Inside The Teenage Brain

I'm always excited when I see an article in the Mass Media -- this time, Parade Magazine accompanying today's Sunday paper (Sunday, November 28, 2010) -- that presents an up-to-date description of how the teenage brain works and how vulnerable it is to assaults, so to speak, by things like alcohol as well as to impulsive thoughts, among other things.

Today's article What's Really Going On Inside Your Teen's Head by Judith Newman pp. 4-6 is very important.  The content also illustrates why it's so difficult to distinguish, at this age, between behaviors associated with some brain disorders and plain old teenager-hood that I used to call testosterone poisoning when it came to adolescent male behavior.  I never figured out a term for what I went through (in my parent's eyes although I was sent away to boarding school which may have been the best solution for all of us) or what my daughter went through.  We were different and yet we both developed eating disorders.

Basically, the teenage brain is different.  Or rather, the teenage brain is still developing as PET scans as well as fMRI's are illustrating.  Not only that but the human brain isn't done baking, so to speak, until one is well into one's twenties and in some cases early thirties.  The prefrontal cortex is the last area of the brain to develop!!!

So, what is going on in there?  and will it be possible to work with a pre-teen and a teen to develop skills to prevent eating disorders from developing?

P.S.   Later today I remembered one of the comments I continued to hear at the NEDA conference, which was that many parents couldn't get a handle on the information provided because it was too technical.  Perhaps at the next conference there might be an opening seminar on the brain that describes the different regions in a layperson's terms and what those regions do.

P.P.S.  Carrie Arnold's book Decoding Anorexia (Routledge 2013) includes a chapter on the brain's regions in layperson's terms.  Chapter 2: Interoception and the Insula, pp 22-37.

More ramblings about set shifting

Dr. Kate Tchanturia's recent appearance and presentation at the October NEDA conference in New York City  on Cognitive Remediation Therapy as well as set shifting has continued to intrigue me.  I came across this thoughtful post the other day about set shifting as a bio-marker for eating disorders.  

Whether my meager ability to use a qwerty keyboard on a cellphone although I can type lickety-split on a regular keyboard has anything to do with this, I'm not sure.  But it would make sense.  I simply cannot translate my ability to use all my fingers on the keys to the hunt and peck approach on the tiny cellphone.  My index finger has a set range of keys my brain looks for, I suppose, on the qwerty.  Yet if I'm using my "old fashioned" cellphone with the accustomed digital display, I have no trouble using my index finger to punch out any combination of letters and numbers.....

Another perspective is that I'm exercising my brain by learning to do something new and setting up new pathways.  Another good exercise is to periodically use your computer mouse with your left hand (if you're right handed).  I really want a Smart Phone.  Guess it's going to take some effort.  My husband's Blackberry keyboard is entirely too small for my bifocal necessity eyes, however.

Why Do You Eat?

Many people will probably answer this question with, “….because I’m hungry.”

Others might launch into a physiological discussion about the mechanisms of hunger and metabolism or about the principles of nutrition. 

But, really, why do you eat?

Earlier on this blog I wrote about Dr. Cynthia Bulik’s terrific book, Crave.  Here’s the link. 

I just finished reading Intuitive Eating: A Revolutionary Program that Works by Evelyn Tribole, M.D., R.D. and Elyse Resch, M.S., R.D,. F.A.D.A. (St. Martin’s Press, 2003).  The book has been on my shelf for awhile, now.  I ordered it after reading comments about it on Facebook as well as Something Fishy.  I had planned to read this book next having finished Dr. Julia O’Toole’s Give Food a Chance and Dr. James Greenblatt’s Answers to Anorexia.   I’m still reading on the topic of nutrition and hope to write more next month but it was important to me to get started on this concept.

When it was clear a few weeks ago that another residential stay for my loved one was necessary, I knew that not only was willingness a must but also a new approach was needed.  When I started reviewing the website of the residential treatment center where my loved one is and that was recommended by her personal therapist, I discovered that the philosophy of Intuitive Eating was integral to the program.  So is the clear acknowledgment that nothing can be accomplished without the person re-achieving a level of nutrition necessary to understand and utilize information.  Again, if the brain is malnourished, the person will find it extremely difficult to learn about and adopt new behaviors.  Medications aren’t very effective, either.  Nutrition must come first.  And, this can take time especially for a person who fears food.

But first, a digression.  I firmly believe that our advertising industry can totally overwhelm one’s ability to honor one’s body/one’s self/one’s hunger.  For those who are predisposed to an eating disorder,  what one sees, hears, and reads on websites with advertisements, on television, in magazines, as links to, for example, Facebook, etc. subtly provides messages that are difficult to ignore.   I think, if one contemplates the question that is the subject of this essay, many of us don’t really have the time to think about it anymore.    Lives tend to be busy and even chaotic.  Meals are taken at the counter in the kitchen or at the drive-thru window or separately when work hours vary or pulled lukewarm from the refrigerator later in the evening. 

It came as an enormous surprise when my husband and I took a trip about three years ago thanks to an award by his company for work well done.  He called me and asked if I’d like to visit Florence.  I paused, wondering what in the world (no offense intended) I might find in Florence, Arizona, that would propel me to say, “yes.”  In fact, I said that.  He laughed and said, “Florence, Italy.”  I was speechless.  This was one of our hoped-for retirement trips that was beginning to seem less likely given all that was going on.  We spent a week there. 

Why am I mentioning this?  Because for the first time in years – seriously – we both came to appreciate  again  (as did everyone we saw, whether tourists or natives) taking time out to sit down and enjoy a leisurely, delicious meal, even at lunchtime.  We savored not only the cooking, but the company, all week long.  One night, on our own, we asked the concierge for recommendations and he steered us about four blocks away to a tucked away place where we arrived only to find out that dinner didn’t start until 7 pm.  No problem.  Other knowledgeable patrons-to-be arrived with cups, a bottle of wine, and some delicious bread which they shared.  We joined them for dinner and had a wonderful time.  I came to appreciate the concept of intuitive eating (although I didn’t know that term).  Neither of us ate too much (one of the reasons being that portions weren’t preposterous) nor did we gain weight.  Everyone took their time.  No one hovered over our table like a vulture waiting to pounce on the first empty plate to hurry us along.   Rather, we enjoyed the experience of eating what and how much we needed and wanted.  It was amazing.  The whole trip was, actually.  A photo was taken of us during the week that we framed.  One of our relatives wondered who the man was in the picture!  My husband looked so relaxed and so happy.  So did I.

So, what is so special about Intuitive Eating?  Why did this book remind me of things Dr. Bulik mentioned in Crave?  Why do we eat?  Why is this important for those with eating disorders?

If your loved one has been diagnosed with an eating disorder s/he has been restricting or has learned to use food in a way that is not healthy, in fact dangerous.  S/he has lost the innate sense of the feeling of hunger that s/he came into the world with.   Your loved one needs to learn how to eat again using techniques that lead to healthy living.  This isn’t an overnight thing; it takes time.

The authors propose ten principles to intuitive eating (pp. 2-29):  “Reject the diet mentality; Honor your hunger; Make peace with food; Challenge the food police; Feel your fullness; Discover the satisfaction factor; Cope with your emotions without using food; Respect [love] your body; Exercise – feel the difference; and Honor your health – gentle nutrition”.  They write that awakening the intuitive eater is a process.  As I noted in an earlier post, our society is linear; the process of recovery is not.  One must be prepared for spurts and stops, for slips and falls, and for time to heal.  The authors note that there are stages to this process (pp. 30-40) and then proceed to discuss these stages in depth.  The stages are:  “Readiness – hitting diet bottom; Exploration – Conscious Learning and Pursuit of Pleasure; Crystallization; The Intuitive Eater Awakens; and the final stage, Treasure the Pleasure.”

All points are important.  I remembered Dr. Bulik’s important work about knowing yourself when I read Chapter 11 in which the authors spend time on “Cope with Your Emotions Without Using Food.”  That was a big one for me.  I did cope with my emotions using food and that behavior became a terrible addiction.  I did not trust for a long time in my ability to find another coping mechanism to take the place of binging and purging to relieve my anxiety.  Beginning to run (moderate exercise at first with thoughtful eating) became a solution for me as did a gradual sense of accomplishment.

Again, this is a process.  I like what the authors note in their Epilogue (p. 245):

“…becoming an Intuitive Eater requires a highly conscious decision and commitment.  It means letting go of the old way of surviving and opening up to a new way of viewing life.  It might take soul searching and introspective work to decide whether dieting [your eating disorder – my words] has been keeping you from your deepest appreciation of life.  Making this viewpoint change can be difficult to accomplish initially, but can ultimately become a way of living that knows no return.”

Yes!  Eat to live!

When the Financial Well Runs Dry

This post will be updated occasionally as I continue to find sites and references.  The piece includes comments following the financial section re obtaining care.
[March 2019]

I celebrated when I heard the news that with the passage of the Health Care Act, families can include their dependents on their health care plans for a longer time - until age 26.  And, your son or daughter does not need to be living with you in your home, either.  I've noticed that some private plans and the State of New Jersey (at least, there may be others) actually already extend that age until 30.  

Now, of course, one of the remaining hurdles is to provide parity in health coverage for those with brain disorders/mental illness including eating disorders.  The Eating Disorder Coalition and others are working towards that goal.  A recent decision re Wit v UnitedHealthCare written about by Steven Dunn on his blog www.adadsjourneywitheatingdisorders.home.blog  addresses this case and its ramifications.

On the insurance point, incidentally, Susan Maccia wrote an article for the Parent and Family Network Newsletter Fall 2011 issue titled, Insurance 201:Single Case Agreements outlining how to obtain special clearance for out of network treatment or out of state (e.g.) treatment.  There is precedent for this, even within Medicaid.

Here's a link to one woman's successful journey to effect change in her state (Missouri) as well as to obtain treatment for her daughter.  Annie Seal's story provides important tips on how to proceed.
 

In the meantime, and until your state or country enacts changes in the law to require insurance companies to pay for whatever treatment is necessary, what's a family to do when private health care coverage is not available for their adult loved one?  The Wall Street Journal among other media has occasionally run articles about people who have needed to declare bankruptcy upon exhausting all their funds.  Other families, whose members have working years ahead of them, have  chosen to completely decimate their retirement plans in favor of keeping a loved one in treatment.  What about people who are still in this battle and are retired or disabled themselves or literally cannot afford to exhaust their retirement funds.  What are other possibilities?

The first is to sit down and take a complete look at your financial picture and your age and ability to keep working.  If you're reading this, you have access to a computer and to sites like those offered by eg MetLife (there are many more and this is not an advertisement; I just happened to see it in the paper) or you can purchase software like Quicken  that has a planning retirement function to analyze what you'll need to live on post-retirement. 

This is an important step, too, because you need a complete picture with which to work when you do negotiate with residential facilities, many of which have funds set aside to help families whose means are not sufficient.  Do not hesitate to ask for help and be sure to factor things in like support for another aging family member or one with special needs.

The next is to consider treatment loans.  There are companies in this country that will work with you to finance long-term treatment.  Your doctor's office or local hospital may have literature about available loans.  edreferral.com provides all sorts of information about obtaining financial support - loans, trials, even free scholarships for the treatment of eating disorders including much of what I write about here.  For example, the non-profit organization called Project Heal also raises funds to provide assistance, if possible, to those who need it. 

A  legal ruling in New York State (legal work done by Kantor and Kantor) opens the door for support for nutritional counseling for those with eating disorders.  

At some point, there comes the time when other resources need to be considered and among those available for adults is Medicaid, SSDI and SSI, and other benefits at the State and Federal level such as Section 8 Housing and food stamps as well as private sources such as Catholic Community Services and similar church-run programs.  The Salvation Army is a resource, as well.

Your adult loved one may be eligible to apply for SSI (check on the asset limitations) or SSDI which can take time but is worth the time and paperwork. S/he should be able to find an attorney who will do this for her/him pro bono and as a compensation will receive a percentage of the declaration of support which usually is retroactive from the time your son or daughter sank into this quagmire of an eating disorder. The attorney will help your son/daughter figure this out as part of the application process.  A judge will have the final say. It's possible on at least the first go-round that the judge will deny your application. Your loved one (and you) needs to know not to give up! The attorney should know this, too, as it is not unusual.

In the meantime, if necessary for your family encourage your daughter/son to sign up for Medicaid which should be available to her/him as a low income/no income individual.  If your adult loved one has worked, s/he probably has paid into the system through payroll deduction and is eligible for these kinds of benefits. Some states offer a low cost health insurance program with a very small co-pay if the person is not eligible for Medicaid.  Many states are struggling with their own financial issues  but it's worth it for your loved one to pursue all these angles.

Once your daughter/son, should s/he choose to apply, is ruled eligible to receive SSI and begins to receive the financial assistance, her/his medicaid health coverage usually becomes part of this entire package.  Keep asking questions.  All states are different.

Your daughter/son may also become eligible for what's known as Section 8 Housing. The application process for this is also long and tedious but ultimately the cost (the rent) is subsidized.  The waiting period can be very long, however. 

Until your daughter/son obtains all/any of this assistance, s/he is going to need to find a place to live if s/he doesn't have one or cannot live with you (for a variety of reasons). S/he or an advocate (usually you) will want to check out long-term group homes or  shelters for those who have brain disorders/mental illness. If one is assigned, her/his mental health provider can help her with this. Usually these places are locked up at night and have someone who leads group sessions and that sort of thing during the early evening. Since they are run by non-profit organizations, there is usually oversight and rules. Often there are chores, so to speak, that they are assigned to do. Other options of course are group homes identified by a mental health provider or friends who are willing to share their home with your loved one for a low rent payment.  The Gospel Rescue Mission is an example here in Arizona.

Your loved one's journey may have included what is known here in Arizona as Title 36 procedures.  Depending on your State's laws, it may be possible for you to have your loved one picked up, taken to a hospital, and legally evaluated for their danger to self.  Some states prohibit this; others have a set time-line during which the person is evaluated.  

If the decision is to keep the person because of their mental/physical state, there is a time period within which next steps must be taken including a decision for a hearing with a judge.  These steps include a more thorough evaluation of, for example, their danger to self.  I'm keeping this general because there's so much variation among states.  

Ultimately, there is the possibility that the judge will rule the person to be SMI, meaning Seriously Mentally Ill, at which point the person can be assigned to a mental health provider that is by law required to oversee the mental health care and treatment of the individual. The judge's ruling may include Court Ordered Treatment. This can include treatment in a residential facility, especially if a precedent has been set.  Again, the laws vary as do the facilities.  Even where I live, those familiar with ED treatment know to which hospital one should take your loved one where they will encounter hospital personnel who are familiar with eating disorders and who are more likely to follow through with commitment and a thorough evaluation.  As I've said before, others are more inclined to simply provide an IV, stabilize electrolytes, and turn the [emaciated and endangered] person back out on the street.  I cannot begin to tell you what it feels like as a parent to watch a facility keep a loved one for only two hours in spite of the person's obviously emaciated condition and then release them.

As more information about eating disorders goes mainstream and doctors and other people in health care are educated, I believe that better and longer treatment will become available. 

Once the Court has declared your family member to be seriously mentally ill, the next step is to find a facility that has a contract with the State for this kind of treatment.  Often one does not exist.  Contact your state legislator or representative for help to find out more information.  If the person is under the age of 18, precedent may have been set by another person needing treatment for the person to travel out of state to good facilities that will accept Medicaid.  Florida, for example, has done this.  Arizona has in the past, as well. These arrangements are known as single case agreements.

Our local mental health community has collaborated in the development of a Crisis Response Center (CRC) at a local hospital where people can go for immediate help and evaluation.  Perhaps yours has done this, as well.  

Some law enforcement agencies require officer training to include working with people who have brain disorders/are mentally ill.  Others do not.  It's important for you to know what is available where you live.