Last month, we briefly introduced you to Dr. Catrina Wilkins (now Dr. Luca), our new child and adolescent psychiatrist. Most recently she was working as a Clinical Assistant Professor at the University of Florida Division of Child and Adolescent Psychiatry. Before that she had been focusing her energy and efforts on her family. During that time, she was also thinking about the kind of psychiatrist she wants to be. Now that she is back in the chair, her vision for herself and the kind of psychiatry she wants to practice sounds sharp and well-defined. It begins with being well-rounded.
“It’s important to know all of the mechanics of medicine and to know the mechanics of how to do an interview.” Luca said. “Anybody can learn that. Anybody can get a checklist and say, ‘This is what I need to know.’ My primary concern is, number one, who you are as a person, because the better I understand that, the better I’m going to be able to come up with a treatment plan that you’re actually going to want to do; and number two, that you view me, not as part of the family, but as someone who is involved not just in your psychiatric care but in your care as a person—definitely a more holistic approach. It’s not unheard of for me to talk about diet, definitely sleep, family dynamics—I want to cover your entire life because all of that is playing a role in what I’m seeing in front of me.”
An important part of this vision for Dr. Luca is an emphasis on therapy. During her residency training, she pushed hard to have more therapy supervisors. While most of her fellow resident physicians had one or two therapy advisors, she had three.
“I was the squeaky wheel, honesty. I just kept asking. I kept making it known that this is what I really want to do.”
This was at time when there was an emerging emphasis on medical interventions in psychiatry, according to Dr. Luca, and she doesn’t feel that this has changed since then.
“It has become even more biologically focused. Medication is being prescribed a lot more.”
Part of that, she believes, is the time crunch many psychiatrists are working under.
“When you put a child psychiatrist in a very time-limited arena, you start shaving off a lot of [therapy]. It becomes, ‘How’s the medication. Is he tolerating it? Are you getting results? Okay, good.’ I don’t think it’s because the physician wants to be like that, but the demands are there. You have a schedule with plenty of patients that need to be seen, but unless you’re spending 30 minutes with each patient, you’re not there.”
As a child psychiatrist, part of being there for children is counseling the parents. Dr. Luca says she sometimes sees parents overcompensating for their child’s illness.
“You’re still the parent.” Luca said. “You still set the boundaries. You still have rules. Do you flex them and bend them some to better accommodate and give the child room? Yeah. But you don’t throw the rules out the window because of some diagnosis.”
Still, her dissent from what she sees as a decline of therapy and an over-emphasis on medication does not mean that she has an aversion to using medications. She does, however, often see that parents are worried about medications changing their children, or worrying that they won’t be themselves. This, she explains, isn’t how it works.
“If they’re depressed, I make them less depressed so they’re able to make better decisions and they’re more available to you to parent. A depressed child is not going to be parented very well. An anxious child is not going to be parented very well.”
At the heart of Dr. Luca’s perspective is a strong desire that she expresses this way:
“I want to see (specifically children) get the care that they need and not be stigmatized.”
It’s what drives her to serve underprivileged populations while maintaining an emphasis on personal responsibility. It’s what drove her work on programs in ADHD and law enforcement, in which she worked with law enforcement officers to help them understand and know how to handle people with ADHD in the justice system. And it’s what drives her work here at Sarkis Family Psychiatry. We are glad to have her here.
Imagine that you have gone to the grocery store and used one of those free blood-pressure machines by the pharmacy. The reading you get is high: 190/102. You would normally assume that the machine is wrong, but you’ve had similar readings at several different machines over past few months. You know that you’ve been under a lot of stress over the last couple of years. You’ve made some mistakes at work, and you think they might be looking to replace you. Since then, your diet has suffered a lot. You think about going to the doctor, but you don’t think you can bear the consequences. If they take your blood pressure and get a similar reading, then you know you’ll be diagnosed. You’ll be a person with hypertension. People will start to look at you differently. Your boss might see it as another reason to get rid of you. Then you might have trouble getting a new job if you don’t keep quiet about your condition. Everybody will be nervous around you, thinking that they have to be careful not to upset you lest you have a heart-attack. God help you if anyone ever sees you walking out of a cardiologist’s office. It might be better to wait. Maybe you can control this yourself.
If this seems like an overreaction, it’s because we don’t look at hypertension this way. We don’t tend to think of people with hypertension as a distinct class of people with shared characteristics: the hypertensive. We tend to see high blood pressure as just one of many common illnesses that we’re likely to get someday. Going to the doctor is more of a mark of common sense than one of shame. It certainly shouldn’t ruin our careers and friendships. Unfortunately, these attitudes are less common when the illness in question is a mental illness. In fact, a 2003 study of depressed patients found that 67% expected stigma to negatively affect their careers, and almost a quarter expected it to affect their friendships, and a 2007 study found that, while more than 50% of people surveyed believed that people with mental illnesses are treated with care and sympathy, less than 25% of those with mental illness agreed. These anxieties are in addition to the suffering caused by mental illness itself.
We might assume that the source of this stigma lay with the misconceptions of an ill-informed general public, but a 2011 position paper from The Canadian Psychiatric Association suggested that stigma is just as prevalent among physicians (including psychiatrists) as it is in the general population. Furthermore, other research finds that some attempts to shield patients from stigma can be counter-productive. A Johns Hopkins study found that when medical centers keep psychiatric records separate from a patient’s other records and put greater limits on those records’ accessibility, they increased the likelihood that patients would be hospitalized.
Stigma appears to be a tricky problem. But researchers have been studying the ways we try to deal with it. A 2007 study from the UK tested programs aimed at reducing stigma and found that, among the strategies studied, testimonials from patients about their struggles with mental illness and their experiences with treatment were the most effective strategy for reducing stigma.
Given the consequences of stigma, we want to do everything we can to reduce it. Earlier this year, we held our first Stop the Stigma event. It was good to see everyone who came and enjoyed themselves, and no one seemed embarrassed about the purpose of the event. Since testimonials have been shown to be effective, we encourage you to leave any testimonials you might want to share in our comment section. It just might encourage another person to finally seek the help they need.
Sarkis Family Psychiatry is very happy to have child and adolescent psychiatrist Dr. Catrina Wilkins joining the staff. Dr. Wilkins trained at UF and will be joining us July 1st. Here is her bio:
Originally from Miami, FL , Dr. Catrina N. Wilkins earned her Bachelor’s of Science at the University of Miami and her Medical Doctorate from the University of Miami Leonard M. Miller School of Medicine. She completed her Adult Psychiatry residency at the University of Florida. During her third year of training she was chosen to serve as a Chief Resident, a position typically reserved for 4th year residents. She went on to complete her training as a Child and Adolescent Psychiatrist. During her final year of training she was selected to serve as a Chief Child and Adolescent Fellow.
In 2011, as part of her desire to perpetuate a better understanding of child and adolescent psychiatry and its nuances, Dr. Wilkins joined the University of Florida Division of Child and Adolescent Psychiatry as a Clinical Assistant Professor. During her time in that position, she created lectures and teaching sessions to educate physician assistants, medical students, pediatric residents, adult psychiatry residents and child and adolescent fellows on various topics of interest and specialization including ADHD, community and minority mental health, as well as mental health services for youth in juvenile justice settings.
Historically, Dr. Wilkins has had a penchant for serving underserved populations. From her undergraduate experiences to the present, she has focused on various community endeavors to fulfill the desire to help those with limited access and education about health and ultimately mental health. She continues to be involved in the community via presentations, lectures and training sessions for various groups which include community pediatricians, Crisis Intervention Team officers, Gainesville Police Department, Alachua Sheriff’s Office, and Reichert House in an effort to spread awareness of child and adolescent mental health concerns, as well as the interplay of ADHD with the justice system. The specific area of interest (ADHD and law enforcement) has also been shared at the annual international CHADD conference the last 3 years.
Over the last 6 years, Dr. Wilkins has had the opportunity to train and work in several different arenas including Gainesville Job Corps, Marion County Juvenile Jail, Meridian Behavioral Healthcare, as well as private clinics thus affording exposure to a wide range of clinical settings and creating a foundation of broad clinical experience.
Self-control, self awareness, better mood, better focus—these are some of the benefits of meditation, and they are also things that many parents would love to see their children achieve. Teaching young children to self-soothe can lay the foundation for raising emotionally healthy teenagers. But how do you get a temperamental toddler to meditate? Sitting quietly without moving sounds suspiciously like time-out—like punishment. In some ways, though, the goals of time-out and meditation are not so different. Pediatric Nurse Practitioner Kathy Noffsinger begins her parenting blog by talking about teaching meditation to children.
Meditation for Children
by Kathy Noffisinger
Even before they’re born, infants have ways of calming themselves. When we see images of infants in the womb, they are often sucking their thumbs. Thumb-sucking is soothing to infants, which is why pacifiers work so well, and in the womb, it helps the pallet spread as it develops. But if that pacifier is taken away, and the child doesn’t learn self-calming techniques before language other forms of self-expression before develop, we start to see tantrums. If parents give in to the tantrums, then the child learns tantruming as a technique instead of self-soothing.
When you’re four years old, you don’t have much control of your environment. When a child is throwing a tantrum, and parents give in, that child learns to get some control by throwing a tantrum. A lot of times we act as the command center. We keep the control, and then we’re surprised when kids can’t control themselves later. Well, did we teach them or did we just overpower them? Starting to give some warnings and choices helps them begin to think about how they’re going to respond when they’re losing it. You can give the child some control through those choices. This can lay the groundwork for meditation by creating a thinking child.
You can’t ask a four-year-old to do breathing meditations, but you can teach them self-calming techniques. A lot of people worry about giving in, so they’ll leave the toddler. That is one technique. But another is taking the toddler into your lap and giving them a big bear-hug and telling them they’re alright: “You’re alright. You just got a little upset. Relax your muscles.” So you can start with two-year-olds. You just have to start on their developmental level.
Anything that creates a sense of closeness or pressure is a good place to start. Beanbag chairs are good. They’re like chairs that hug you. Having kids roll on the floor also works. Kids love closets and tents, so you can make a space like that for them. It’s a space they can go to and learn to go to when they get upset. Say a child hits you. You can say, “Okay, you’re going to time-out. Do you want to go to your tent?” So you’re teaching that when they’re upset, they have a choice to self-soothe.
Now you can add guided imagery. For a toddler, it may not be a beach in the Caribbean; it may be a scene from their favorite movie. You can ask them, “What’s Barney doing now?”
When you’re ready to teach them to meditate, one of the things that I think is fun is that you lay them like crosswork. Have one child lie down on her back. Then have the other child lay his head on the other one’s belly. You can make a chain of them like this:
Have each person relax and stay quiet and focus on the other person’s breathing. They’ll feel their head rising and falling as the other child breathes, and they’ll feel themselves raising the other child’s head with their own breathing. You can get a whole family to do this for five minutes. It doesn’t take long. It also helps you practice breathing from your belly, which is a good way to reduce stress. So it’s good for Mom and Dad’s health, too.
ADHD is often thought of as a childhood disorder. Although it may only affect some people during childhood, it continues to affect many into adulthood. Several studies have looked at the long-term effects of ADHD. One of the most recent ones gives us a look not just at the persistence of ADHD, but also at its effects on those who suffered from the disorder as children.
The Wall Street Journal ran a story last Sunday which reports the results a new study of adults who were diagnosed with ADHD as children. That study compared the incarceration rates, mortality rates, and incidents of other psychiatric disorders in adults who had been diagnosed with ADHD as children to adults from the same age group who had not been diagnosed. The adults with childhood ADHD were at greater risk of suffering from ADHD as adults but were also at greater risk of incarceration, and over three-quarters of those with adult ADHD were found to be suffering from at least one other mental disorder while fewer than half of those without adult ADHD (whether or not they had ADHD as children) had additional diagnoses.
Similar results were found in an earlier study that compared men who were diagnosed with ADHD as boys to men who had not. That study found that those who had been diagnosed were less likely to have a high school diplomas or college degrees. They were less likely to be employed, and those who were employed were making less money on average than those who did not have ADHD in childhood. They also had less successful marriage and were more likely to abuse drugs.
The authors of that study recommend continued monitoring of children diagnosed with ADHD, and Dr. William Barbassi, an author of the recent study mentioned in the Wall Street Journal recommends that children with ADHD be evaluated for other conditions.
Finally, an even earlier study found that children diagnosed with ADHD who received long-term follow-up care had better outcomes, regardless of the kind of treatment received.
The results of this and other research suggest that if you were diagnosed with ADHD as a child, further assessment and care may be wise, even if you no longer have apparent symptoms.
Dr. J has a new post up on his blog “What You Don’t Know about Sleep.” In it, Dr. J tells us why some of us sleep like Thomas Edison and some of us sleep like Albert Einstein. The answer involves genetics and, possibly, bacon.
Send us your questions for Dr. J, and we’ll see if breakfast is still the answer.
“Nature or nurture,” has long been the debate when it comes to diagnosing the cause behind mental illness. Researchers have conducted innumerable studies searching for the factors that contribute to overall mental development, specifically the factors that determine whether or not an individual is predisposed to a mental illness such as major depression, schizophrenia, or bipolar disorder.
The degree to which genetic factors (i.e. nature) determine whether or not an individual develops an illness is known as its “heritability”. An illness that is completely determined by genetics would be 100% heritable.
Almost all mental illnesses have a genetic component (nature); however, the importance of genetics in determining the onset of illness differs a great deal between disorders.
One of the best methods for determining the contribution of genetic factors has been to compare identical twins. Basically, scientists determine if one twin has the disorder the odds that other twin also has the disorder. Schizophrenia has been found to be one of the most heritable of all psychiatric disorders with a heritability score of 0.8—the onset of Schizophrenia is 80% based on genetics and 20% based on environmental factors.
Psychiatric illnesses that are also highly heritable include Autism (0.9), Bipolar disorder (0.85), and Attention Deficit Disorder (0.7). In contrast, Unipolar Major Depressive Disorder (0.37) and anxiety disorders (0.32) are much more dependent on environmental factors rather than genetic.
The “nurture” factor is comprised of everything else that has happened during an individual’s life. Stressful events/home environments and medical problems early in life are two of the most common environmental contributors towards development of a mental illness.
Some of the most common medical problems include (1) problems during pregnancy (e.g. mother’s alcohol or drug use), (2) problems during delivery (e.g. low oxygen levels), (3) gastrointestinal problems related to feeding (e.g. reactions to elements of mother’s diet), (4) specific health problems (e.g. asthma), (5) medications needed to treat health problems, (6) reaction to vaccinations, (7) prolonged high fevers, and (6) injuries – particularly to the head.
Probably the greatest contributing factors leading to development of mental illness relate to traumatic childhood experiences. Sexual, physical and emotional abuse during childhood all lead to a dramatic increase in the likelihood that an individual will later develop a mental illness. Highly stressful home environments are also a major contributor; examples include frequent conflicts and arguments between parents (or between parents and siblings) and witnessing violence. Children can also be traumatized by the death of a family member or by the change in the home when a family member becomes severely ill. Finally, parents with substance abuse problems or untreated psychiatric disorders have a very negative impact on their children’s emotional development.
We are also becoming increasingly aware of the emotional harm that can be caused by negative school experiences. For example, bullying by other children and even by teachers can also result in severe long-term emotional damage. The realization of these issues has led to anti-bullying campaigns nationwide, and the implementation of these campaigns has placed a larger importance on the overall mental health of school-aged children and teenagers.
While the issue of, “nature or nurture,” may not ever be black and white, research has developed many tools to determine if an individual is predisposed to a mental illness. For more information regarding mental illnesses, please visit the National Alliance on Mental Health (NAMI) website here.
Last September, Elias H. Sarkis, MD, Founder of Sarkis Family Psychiatry, became a Distinguished Fellow of the American Academy of Child and Adolescent Psychiatry. Attaining this status requires, among other things, three other AACAP Fellows writing letters of recommendation that attest to the candidate’s excellence in several areas of scholarship and service. You can read about the full requirements on the AACAP’s website.
The following month, the American Board of Psychiatry and Neurology honored Dr. Sarkis by asking him to be an examiner for the Child and Adolescent Psychiatry oral examinations in Houston. These exams are given to practicing psychiatrists who have already received board certification in psychiatry and are seeking certification in the sub-specialty of child and adolescent psychiatry.
“It’s a great honor,” Dr. Sarkis said of the invitation. “Most psychiatrists don’t get to do it.”
Board certification, though not required to practice medicine, is a testament to a physician’s competency. Sitting for the exams is, therefore, a major event in a doctor’s career. To earn this certification, candidates must pass a written exam covering both general and child and adolescent psychiatry and an oral exam.
“One of the more traumatic events of my life was being examined,” said Dr. Sarkis, who received his certification in Child and Adolescent Psychiatry in 1992. “You’re having to examine a real patient in front of two examiners. It’s a very intimidating experience.”
Not every doctor who takes these exams passes. “There is a 25% fail rate,” Dr. Sarkis said, “which is remarkable given how much they’ve done to get that far.”
After examining a patient in the presence of two examiners, the candidate describes to the examiners his or her findings and recommendations and then answers the examiner’s questions.
“I’m very happy to say that most of the candidates were rather excellent.” Dr. Sarkis said.
Among the qualities Dr. Sarkis says he looks for in a candidate are respect for patients, effective and appropriate communication, an ability to get good and useful information from a patient, and an ability to come up with a good treatment plan. These are, of course, the same things Dr. Sarkis looks for when hiring a provider for his clinic, but he says there are differences.
“It’s very different because you’ve got a lot more power,” he said of his role as an examiner, “and you’re having them examine a patient, which isn’t something you can do when you’re hiring.”
Now that Dr. Sarkis has served as an examiner, it is likely he will serve again in the future. So, in addition to serving patients in the Gainesville area, Dr. Sarkis will continue to make sure that other doctors are fully capable of serving theirs.