), in simple terms, is a condition involving an obsessive focus on one or more perceived flaws or defects in appearance. While the perceived flaw may be minor and inconspicuous, individuals struggling with this disorder are inclined to spend a large proportion of their waking hours worrying and finding means to fix these flaws. This includes seeking dermatological or cosmetic procedures and exercising excessively to fix their appearance. Depending on its severity, BDD can be disabling – the emotional distress it causes can affect one’s functioning at social events, work and in the public eye.

BDD is estimated to affect approximately 2 percent of the adolescent and adult population worldwide, and preliminary studies in Singapore have also noted a similar proportion. This figure is, however, likely to be underreported due to the nature of the disorder, where affected individuals are unable to recognise the symptoms of the disorder. Coupled with the lack of awareness of BDD, people associate these BDD symptoms with the “physical flaw” itself.

While there is no definitive cause, there are risk factors that can contribute to the onset of BDD. These can include bullying or abuse, perfectionism, constant competition with others, genetics, and other mental health conditions such as depression, anxiety or obsessive-compulsive disorder (OCD). With the prevalence of social media, this condition is further exacerbated as it perpetuates body image comparison and the image of an “idealised body”. This can trigger such compulsive behaviour in vulnerable individuals, especially if they struggle with low self-esteem. Chemical imbalances can also trigger the onset of BDD in the brain or the use of certain drugs such as ecstasy in susceptible people.

What is the diagnostic criteria for BDD?

For a BDD diagnosis, there is a set of criteria that the individual must meet. According to the Diagnostic Statistical Manual of Mental Disorders (DSM V), they are:

  1. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.
  2. At some point during the course of the disorder, the individual has performed repetitive behaviours (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns.
  3. The preoccupation causes clinically significant distress or impairment in social, occupational or other areas of functioning.
  4. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.

In addition, the individual would need to be assessed on their degree of insight regarding body dysmorphic disorder beliefs. In other words, how convinced are they that their bodies look “deformed” or “ugly”? A person with good or fair insight recognises that these beliefs are definitely or probably false. A person with poor insight would think that these beliefs are probably true. In the worst-case scenario, a person with absent insight or delusional beliefs would be completely convinced that their body dysmorphic beliefs are true.

What forms of treatment are available for BDD?

A combination of psychotherapy and pharmacotherapy is often implemented in the treatment plan for BDD. Cognitive Behavioural Therapy (CBT) is a psychotherapeutic method which aims to help one recognise maladaptive thought and behaviour patterns, and teach self-help coping strategies that can improve one’s quality of life. CBT has been proven to be an essential form of treatment for other mental health conditions as well, including depression and anxiety disorders. CBT for body dysmorphia would focus on helping the patient build self-esteem, and learn to tolerate the distress of “exposing” their perceived defects to others. It helps them manage their concerns with healthier coping mechanisms instead of taking extreme measures to fix their appearance. This includes training them to cope with symptoms of anxiety.

Medication is sometimes used in combination with CBT for maximum efficacy. One common medication used to relieve BDD symptoms include antidepressant medications. Selective Serotonin Inhibitors (SSRIs) in particular, can ease and reduce compulsivity, as well as overwhelming symptoms of anxiety or depression.

You may wonder why we don’t proceed with cosmetic or surgical procedures to correct their perceived flaws, especially if they seek such measures. As mentioned, BDD often involves flawed beliefs surrounding an inconspicuous or minor flaw in appearance. We must acknowledge that any medical or surgical procedure carries health risks, regardless of the extent of the surgery. Any unnecessary alterations or body modifications may not only lead to undesirable health effects but may also lead to dissatisfaction with the results. Should the surgical procedure not turn out as expected, this could worsen the patient’s BDD.

If you believe a loved one may be showing signs of BDD, do encourage them to consult one of our mental health professionals at Promises Healthcare. 

References:

  1. https://www.channelnewsasia.com/commentary/body-dysmorphia-vanity-obsession-mental-health-treatment-1883421 (Accessed 25/07/2022)
  2. https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t19/ (Accessed 25/07/2022)
  3. https://www.mind.org.uk/information-support/types-of-mental-health-problems/body-dysmorphic-disorder-bdd/causes/ (Accessed 25/07/2022)