Monday, March 21, 2011

Cross-Dressing - Prevention by Parenting?

cross-dressing symbol
Cross-dressing is associated with problems in parenting and may be preventable. Recently a male student in Pune was found dead with a wig and female articles of clothing lying about his room.

Types of cross-dressing

Cross-dressers in society are psychologically indistinguishable from non-cross-dressing men (Brown 1996).
  1. Fetishistic transvestism
  2. Almost three percent of men and 0.4% of women have had at least one episode of transvestic fetishism (sexual arousal from cross-dressing) (langstrom 2005). However, these 'nuclear' transvestites are less likely to venture out dressed in public.
  3. Transvestism
  4. 'Marginal’ transvestites experience non-sexual pleasure from cross-dressing and are more likely to appear in public while cross-dressed. They are probably a separate group and more likely to be homosexual.
  5. Transsexualism
  6. Cross-dressers could also be transsexuals who desire surgical sex reassignment. Cross-dressing in Asians is one of the earliest signs of transexualism (Tsoi 1990).

The cross-dresser's childhood

(RL Schott 1995)
Cross-dressers are usually the eldest male child in their family. Most had a very positive relationship with their mothers and a very negative relationship with their fathers.
As children cross-dressing was furtive and secret - the covert group of cross-dressers. In the overt group (up to 20%), cross-dressing was initiated and openly encouraged - up to school age and sometimes beyond - by a mother, sister, or other female extended family member.
Young boys, in contrast to young girls, must struggle to separate psychologically from their mother in order to establish their own gender identity. Identification as a male, as being of the opposite sex from the mother, requires individuation and separation from her. Disturbances in masculinity (cross-dressing) may be an expression of impairments in this process. The eldest male child may be especially vulnerable for lack of a role model or cushion between himself and the mother.

Cross-dressing facts

(Docter 1997)
  • Usually starts before the age of 10 years.
  • Initially associated with sexual pleasure and orgasm. However, up to 90% of cross-dressers continue to do so for non-orgasmic pleasure.
  • The most commonly used articles are female underclothing and wigs.
  • Considered as an expression of the feminine part of the self, rather than as just the self with different clothes. Cross-dressing is an expression of consciously felt femininity (Levine 1993). Hence the symbol.
  • Cross-dressers prefer complete to partial cross-dressing.
  • Cross-dressers are not bold in their public appearances. About a quarter appear cross-dressed in public and a similar number have ever used the lady's restrooms - the final frontier of femininity. With increasing awareness and activism public appearances by this group of people are increasing.
  • Transvestism in adulthood is associated with guilt. Most cross-dressers get rid of their feminine clothing at some time due to feelings of shame.
  • Most wives are aware of their partners cross-dressing. Up to a quarter of them are completely accepting of the behaviour.

When is cross-dressing normal in children?

    Cross-dressing boys are first brought for psychiatric evaluation by their parents when they are discovered in their mother's underclothes. The sexual outcome of early isolated cross-dressing is not predictable.
  • It is not uncommon for boys to prefer aesthetic activities like dance or singing to football or wrestling. 
  • They occasionally role-play as a girl, play with a doll, or dress up in a girl's or woman's costume.
    Cross-dressing is associated with transvestism and transsexualism when there is
  1. Stated preference for being a girl and for growing up to become a woman
  2. Repeated cross-sex fantasy play
  3. Preference for traditionally female-type activities like knitting and baking
  4. Female peer group

How to deal with a cross-dressing child

Parents bring their cross-dressing child for psychiatric evaluation when they fear he will become homosexual or transsexual. We have already seen that  parenting style affects the child's social, emotional and behavioural development. At this early stage the focus should be on making the child comfortable with himself or herself and to reduce social stigma (Lev 2005).

Integrate the child into his peer group

This is essential to prevent teasing
  • By ages 4-5 boys and girls differ in their manners of walking, running, throwing a ball, and narrating a story. Point out these gestures and mannerisms.

Emphasise a positive father-son experience

Whether the father is distant or the boy is more attuned to his mother - the boy with gender identity disorder typically has a strained relationship with his father.
  • The father must compromise his busy work schedule to build a relationship with his son.
  • Nonathletic activities can be mutually enjoyable.
  • Taking the son to work provides a better image of who father is.
  • Board games, video games, and a shared father-son activity, such as model making and visits to the zoo are helpful.

Convey happiness with the sex of the child

The child may believe that the parents wanted a child of the other sex. Sometimes parents did and conveyed the wish to the child.
  • Parents must convey the message that they wanted a child of the same sex.
  • Convey that they are happy with the sex of their child.

Teach the boy that sex is irreversible

Psychologically children have not achieved gender constancy at ages 4 to 6. They may think that by cross-dressing or changing hair length they change their sex.
  • The anatomical differences between the sexes should be made explicit
  • Point out that superficial changes will not change their sex.

References
  1. Brown GR, Wise TN, Costa PT Jr, Herbst JH, Fagan PJ, Schmidt CW Jr. Personality characteristics and sexual functioning of 188 cross-dressing men. J Nerv Ment Dis. 1996 May;184(5):265-73.
  2. Richard F Docter and Virginia Prince. Transvestism: A survey of 1032 cross-dressers. Archives of Sexual Behavior; Dec 1997; 26, 6.
  3. Långström N, Zucker KJ. Transvestic fetishism in the general population: prevalence and correlates. J Sex Marital Ther. 2005 Mar-Apr;31(2):87-95.
  4. Arlene Istar Lev. Transgender emergence: therapeutic guidelines for working with gender variant people and their families. Haworth Clinical Practice Press. New York. 2005.
  5. Levine SB. Gender-disturbed males. J Sex Marital Ther. 1993 Summer;19(2):131-41.
  6. Richard L. Schott. The childhood and family dynamics of transvestites. Arch Sex Behav. 1995 Jun;24(3):309-27.
  7. Tsoi WF. Developmental profile of 200 male and 100 female transsexuals in Singapore. Arch Sex Behav. 1990 Dec;19(6):595-605.

Monday, March 14, 2011

Whitener Addiction - Death by Inhalant

whitener correction fluid
Whitener (correction fluid) inhalation caused the death of a Pune student recently. Whitener is abused as an inhalant in India. Whitener exerts its effects through trichloroethane, a volatile solvent. Inhalants include other substances such as petrol and toluene. These substances are cheap, accessible and readily available to children and adolescents.

Epidemiology

Solvent abuse is prevalent among street children and working kids. Teenagers start using solvents to gain entry into a gang, and occasionally as experimentation. Its use in a college student is unusual. But this may be a developing pattern indicating spread of the habit into middle class homes. (Kumar S 2008). Most adolescents are one-time or short-term users. Those who abuse inhalants persistently usually have conduct disorders.

Methods of inhalant abuse

  1. Sniffing - direct inhalation from a container or piece of clothing sprayed with the substance.
  2. Huffing - holding a soaked cloth over the nose or mouth to increase the concentration of vapours.
  3. Bagging - breathing from a paper or plastic bag containing the volatile substance to further increase the concentration (Henretig, 1996).

Mechanism of action

Young people abuse volatile solventsby deliberately inhaling available vapours 15–20 times over 10-15 minutes. This results in concentrations of up to 10000ppm as against the industrial standard of 50-100ppm (Bowen et al., 2006).

Inhaled organic solvents like toluene cross from the blood into the brain within minutes. In the brain cells solvents act on specific receptors (NMDA and GABA) to produce effects similar to those of alcohol. Toluene, a common solvent in thinner and paint, increases opiate receptors in the Nucleus Accumbens - a key brain area associated with the reward system and the experience of pleasure. Toluene enhances dopamine release in the Nucleus Accumbens.

Effects on the body

(Lubman 2008)
  • At low concentration (500-4000ppm) transient euphoria and disinhibition make abusers prone to risk taking and accidents.
  • At higher concentrations (6000-15000ppm) dizziness, sleepiness, slurred speech, blurred vision and headaches appear. Users appear confused, unbalanced, or begin responding to hallucinations.
  • Higher doses result in seizures, coma and cardiopulmonary arrest .

Death by inhalant

  • Sudden sniffing death is the most common cause. Even first-time experimental users are at risk of sudden sniffing death as a result of heart rhythm abnormalities especially if the user is startled or agitated. 
  • Suffocation and burns from exploding solvents
  • Accidental injury as a result of impulsive risk taking and impaired motor skills while intoxicated. 
  • Suicide accounts for up to 40% of inhalant-related deaths
  • First-time users are also likely to die, perhaps because they are inexperienced at this dangerous pastime.

Recognition

Inhalant abuse should be suspected in teenagers showing intermittent intoxication,and signs of recent inhalant abuse including paint or oil stains on clothing or skin, spots or sores around the mouth, red eyes, runny nose, chemical odor on the breath, and a dazed appearance (Anderson, 2003).

Mass screening in schools could be undertaken as part of the annual health check. The mental health component for middle and high schoolers should include the CRAFFT. The CRAFFT is a validated short screening instrument for substance abuse in teenagers.

Laboratory diagnosis is not reliable as these volatile substances
  • Do not persist in the body beyond a few hours
  • They are undetectable in urine samples because of their volatility
  • Hippuric acid, a long lasting toluene metabolite is also produced by foods and  raises the question of false positives. Also, it is usually not available for testing in emergency

Outcome

For most adolescents inhalant use should be regarded as a passing phase or fad. A few persistent users have antisocial personality disorder and abuse other substances. Chronic users develop damage to all organ systems - heart, lungs, brain, kidneys, and liver. The good news (Cairney et al., 2005) -
Damage to the brain is reversible with abstinence

Treatment

There is no specific medication to treat intoxication or for abstinence.

If you suspect a child is intoxicated with an inhalant stay calm and do not alarm him or her. Startling or frightening the child precipitates hallucinations and can also lead to ‘sudden sniffing death’ due to the effect on heart rhythm. Initiate cardio-pulmonary resuscitation (CPR) until help arrives if there is no heart beat or breathing.

When the child or adolescent recovers the incident should be discussed non-confrontationally. Remember, even a single inhalation can kill the child. Also abuse of other substances is frequent with regular whitener abusers. After talking it over commit to seeking psychiatric help. Social, environmental and recreational opportunities need to be addressed.

References
  1. Carrie E. Anderson, and Glenn A. Loomis. Recognition and Prevention of Inhalant Abuse. Am Fam Physician. 2003 Sep 1;68(5):869-874. (Also gives good links for information on inhalant abuse and prevention)
  2. Bowen SE, Batis JC, Paez-Martinez N, Cruz SL. The last decade of solvent research in animal models of abuse: mechanistic and behavioral studies. Neurotoxicol Teratol. 2006;28:636–647.
  3. Cairney S, Maruff P, Burns CB, Currie J, Currie BJ. Neurological and cognitive recovery following abstinence from petrol sniffing. Neuropsychopharmacology. 2005 May;30(5):1019-27.
  4. Henretig F. Inhalant abuse in children and adolescents. Pediatr Ann. 1996 Jan;25(1):47-52.
  5. Kumar S, Grover S, Kulhara P, Mattoo SK, Basu D, Biswas P, Shah R. Inhalant abuse: A clinic-based study. Indian J Psychiatry. 2008 Apr;50(2):117-20.
  6. D I Lubman, M Yücel and A J Lawrence. Inhalant abuse among adolescents: neurobiological considerations. Br J Pharmacol. 2008 May; 154(2): 316–326. Published online 2008 March 10. doi: 10.1038/bjp.2008.76.



Monday, March 7, 2011

Jealousy, rage and murder

jealousy, rage and murder
In a jealous rage a Pune immigrant murdered his family - wife and two daughters - with an axe. He then attempted suicide. He suspected his wife of infidelity.

Evolution of jealousy

As with socio-sexuality, jealousy has an evolutionary basis that arises out of natural selection (Harris, 2003). Sexual jealousy drives males to guard against cuckoldry thereby ensuring that a rivals genes are not passed on through their mate. Emotional jealousy drives females to ensure her mates continued investment in her own offspring.

Psychodynamics of jealousy, rage and murder

  • Freud showed morbid jealousy to be the deepest form of paranoia. His analysis indicated use of the defense mechansims of denial and projection to protect against threatening homosexual impulses - I do not love him—she (a wife, lover) loves him. Othello struggled with jealousy until he murdered Desdemona and then committed suicide.
  • Murder or homicide can be understood as rage directed externally while suicide is rage directed inwards. Suicide is thus an inverted homicide (Menninger 1938). This argument is supported by the similarity in characteristics of perpetrators of murder-suicide and those of persons who commit only suicide (Palermo 1997).

Family murder-suicide by males

The jealous male resorts to spouse abuse. The resulting screams are usually ignored by society. If the woman has some independence repeated incidents may result in splitting from her partner. Here again her children may be used as hostages to keep her compliant. It is rare for the morbidly jealous male to be brought for psychiatric evaluation without some external coercion. The tragedy of a family murder-suicide is that its indicators are ignored by the family's society.
  • Wife murders are commonly based on jealousy and suspicion of infidelity. Dr O Somasundaram (1970) showed that 30% of ‘The men who kill their wives’ were cases of sexual jealousy and 10% had delusional jealousy.  
  • When the children are suspected to be those of the paramour, paternity testing through DNA samples is sought at Hyderabad. Or the children could also be put to death along with their mother. 
  • Family murder followed by suicide of the assailant is significantly associated with morbid jealousy in upto a quarter of cases (Goldney 1977, Adinkrah 2008).

How does morbid jealousy manifest in women?

  • The newly wed woman who turns jealous is tormented by her suspicions. At this stage the delusion is not yet fixed. The process of paranoia is not entrenched. The woman is aghast at her own attraction towards other males. She struggles to conceal her thoughts and impulses. Freud’s analysis of the process of morbid jealousy is rendered explicit. When she musters the courage to confront him the caring spouse will seek psychiatric consultation if it is available.
  • The slightly less caring husband will seek psychiatric consultation for his delusional spouse when it affects his work. She has tried private investigators and other sources to identify the paramour and to check his mobile phone records. At this stage she may also consult with a psychiatrist to recruit his help against her husband. Her husband is alarmed only when his boss or a female colleague is entreated to join cause in the search for his paramour.
  • The least caring spouse will try to beat the suspicions out of her. However, by their very nature the delusions are strengthened with each blow. She may then herself seek psychiatric help for her emotional problems or may be referred for the same after treatment for physical abuse. The morbidly jealous woman may also beat her partner.(Stuart, Moore et al., 2006).

Underlying mental illness is apparent before the family murder-suicide

References
  1. Adinkrah M. Husbands who kill their wives: an analysis of uxoricides in contemporary Ghana. Int J Offender Ther Comp Criminol. 2008 Jun;52(3):296-310. Epub 2007 Oct 8.
  2. Freud S. Psychoanalytic notes upon an autobiographical account of a case of paranoia (dementia paranoides). In Standard Edition of the Complete Work of Sigmund Freud, vol 12. Hogarth Press, London, 1966.
  3. Goldney RD. Family murder followed by suicide. Forensic Sci. 1977 May-Jun;9(3):219-28.
  4. Harris CR. A review of sex differences in sexual jealousy, including self-report data, psychophysiological responses, interpersonal violence, and morbid jealousy. Pers Soc Psychol Rev. 2003;7(2):102-28. Erratum in: Pers Soc Psychol Rev. 2003;7(4):400. Comment in:Pers Soc Psychol Rev. 2005;9(1):62-75; discussion 76-86.
  5. Menninger K. 1938. Man Against Himself. New York: Harcourt, Brace.
  6. Palermo GB, Smith MB, Jenzten JM, Henry TE, Konicek PJ, Peterson GF, Singh RP, Witeck MJ. Murder-suicide of the jealous paranoia type: a multicenter statistical pilot study. Am J Forensic Med Pathol. 1997 Dec;18(4):374-83.
  7. Somasundaram O. The men who kill their wives. Indian J Psychiatry 1970;12:125.
  8. Stuart GL, Moore TM, Gordon KC, Hellmuth JC, Ramsey SE, Kahler CW. Reasons for intimate partner violence perpetration among arrested women. Violence Against Women. 2006 Jul;12(7):609-21.



Monday, February 28, 2011

Narcoanalysis - spies, lies and truth serum

narcoanalysis - the 'truth' might set us free
The 'truth' might set us free
Permission for narcoanalysis on a spy was refused by the Pune courts a few days ago. The investigating authorities have perceived this as a setback in arriving at the ‘truth’.

Method

In a clinical settting narocoanalysis and narcotherapy are conducted in a treatment room. The patient lies quietly with an iv line in place. While the psychiatrist recapitulates the patients history in a low monotone a nursing assistant injects thiopentone sodium to terse instructions of “push 50” or “25 slow”. Thiopentone sodium is no rare drug. It is used everyday to induce general anaesthesia. At lower doses in willing patients it produces a state of relaxation. You have to be careful the patient does not doze off or start slurring in speech. At the start of the narcoanalysis attention has to be paid to the patient's posture and eye movement. Horizontal eye movements indicate a state of sufficient relaxation to proceed with the deeper probing interview. Subsequent aliquots are adjusted with the aim of maintaining this state during the rest of the interview.

Psychiatric indications

  • The aim of narcoanalysis is to produce an abreaction in hysteria and other disorders in which there is an element of dissociation. During abreaction the patient recalls traumatic experiences and, by talking about them, discharges associated disturbing emotions. Abreaction facilitates subsequent and sometimes dramatic recovery (Breuer & Freud 1957). However, there are only anecdotal - though fascinating and highly readable - reports for the effectiveness of narcotherapy (Miller 1954, Denson 2009). The theory is based on the unconscious suppression of emotion through use of psychological defense mechanisms. It may not apply when suppression is done consciously as in most forensic cases .
  • Narcotherapy is effective in relieving catatonic mutism (McCall et al 1992).

Drawbacks

(Jesani 2008)
  1. Narcoanalysis was never considered as a method to get at the ‘truth’. It was just the patients perception of whatever he or she believed at that time. A similiar process occurs every night in the bar when a garrulous, intoxicated person talks about whatever is bothering him or her.
  2. A person can consciously lie during the procedure and get away with it.
  3. At times it is difficult to separate actual events from fantasy.
  4. You can even plant an idea into a persons mind through leading questions and later they would have no doubt it was their own.

Present status

A PubMed search using the MeSH term ‘narcotherapy’ gives just two articles in the last ten years. There are no randomised control studies - the scientific standard - to demonstrate the reproducibility of results obtained by narcoanalysis for information gathering, abreaction, or lie detection. Randomised control studies would give us an idea of the procedures sensitivity - the number of actual cases that would not be detected; and its specificity - the number of innocents who would be implicated. Presently all we have to go on are anecdotal reports of narcoanalysis practitioners . Not enough evidence to rely on narcoanalysis for deciding the fate of an unwilling subject. Not even for spies caught in Pune. Even the judiciary is sceptical of narcoanalysis..

References
  1. Breuer, J. Freud, S. 1957. Studies on Hysteria. New York: Basic Books.
  2. Denson R. Narcotherapy in the treatment of post-traumatic stress disorders: a report of two cases. J Psychoactive Drugs. 2009 Jun;41(2):199-202.
  3. Jesani A. Willing participants and tolerant profession: medical ethics and human rights in narco-analysis. Indian J Med Ethics. 2008 Jul-Sep;5(3):130-5. PubMed
  4. WV McCall, FE Shelp and WM McDonald. Controlled investigation of the amobarbital interview for catatonic mutism. Am J Psychiatry 1992; 149:202-206.
  5. Michael M. Miller. Certain Factors Pertaining to the Value of Narcoanalysis in Securing Testimony. J Natl Med Assoc. 1954 July; 46(4): 238–241. PMC
  6. PubMed. PubMed MeSH search for 'narcotherapy'. Accessed 27-Feb-2011.

Thursday, February 24, 2011

Academic stress in youth

stressed youths
Stressed youths relaxing
Academic stress is a significant aspect of youth. Youth is the developmental phase between puberty and working adulthood. It is a period of continuing student-hood. This is a distinctive feature of youth - it exists only for those who undergo post-secondary education. This is for the privileged few who do not join the workforce full-time after schooling.

Youth is a valuable time for serious experimentation. The young person is not fettered by long-term commitments. In contrast to adolescence, youth is a period of independence - the peer group is no longer a dominant influence. There is greater freedom to develop as an individual. The young person evolves a personal perspective on life and develops a sense of direction before tackling the duties of adulthood.

However this stage of life is by no means stress-free. By definition youth is associated with academics. Academic demands are perceived as significant stressors by youths (Rao 2000, Goff 2011). These demands include workload and time constraints (Jungbluth and colleagues 2011). On entering college the youth is suddenly exposed to an unsupervised life of parties, college events, projects, and an intense curriculum, all of which make demands on time.

Why do academic stressors acquire such significance in youth? Why do students who have done well in their 12th and got into good courses find it difficult to cope with the academics? Well, until high school the student has a limited syllabus. Students in good schools rely almost entirely on the notes dictated by their teachers. Also the exam system is designed so that most students can achieve high scores with minimal time spent on study. All this changes in college. When the youth enters college, he or she is confronted with the entire gamut of knowledge in a particular field. Without the skills to filter, assimilate and reproduce information in context the youth experiences stress.

There is also the problem of youths whose career path was chosen by their parents despite their protests or otherwise. These youth may find themselves completely out of their depth in a course for which they have little interest or aptitude.

Students cope with academic stressors using a combination of emotion-focused strategies like self-blame, or bunking, and problem-focused strategies like reading guide books, and cheating. Study skills training and the acquisition of good learning habits are essential life-skills for students. We have already shown that study skills are effective and can be successfully acquired.
Study skills training should be a part of every freshers curriculum.

References
  1. Jungbluth C, Macfarlane IM, Veach PM, Leroy BS.Why is Everyone So Anxious?: An Exploration of Stress and Anxiety in Genetic Counseling Graduate Students. J Genet Couns. 2011 Jan 25. [Epub ahead of print]. PubMed
  2. Goff AM. Stressors, academic performance, and learned resourcefulness in baccalaureate nursing students. Int J Nurs Educ Scholarsh. 2011;8(1):Article1. Epub 2011 Jan 24.
  3. Rao K; Moudud S; Subbakrishna DK. Appraisal of stress and coping behaviour in college students . Journal of Indian Academy of Applied Psychology. 2000 Jan- Jul; 26(1-2):5-13



Sunday, February 20, 2011

Study skills - effective learning habits for students

study skills
Effective study skills are essential learning habits for students. Some students have a knack of learning much in a short time. Others study for hours without much progress. An important differentiating factor is the method of study. Effective study habits can be learned (Barry L. Richardson and Murray Saffran 1985, D F Alexander 1985). The good student must not rely on “study drugs” as these are associated with addiction, panic reactions, confusion, and medical complications including heart attack and stroke (Steve Sussman and colleagues, 2006).

Habit No 1: Apply book learning to daily life

Those who learn rapidly apply their imagination freely to their studies. They see that every subject of study deals with something vital in the affairs of the world, and probably of personal relevance.
Allow the knowledge you are acquiring to become an active part of your daily life, with some bearing on normal activities. Thinking about studies in this way will help build greater interest and also help you to understand and remember things better.

Habit No 2: Think of the long term reasons for studying

Imagine yourself as the CEO in a multinational company; as an internationally acclaimed designer; as an architect creating the perfect city, as the next software entrepreneur, or picture yourself as the valued management expert. Hold that image in your mind and add some detail to it every day.
Visualising these ultimate goals, will give you fresh energy to keep going, because whatever your dreams; your studies are a necessary step towards achieving them.
Many students don’t know what they want to do after their board or other graduation exams. I’ve found Aptitude Testing to be a great way to get them thinking and motivate them to study. Parents usually get this done after the exams. Aptitude assessment before the exams has the added advantages of motivation for study, as also reducing anxiety related to making career choices.

Habit No 3: Organise your work

Successful study is largely a matter of good organisation.
  • Establish a regular routine. As far as possible study at the same time and place each day. A quiet, well-lit room, free from distractions is best.
  • Work out a daily timetable, to guide your activities. Do not be over ambitious with your timetable. Keep it flexible and do not try to learn more than you can comfortably manage.
  • Begin your major assignments well in advance of the required finishing dates to avoid having to complete them in a rush.

Habit No 4: Follow good study technique

Effective learning habits also minimise test anxiety.
Make notes and underline key sentences. Notes should be brief and to the point. Let notes assist your memory, not replace it.
Concentration is a necessary study habit. Resolve, for instance, to study ten pages without a break and then relax. Break up the learning of a lengthy item into sections, concentrating on each separately.
Start at the appointed time everyday. Do not make excuses – ‘I have to get into the right mood’; ‘I’ll just watch TV for 5 more minutes’. Just plunge into your work.

Habit No 5: Enhance your Memory

Memory depends on association, attention and repetition.
  1. Association can be developed by deliberately setting out to form associations or links with given words or facts.
  2. Attention is necessary for registration in the mind. Attention comes from interest in the subject, exercising the brain on it, and by focusing on one’s work in as much detail as possible.
  3. Interest can be inculcated. The more you know about something, the more interesting it becomes.
  4. Develop understanding. It is easier to remember something that is clearly understood. Aids to understanding include a wide vocabulary, good command of language, wide reading and plenty of discussion.
  5. Repetition helps in fixing memory. It is most effective if interest and understanding are involved.

Habit No 6: Build a positive attitude

Think positively. Do not picture defeat, or failure. Use your imagination to dwell upon the positive aspects of life - happiness, hard work, success, health.
People who succeed in examinations begin by believing that they will succeed. Keep telling yourself you are certain to be successful when you do the required work.
Examinations are designed for the average student to pass and the outstanding student to get a distinction.
What thousands of ordinary people have done, YOU can certainly do.
References
  1. Barry L. Richardson and Murray Saffran. Effects of a Summer Preview Program of Study Skills and Basic Science Topics on the Academic Performance of Minority Students. J Natl Med Assoc. 1985 June; 77(6): 465–471. PMC
  2. D F Alexander. The effect of study skill training on learning disabled students' retelling of expository material. J Appl Behav Anal. 1985 Fall; 18(3): 263–267. doi: 10.1901/jaba.1985.18-263.PMC
  3. Steve Sussman, Mary Ann Pentz, Donna Spruijt-Metz, and Toby Miller. Misuse of "study drugs:" prevalence, consequences, and implications for policy. Subst Abuse Treat Prev Policy. 2006; 1: 15. Published online 2006 June 9. doi: 10.1186/1747-597X-1-15 PMC.



Teaching, Learning, Aptitude, student

Monday, February 7, 2011

Social Networking - Psychological Effects on Teenagers

Parents worry that social networks like Facebook could have harmful psychological effects on their children. They seek consultation for social network related behaviour of their teenagers when academic grades fall due to excessive time spent on Facebook, when the teenager is subjected to cyberstalking, or when they themselves are disturbed by the online self-profile of their child. What do we know about some of these social networking behaviours that bring parents and their children to the Clinic?

Friends, self-presentation and self-esteem

Posting a profile assists the teenager in gaining self-awareness. Becoming self-aware by viewing one's own Facebook profile enhances self-esteem (Gonzales and Hanock, 2010).

A larger number of Facebook friends and  an exaggerated positive self-presentation does enhance the teenager’s well-being. However this is not necessarily associated with a sense of belonging to a supportive group. A more honest self-presentation does increase happiness and is also grounded in social support provided by Facebook friends (Kim and Lee, 2010). However, adolescents having more than 300 FB friends have increased levels of cortisol, a stress hormone, that makes them prone to depression in later life (Morin-Major et al, 2016)

Children whose self-worth is based on public contingencies (others' approval, physical appearance, outdoing others in competition) indulge in more photo sharing. People whose self-worth is contingent on appearance have a higher intensity of online photo sharing. Those with private-based contingencies (academic competence, family love and support, being a virtuous or moral person, and God's love) spend less time online (Stefanone et al 2010).

Facebook vs face-face

Impressions formed from face-to-face interaction and from personal web pages generally correspond. So, people liked in face-to-face interaction are also liked on the basis of their Facebook pages. Whether online or offline, people who are socially expressive are liked. People who express themselves non-verbally though gestures and body language in face-to-face interaction are also expressive online. The same goes with self-disclosure - when there is more disclosure offline there is more disclosure on line (Weisbuch et al, 2009).

Facebook and WhatsApp mostly act as an extension of face-to-face interaction. However, some users do rely on Facebook and WhatsApp for interpersonal communication more than face-to-face interaction (Kujath 2010).

Predictors of excessive use

  • Extroverted and unconscientious individuals spend more time on social networking sites and their usage tends to be addictive (Wilson K et al, 2010).
  • Shy people  also like Facebook and spend more time on it. However, they have few Facebook "Friends” (Orr et al, 2009).
  • Narcissistic personalities also have high levels of online social activity. They are recognised online  by the quantity of their social interactions, their main photo self-promotion, and attractiveness of their main photo (Buffardi LE 2008, Mehdizadeh 2010).

Needs satisfied by Facebook

The four primary needs for participating in groups within Facebook are socialising, entertainment, self-status seeking, and information (Park et al 2009). The majority of students use friend-networking sites for just that - making new friends and locating and keeping in touch with old ones (Raacke and  Bonds-Raacke 2008).

Negative outcomes

Broad claims of unwanted sexual solicitation or harassment, associated with social networking sites may be unjustified. The risk of victimisation for a teenage is more likely through instant messaging (IM) and chat (Ybarra and Mitchell 2008).

Parental supervision is a key protective factor against adolescent risk-taking behavior
Unmonitored internet use may expose adolescents to risks such as cyberbullying, unwanted exposure to pornography, and revealing personal information to sexual predators  (Pujazon-Zazik and Park 2010).
References
  1. Buffardi LE, Campbell WK. Narcissism and social networking Web sites.Pers Soc Psychol Bull. 2008 Oct;34(10):1303-14. Epub 2008 Jul 3. PubMed
  2. Gonzales AL, Hancock JT. Mirror, Mirror on my Facebook Wall: Effects of Exposure to Facebook on Self-Esteem. Cyberpsychol Behav Soc Netw. 2010 Jun 24. [Epub ahead of print] PubMed
  3. Kim J, Lee JE. The Facebook Paths to Happiness: Effects of the Number of Facebook Friends and Self-Presentation on Subjective Well-Being. Cyberpsychol Behav Soc Netw. 2010 Nov 30. [Epub ahead of print]. PubMed
  4. Kujath CL. Facebook and MySpace: Complement or Substitute for Face-to-Face Interaction?
  5. Cyberpsychol Behav Soc Netw. 2010 Jun 24. [Epub ahead of print]. PubMed
  6. Mehdizadeh S. Self-presentation 2.0: narcissism and self-esteem on Facebook. Cyberpsychol Behav Soc Netw. 2010 Aug;13(4):357-64. PubMed
  7. Julie Katia Morin-Major, Marie-France Marin, Nadia Durand, Nathalie Wan, Robert-Paul Juster, Sonia J. Lupien. Facebook behaviors associated with diurnal cortisol in adolescents: Is befriending stressful? Psychoneuroendocrinology. 2016. 63: 238–246. 
  8. Orr ES, Sisic M, Ross C, Simmering MG, Arseneault JM, Orr RR. The influence of shyness on the use of Facebook in an undergraduate sample. Cyberpsychol Behav. 2009 Jun;12(3):337-40. PubMed
  9. Park N, Kee KF, Valenzuela S. Being immersed in social networking environment: Facebook groups, uses and gratifications, and social outcomes. Cyberpsychol Behav. 2009 Dec;12(6):729-33. PubMed
  10. Pujazon-Zazik M, Park MJ. To tweet, or not to tweet: gender differences and potential positive and negative health outcomes of adolescents' social internet use.Am J Mens Health. 2010 Mar;4(1):77-85..PubMed
  11. Raacke J, Bonds-Raacke J. MySpace and Facebook: applying the uses and gratifications theory to exploring friend-networking sites. Cyberpsychol Behav. 2008 Apr;11(2):169-74. PubMed
  12. Stefanone MA, Lackaff D, Rosen D. Contingencies of Self-Worth and Social-Networking-Site
  13. Behavior. Cyberpsychol Behav Soc Netw. 2010 Jun 24. [Epub ahead of print]. PubMed
  14. Weisbuch M, Ivcevic Z, Ambady N. On Being Liked on the Web and in the "Real World": Consistency in First Impressions across Personal Webpages and Spontaneous Behavior. J Exp Soc Psychol. 2009 May;45(3):573-576. PubMed
  15. Wilson K, Fornasier S, White KM. Psychological predictors of young adults' use of social networking sites. Cyberpsychol Behav Soc Netw. 2010 Apr;13(2):173-7. PubMed
  16. Ybarra ML, Mitchell KJ. How risky are social networking sites? A comparison of places online where youth sexual solicitation and harassment occurs. Pediatrics. 2008 Feb;121(2):e350-7. Epub 2008 Jan 28. PubMed

Sunday, January 30, 2011

How to stop copycat suicides in students

Over the last two months three teenage students from the same Pune school have died by copycat suicide. 'Copycat’ suicides are frequent among adolescents aged 15-19 years. They occur more often than expected by chance alone. There has been an increase in teenage clusters in more recent years (Gould et al1990).

copycat suicide

Patterns of ‘copycat’ suicide

There are two patterns of suicide clusters: point clusters, which are localised in both space and time (spatio-temporal), and mass clusters, which are localised in time only.

Point clusters

A point cluster is a temporary increase in the frequency of suicides within a small community or institution like a school or hospital. This differentiation is important as even limited resources can be effectively mobilised for prevention.

Mass cluster

A mass cluster is a temporary increase in the frequency of suicides within an entire population. Mass clusters are typically associated with high-profile celebrity suicides that are publicised and disseminated in the mass media. Prevention here is mainly by media restraint.

This article is concerned with point cluster copycat suicides that occur in schools.

Causes of ‘copycat’ suicide

Modelling

One of the causes of suicide is social learning. ‘Copycat’ suicides are caused at least in part by exposure to another individual's suicide and through the imitation of suicidal behaviour. Suicide modeling is a real phenomenon and there is ample evidence of its impact on suicide clusters (Mesoudi 2009, Insel and Gould 2003).

Homophily

Point clusters may also occur due to of homophily, the tendency for individuals with similiar interests and outlook to preferentially associate with one another. Students who are have poor academic performance, are delinquent or abuse drugs tend to associate together. These high-risk clusters may form suicide clusters due to each member's independently high risk of suicide (Joiner 1999).

Poverty

Community household poverty increases the risk of adolescent suicidal behavior. These communities place adolescents at a higher risk for associating with suicidal others. Adolescents brought up in poor communities would thus be subjected to the processes of both homophily and social modelling for suicide behaviour (Bernburg JG et al 2009 ).

Prevention of copycat suicide

One suicide in the school is tragic by itself. However, given the tendency for teenage suicides to occur in clusters urgent action needs to be taken to prevent further deaths. Successful suicide prevention programs have three general strategies - universal, selected and indicated. (Goldsmith et al 2002).

Universal approaches

These are strategies that target the entire school population. What the school does after the index suicide is important for prevention of point cluster suicides (Doan et al 2003). 
DO
  • Respond within 24 hours of the suicide
  • Show concern and empathy
  • Inform all staff members about the suicide and provide a debriefing session where staff may voice their concerns, apprehensions, and any questions they may have.
  • Inform school board members
  • Ensure all teachers announce the death of the student by suicide to their first class of the day
  • Provide counseling sites throughout the school for students
  • Assign a school liaison to handle all media inquiries in order to avoid sensationalistic stories concerning the suicide
  • Monitor the school’s emotional climate (Has there been an increase in fights or school delinquency following a death by suicide?).
  • Evaluate all activities done following a death by suicide (How did your school respond? What worked and what did not work?).
  • Utilize an established linkage system or community network in order to make referrals to the appropriate services as well to exchange information concerning the appropriate steps for treating those affected by the suicide.
  • Utilize an established school response crisis team, which should include a diverse group of school professionals, such as the principal, counselor, teacher and possibly the school nurse.
DON'T
A major aspect of preventing cluster suicides lies in not glamourising or memorialising the act in any way. This would include attention to points as below.
  • DON'T plant a tree or object in order to honor the student.
  • DON'T hold a memorial service for the student at the school.
  • DON'T describe in great detail the suicide (method or place).
  • DON'T dramatise the impact of suicide through descriptions and pictures of grieving relatives, teachers or classmates.
  • DON'T glamorise or sensationalise the suicide.

Selected approaches

Further specific strategies are for at-risk student groups. This would include screening and counselling of the student's known friends and group. Other at-risk children such as those with a previous history of attempted suicide, those known to have mood disorders, or substance use problems should also be specifically screened.

Indicated approaches

Students who show signs of suicidal potential should not be left alone. They should be given empathic support until they can be assessed by a psychiatrist, psychologist or counsellor and more definitive measures instituted. The signs of suicide potential include
  • statements about suicide or that things would be better if the student was dead
  • talking or writing about death, dying, or suicide

Every Pune school should have a mechanism in place to deal with the aftermath of student suicide to prevent copycat suicides in teenagers.

References
  1. Bernburg JG, Thorlindsson T, Sigfusdottir ID. The spreading of suicidal behavior: The contextual effect of community household poverty on adolescent suicidal behavior and the mediating role of suicide suggestion.Soc Sci Med. 2009 Jan;68(2):380-9. Epub 2008 Nov 18.
  2. Doan, J., Roggenbaum, S., & Lazear, K.J. (2003). Youth suicide prevention school-based guide (c/p/r/s)—Checklist 7a: Preparing for and responding to a death by suicide: Steps for responding. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute. (FMHI Series Publication #219-7a).
  3. Goldsmith SK, Pellmar TC, Kleinman AM, Bunney WE, eds. Reducing suicide: a national imperative. Washington, DC: National Academy Press; 2002.
  4. Insel BJ, Gould MS. Impact of modeling on adolescent suicidal behavior. Psychiatr Clin North Am. 2008 Jun;31(2):293-316.
  5. Joiner JTE. The clustering and contagion of suicide. Current Directions in Psychological Science. 1999;8:89–92
  6. Mesoudi A. The cultural dynamics of copycat suicide. PLoS One. 2009; 4(9): e7252. Published online 2009 September 30. doi: 10.1371/journal.pone.0007252.

Sunday, January 23, 2011

Manage exam stress: what Pune’s students need to do

St Germain's
Exams at St Germain's
Pune students need to differentiate true exam stress or test anxiety from rational test anxiety that occurs due to a lack of adequate preparation. Both conditions need to be addressed differently. True test anxiety is diagnosed when the student panics, "blanks out", or overreacts despite the following (Hanoski 2008):
  • there is enough time for studying
  • study strategies are adequate
  • attendance is regular
  • class material is understood

Managing rational test anxiety

(Morgan et al, 1986)
When there is adequate time for preparation effective learning habits minimise rational test anxiety.

Effective learning habits

We begin at this stage if the student comes to the clinic 6-8 weeks before the exams. Acquiring effective study skills is essential for all students.
  • Plan and stick to a study schedule. This simple yet crucial first step is often neglected.
  • Spend at least half the study time in elaborative rehearsal, thinking about what is being rehearsed and relating it to other things that are known or being learnt
  • Organise the study material to form retrieval cues or reminders for recall
  • Get feedback on how well things have been learnt and remembered
  • Review before the exam in the same way things were learnt in the first place. Focus the review on the type of exam.
  • Over learn the material. Go back and re-learn it after a few days.

Prior to the exam

 (University of Illinois)
These techniques are applied 1-2 weeks prior to the exam
  • Avoid "cramming" for a test
  • Combine all the information presented throughout the year. Work on mastering the main concepts.
  • Anticipate questions that may be asked and try to answer them by integrating ideas from lectures, notes, texts, and supplementary readings
  • Select important portions that can be covered well if you are unable to cover all the material given throughout the term, 
  • Set a goal of presenting knowledge of this information on the test.

True (Classic) Test Anxiety

True or classic test anxiety occurs despite effort to study and requires further measures. Again these measures vary as per the phase of the examination.

Pre-test

These measures can be instituted at any time prior to the exam and should become routine for all students.

Adopt a health-promoting lifestyle

Behavioural measures
  • Assertiveness - claim space and environment for study, study materials, access to experts
  • Time management - especially with a view to program adequate study hours by identifying periods in which time is spent on distractions
  • Recreation and social activities - essential for maintaining concentration, and motivation. Should be programmed daily in small quantities
Physical measures
  • Nutrition - don’t skip meals. Eat plenty of fruit and coloured vegetables
  • Exercise - the amount can be varied. Incorporate some stretching exercises and some aerobics like skipping or same place jogging.
  • Relaxation - use a muscle relaxation technique or any form of meditation that doesn't take more than a few minutes
  • Sleep hygiene - for adequate, predictable and refreshing sleep
Cognitive and emotional measures
  • Cognitive restructuring - see the exam as a means not an end. Keep in mind the ultimate goal you are working towards. This goal may differ from those of your parents and school. Aptitude testing, career guidance and counselling help match your expectations and capabilities with that of your family and school.
  • Stress inoculation - take regular mock exams under the same conditions as the actual test
  • Anxiety management techniques

Attention to practical aspects of the exam

  • Find out where the test is scheduled to take place and how long it will take to get there
  • Look at the buildingso that it feels more familiar.
  • Know the rules as to what can be taken into the exam room etc [28].

The Day of the Test

  • Begin the day with a moderate breakfast, avoid coffee
  • Do something relaxing the hour before the test
  • Plan to arrive at the test location early
  • Avoid classmates who generate anxiety

During the Test

There are basic test taking strategies and specific anxiety management techniques that the student needs to learn (Hinton and Casey 2006).
Before answering
  • Review the entire test and then read the directions twice.
  • Think of the test as an opportunity to show what you know then begin to organise time efficiently.
Focusing exercise
  • Take a deep breath. Look straight ahead at something inanimate (the wall, a picture, the clock)
  • Focus the mind on the positive thought 'I CAN DO this exam' while breathing out.
Do the easiest parts first
  • For essay questions start by constructing an outline.
  • For short-answer questions answer exactly what is asked.
  • If there is difficulty with an item involving a written response show some knowledge.
  • If proper terminology evades you show what you know with your own words.
  • For multiple choice questions read all the options first, then eliminate the most obvious. If unsure of the correct response rely on first impressions, then move on quickly. Be careful of qualifying words such as "only," "always," or "most."
Stick to time
  • Do not rush through the test.
  • Wear a watch and check it frequently
  • If it appears you will be unable to finish the entire test, concentrate on parts you can answer well.
Recheck your answers only if you have extra time - and only if you are not anxious.

Anxiety management techniques

Learn a few of these techniques and stick to the ones that suit you. Use them whenever you panic while studying or during the exam. If problems persist despite using these techniques there are safe and effective medications that can be used just prior to the exam.
Thought-stopping
  • Anxiety produces negative thoughts ('I can't answer anything', 'I'm going to panic' etc).
  • Halt the spiralling thoughts by mentally shouting 'STOP!' Or picture a road STOP sign, or traffic lights on red.
  • Once the thoughts are stopped continue planning, or practise a relaxation technique.
Mild pain
  • Pain effectively overrides all other thoughts and impulses.
  • Lightly press your fingernails into your palm
  • Place an elastic band around your wrist and snap it lightly
Use a mantra
  • A mantra is a self-repeated word or phrase.
  • Repeatedly say 'calm' or 'relax' your breath
Distraction
  • Distract attention from anxious thoughts and keep your mind busy
  • Look out of the window, count the number of people with spectacles
  • Count the number of desks in each row
  • Make words out of another word or title
Bridging objects
  • Carry something having positive associations with another person or place
  • Touching the bridging object is comforting
  • Allow a few minutes to think about the person
Self-talk
  • In exam anxiety or panic there are often negative messages, 'I can't do this' 'I'm going to fail' 'I'm useless'. Consciously replace these with pre-rehearsed positive, encouraging thoughts:
  • 'This is just anxiety, it can't harm me',
  • 'Relax, concentrate, it's will be OK',
  • 'I'm getting there, nearly over'.
After the Test
  • Whatever the result of the test, follow through on a promised reward - and enjoy it!
  • Try not to dwell on all the mistakes.
  • Do not immediately begin studying for the next test. Do something relaxing for a while! (University of Illinois 2007).

Exam stress in students requires active management. State boards are taking exam anxiety and its adverse fallout seriously. The Central Board of Secondary Education (CBSE) has brought out a handbook, Knowing Children Better, offering information and advice on handling exam stress. When problems persist students and parents should not hesitate to seek psychiatric help (Malhotra 2007).

References

  1. Geetanjali Kumar. Knowing Children better. CBSE. New Delhi. 2005.
  2. Hanoski TD. Test anxiety: what it is and how to cope with it. http://www.ualberta.ca/~uscs/counselling_links.htm Accessed 27-Jul-08.
  3. Hinton A, Casey M. Managing Exam Anxiety and Panic-A guide for students. 18-Sep-2006. http://www.brookes.ac.uk/. Accessed 27-Jul-08.
  4. Malhotra S. Dealing with exam stress amongst students: Challenge for psychiatrists. Abstracts of 59th Annual National Conference of Indian Psychiatric Society. Indian J Psychiatry 2007;49:1-60. Available from: http://www.indianjpsychiatry.org/text.asp?2007/49/5/1/33280
  5. Morgan CT, King RA, Weisz JR, Schopler J. Introduction to psychology. 7th Edition. New York. McGraw-Hill Book Company, 1986
  6. University of Illinois. Test Anxiety. 2007. http://www.counselingcenter.uiuc.edu/. Accessed 27-Jul-08.

Sunday, January 9, 2011

How to refuse alcohol - keepin' it REAL

How to refuse an alcohol containing drink? The lead up to the festive season comes with a slew of articles on how to consume alcohol without experiencing a hangover. Then come the lessons on managing a hangover. Finally by New Year, come the statistics on drunken driving and police action on youngsters partying in rural Pune hideouts. Nothing about how to refuse alcohol while partying.

Alcohol refusal strategies

MN Gosin(2003) has classified drug resistance strategies into four types summarised by the acronym REAL
R - Refuse: say no.
E - Explain: decline with an explanation
A - Avoid: stay away from situations where alcohol is offered
L - Leave: exit situations where alcohol is offered

refuse alcohol;
Don't reach for it

10 tactics to resist alcohol at a party

These tried and tested ways to politely resist alcohol are classified along REAL lines. Remember you have the right to choose not to consume alcohol at any time. If that’s not respected you are probably in the wrong company. Once you take your stand don’t hold back. Participate, then you are less likely to be singled out to have a drink forced on you.
  1. Firmly decline alcohol. Ask for a soft drink. Don’t apologise. When your friends recognise you mean it this time they will not press you. (R)
  2. Go for a soft drink ‘to start with’. ‘Stick with this’ if your friends remember to ask later. Grab a soft drink and don’t let go. Once you have a soft drink in your hand it is easier to just wave the alcohol offer away. (R)
  3. In the initial stages keep a glass constantly in your hand. Make sure its at least a third full at all times. (R)
  4. Don’t reach for any glass of alcohol, even if it’s paid for by one of your friends. There are enough people around who will drink it gladly. (R)
  5. Volunteer to be the ‘designated driver’. If there are more than one of you claiming this position your task is easier. See point 8. (E)
  6. Insist that you’re on medication that reacts with alcohol (eg Tiniba for a stomach problem). If you are known to have diabetes or hypertension say your doctor advised you not to drink alcohol (He did, didn’t he?). (E)
  7. Say you have to work on a presentation/ pick up your mother after the party. Any plausible reason for the need to remain sharp will do.(E)
  8. Stick with a known tee-totaller in the group. Its easier to resist exhortations to drink alcohol when you have a partner.(A)
  9. When invited inform that you won’t be drinking alcohol. They’ll say its for the pleasure of your company. Hold them to it at the party (A)
  10. Leave when you suspect your soft drink may be spiked. (L)

Do these strategies work?

(Kulis et al, 2008)
  • Refusal - significantly reduces binge drinking.
  • Explanation - may not be so effective, at least in teenagers.
  • Avoidance - significantly reduces alcohol use
  • Leaving - significantly reduces binge drinking

What worked for you?

  1. Gosin M, Marsiglia FF, Hecht ML. Keepin' it R.E.A.L.: a drug resistance curriculum tailored to the strengths and needs of pre-adolescents of the southwest. J Drug Educ. 2003;33(2):119-42.PubMed
  2. Kulis S, Marsiglia FF, Castillo J, Becerra D, Nieri T. Drug resistance strategies and substance use among adolescents in Monterrey, Mexico. J Prim Prev. 2008 Mar;29(2):167-92.PubMed