Aggression in children - need for parental intervention

Aggression is uncommon in school children and should be addressed

A Pune teenager was kidnapped and murdered by his school friends a few weeks ago. The victim was deliberately selected and his parents were manipulated for a ransom. Violence, theft and destructiveness are end stage behaviours of conduct problems in children and adolescents.

Trajectories of aggression in children

The commonest path of violence in children is 'adolescence-limited'. The antisocial behaviours usually occur when the adolescents are 'hanging out' in a group.  This type of aggression reflects an anti-authoritarianism. Anti-authoritarianism results from frustration over being denied the benefits of full adult independence despite reaching physical maturity. Adolescent limited aggression is less violent, relies on peer encouragement, and generally diminishes by adulthood  These adolescents are usually able to integrate into society as young adults.

A less common path of violence is 'life-course-persistent'. In this group of antisocial children, problem behaviors unfold in a sequence at home and school

1. Early noncompliance - with excessive arguing and disobedience
2. Poor rule adherence - staying out late, playing in prohibited locations
3. Low frustration tolerance - temper tantrums, abusiveness, aggression

Aggression is common among preschoolers. The prevalence rate of aggression in children reduces dramatically once they enter school. Children whose fighting does not  reduce in the early school years are at high risk for persistent violent behavior. This important subgroup of proactively aggressive youth is profoundly indifferent to the consequences that their misbehavior has upon others. They rarely display genuine remorse. Their personality of 'callous-unemotional traits' is characterised by a lack of empathy, self-centeredness, and shallowness. As youths they are responsible for a large number of violent offenses. Their aggressive behavior is often persistent as features of psychopathic or sociopathic personality.

Parenting can prevent violence

1. Make aggression irrelevant by modifying the setting
Aggression is significantly affected by the parent-child relationship. Children with conduct problems tend to have acrimonious and negative interactions with their parents. The parent is perceived as just an agent of coercion. It is important to change this environment. Positive interactions between the parent and child serves to reinforce the perception of the parent as a source of positive attention, affection, support and encouragement. This makes the child responsive to parents' authority and to the rewards and punsihment that  the parent dispenses.
2. Make aggression ineffective by modifying its consequences
The reactions of others to the aggressive behavior sustains and reinforces it. They may give in to what the child wants, give up trying to get compliance, or even bar the child from school -  which may be exactly what the child wants. To render the aggression ineffective parents/ teachers have to respond by ignoring milder misbehaviour and handing out consequences. These include time outs, loss of privileges (TV, cell phone, Facebook) that the child will want to avoid, and limit setting (curfew times, restricting location).

Parents need to establish  their authority and implement some of these measures in aggressive children. This teaches children that aggression is an ineffective means of fulfilling a particular wish. These lessons are better learned early under caring parents rather than later in a centre for juvenile delinquents.

References
Brennan LM. Toddler-age externalizing behaviors and school-age academic achievement: independent associations and the impact of parental involvement University of Pittsburgh. Thesis presented 27-Aug-2010.

Healthy Baby Contests - judging psychological development objectively

Psychological development is a key aspect of any ‘Healthy Baby Contest”. Pathfinder Clinic judged the psychological development of toddlers participating in one such local event. Healthy baby contests are among the most attractive activities organized by many preschools and communities. Assessment is a sensitive issue at any Healthy Baby competition. Parents of contestants are concerned regarding partiality and subjective errors. Judging a Healthy Baby Contest objectively is crucial to the credibility of the event.

Can psychological development be objectively assessed in 5 minutes?
Psychological assessment can be time consuming and difficult to operationalize. The child’s development is captured in speech, social interaction, and manipulation of every- day objects. Usually a child’s developmental milestones are judged ‘objectively’ based on the parents responses to available screening questionnaires.

We decided to get our knees dirty and go down to toddler level to get a direct assessment of where they were at. The caveat, the organisers wanted us out of the way in two hours. We judged 39 toddlers aged 2 to 4.5yr. We took three hours; less than 5 minutes per child on an average.

Method

The atmosphere around the play rooms was intense -  mainly contributed by parental anxiety. Pre-school coordinators ensured each child walked into the room with their parents. Despite some adult anxieties each family was safely seated at toddler level. Every child was greeted and asked their name. They were then asked to point to and name parts of the body and animal figures;  draw age-appropriate figures; manipulate wooden blocks or coloured beads; and catch a large ball.

Children were assessed on these categories

1. Speech and language
2. Social function
3. Fine motor function
4. Gross motor function
5. Cognitive function

The scores were entered into a proforma and results tabulated

Are healthy baby contests a waste of time?

Of course things didn’t always go smoothly, but under all the levity some serious assessment work was done. We learnt from the kids. Fans and lights are passe as objects to point out - a laptop will always bring out a prompt pointing index finger. The advantages are apparent

• With a reliable scoring system, the results are easy and quick to interpret and more acceptable.
• The results can be explained scientifically
• The protocol can serve as a guideline for educating caregivers and teachers regarding simple criteria for monitoring the child’s health status. These also serve as a checklist for their activities.
• Screening of at risk children - one child screened positive for autism (prevalence rate in the literature is 1 in 110). The parents were advised the need for follow-up.
• Data obtained is used to establish local norms for child development

Healthy Baby Contests can have a positive impact on the community when conducted scientifically. Psychological development of infants and toddlers can be effectively judged through direct observation in a short time-frame.

References

1. Bhat G, Pardeshi S, Kakrani V, Pratinidhi A. Making healthy baby contests more objective. Indian J Med Sci [serial online] 2001 [cited 2012 Mar 23];55:553-8. Available from: http://www.indianjmedsci.org/text.asp?2001/55/10/553/12035
2. M.L. Kulkarni, G.L. Mohan. Healthy Baby Contests-Beyond show, Beyond Objectivity Towards Health Education Indian Pediatrics 1999; 36:417-418 http://www.indianpediatrics.net/apr1999/apr-417-418.htm

Bipolar disorder and hypomania - irritability and depression

Chronic unstable mood with irritability and superimposed bouts of depression is a common form of bipolar II disorder or hypomania. Persons with this pattern of illness tend to have an unstable course and stormy interpersonal relationships. They also have more irritable and hostile hypomanic episodes. The classical Bipolar II disorder or hypomania of mild elevation of mood, sharpened and positive thinking, and increased energy and activity levels is less disruptive.

Persons with this irritable type of hypomania and bipolar illness have unrealistically high expectactions of those with whom they interact; whether at the workplace, at home, or other casual day-to-day interactions. When these expectations are not met they pass on their irritation and negative mood to unsuspecting others.

There is usually a grain of truth in their version of the incident, but the growing number of incidents with various people at all levels reduces their credibility. At the workplace they are frequently in search of a new job and personally they have problems sustaining meaningful relationships.

Anger management alone is usually not effective. It needs to be combined with specific treatment for the bipolar illness. At the clinic couples and individuals come in for anger and interpersonal issues that are not resolved with counselling.

"I never realised how much my moods controlled my actions"

Treatment for bipolar disorder including hypomania hinges on medication and psychotherapy. Treatment requires patience by all parties in the therapy. Relapses are frequent when medication is stopped.

"I can see the difference when he stops his medication;

help me get him back, doctor"

It takes time for the affected person to accept he or she has hypomania or bipolar illness. The degree of realisation fluctuates during the course of therapy. Regular psychiatric review is essential to prevent relapse in bipolar illness and hypomania

Mental health checklists and screening tests for rampaging bus drivers

Checklists and psychological screening questionnaires for mental illness are effective, easy to use and widely available. Pune was shocked into considering the need for mental health screening of its bus drivers after one of them wilfully killed eight people and injured 32 others. He hijacked a bus at the depot and mowed down victims in broad daylight. Amidst the protests, and outrage the Pune administration has decided that all its bus driver undergo psychological testing.

We have already looked at screening of police personnel for mental health problems, and also screening of teenagers for alcohol and drug abuse. Here we specifically examine the feasibility of regularly screening the 8600 PMPL staff and Pune bus drivers for mental health problems.

Mental illness in bus drivers

• Mental health problems are higher for bus drivers who suffer from back pain, are dissatisfied with their jobs or undertake long-distance driving. This is more so for employees who have worked for >10 years. (Issever et al 2002)
• Aggressive bus drivers have more anxiety, hostility, and anger. They display competitiveness when driving aggressively, and display anger at slow drivers and traffic obstructions (Galovski 2002). Aggressive drivers with Intermittent Explosive Disorder (IED) endorse more assaultiveness and resentment. They display more impatience, hostility and have an angry temperament.
• Bus drivers have higher hospital admissions with diagnoses of mood reactions, paranoia and non-specific psychoses. (Ugesker 1989)

Ideal mental health screen

Easy to administer

it is to be conducted regularly without consuming excessive time

Culturally acceptable

anything stigmatising will be shunned

Sensitive

picks up potentially vulnerable persons

Specific

excludes those who do not have mental health problems

Easy to interpret

results should be available immediately

The aim of mental health screening is to identify individuals who require a more detailed examination. One counsellor will never be able to carry out any evaluation of 8600 staff.

Mental health checklists and screening instruments

There are already valid (test identifies persons mental illness) and reliable (results remain the same when administered by different testers and on re-testing) checklists for mental health screening. Two mental health screening instruments that satisfy many of the ideal criteria are the COOP/WONCA charts and the WHO-5 questionnaire. Both have high diagnostic accuracy for mental disorders. Specificity, sensitivity and positive predictive values range from 0.85 to 0.87 (Anything more than 0.7 is good).

COOP/WONCA

The COOP/WONCA measures six core aspects of functional status: physical fitness, feelings, daily activities, social activities, change in health and overall health through six charts. The charts have been successfully used in illiterate populations, and have guidelines for translation where required. The average time for completion is less than five minutes. One-time assessment with the COOP/WONCA Charts is a valid and feasible option for screening for mental disorders at the primary care level.

WHO-5

The WHO-Five Well-being Index (WHO-5) is a set of 5 questions that can be used when six charts are too much.

A mental health check is most acceptable as part of the regular or annual ‘health check’. Those who score above the cut-off are taken up for detailed assessment by a psychiatrist or other mental health professional. No additional man-power is required. The process will not cost in crores. Our roads will be safer.

We need to use available checklists and screening tests for early detection of mental illness in Pune’s bus drivers.

References

1. Galovski T, Blanchard EB. Psychological characteristics of aggressive drivers with and without intermittent explosive disorder. Behav Res Ther. 2002 Oct;40(10):1157-68. 
2. Issever H, Onen L, Sabuncu HH, Altunkaynak O. Personality characteristics, psychological symptoms and anxiety levels of drivers in charge of urban transportation in Istanbul. Occup Med (Lond). 2002 Sep;52(6):297-303. 
3. Joao Mazzoncini de Azevedo-Marques, MD, PhD1 and Antonio Waldo Zuardi, MD, PhD. COOP/WONCA Charts as a Screen for Mental Disorders in Primary Care.  Annals of Family Medicine 9:359-365 (2011) doi: 10.1370/afm.1267
4. C. van Weel, C. König - Zahn, F.W.M.M. Touw - Otten, N.P. Van Duijn, B. Meyboom - de Jong. Measuring functional status with the COOP/WONCA charts: a manual. Northern Centre of Health Care Research 1990. ISBN 90 72156 33 1 
5. WHO. WHO-Five Well-being Index (WHO-5) Accessed 17-Feb-2011 
6. Ugeskr Laeger. Psychiatric admissions among city bus drivers. A prospective study. Ugeskr Laeger. 1989 Jan 30;151(5):302-5. 

Dyslexia - Difficulty with Reading, Maths & Spelling

Difficulty with reading, spelling and maths is rampant among Indian students. Two recent reports have highlighted this academic underachievement. The academic infrastructure is definitely a major contributor. However, unrecognised dyslexia or other learning disability also needs to be considered by every concerned parent and enlightened teacher. We have already discussed the management of dyslexia. Here we underline the urgent need for action.

India ranked 72nd of 73 countries in a comparative international survey (PISA) of 15-year-old students. All students were assessed on the same test for knowledge and skills in reading, mathematical and scientific literacy. A sample of more than 5000 students from 200 Indian schools were assessed in this program. In none of these categories did more than 17% of Indian students scored above baseline levels as compared to 81% of students from OECD countries (US, UK, Australia etc).

15-year-olds scoring above baseline 

Test	India	China	OECD avg
Reading	11-17 %	95.3%	81%
Mathematics	12-15%	94.5%	75%
Science	11-16%	96.3%	82%

The Annual Status of Education Report (2010) paints an equally dismal picture.
Reading ability

• Only half the students in Class 5 can read the Class 2 text

Maths

• Only a third of Class 1 children can recognise numbers 1-9
• Only a third of Class 3 students can do subtraction in two digits
• Only a third of Class 5 students can do simple division
• A third of Class 8 students could not use a calender

This may be a scathing indictment of our education system, but it also reflects the presence of unrecognised Learning Disorder in our students. Learning Disorder affects 5-10% of students worldwide. Learning Disorder manifests in varying combinations and severity of difficulty with reading, spelling and arithmetic.

If your child has difficulty reading, spelling or in mathematics

• Have them assessed for dyslexia or other learning disability
• The earlier remedial teaching is instituted the more likely the child is to benefit
• Identification of dyslexia or learning disability entitles your child to waivers at the 10th and 12th board exams.

The Right of Children to Free and Compulsory Education Act (RTE) of 2009 lays down the duties of government, local authorities and parents; the responsibilities of schools and teachers; and the norms for schools. These norms include the number of teachers, buildings, minimum teaching hours, teaching aids, library, and recreational equipment. However, the teaching to be done is not mentioned and nor is it monitored. Rote learning is emphasised. Students fail to acquire basic reading, writing and calculation skills that are required to continue learning as adults.

Don't just wait for the government 

Act NOW to secure your child's place in a global future

References:

1. ASER 2010 - Rural. Annual Status of Education Report (Rural)Date of publication: January 14, 2011
2. Maurice Walker. PISA 2009 Plus Results: Performance of 15-year-olds in reading, mathematics and science for 10 additional participants. ACER Press. Victoria. 2011.  ISBN: 978-1-74286-067-1
3. The Right of Children to Free and Compulsory Education Act (RTE). 

Recovery from mental illness

Recovery to meaningful functioning after even severe mental illness is the present standard of care in mental health treatment. Recovery is made possible by medications that are now widely available at a reasonable cost. Planning and persistence with treatment need to be ensured to achieve a quality recovery.

Recovery from mental disorders is a process of change through which individuals

1. improve their health and wellness
2. live a self-directed life
3. strive to reach their full potential

The road to recovery from mental illness has four components that together give meaning to life.

1. Health

Overcoming or managing the disease and living in a physically and emotionally healthy way.

Start with the basics - medication, meals, sleep and exercise. Establishing routines for these basic health tasks are essential for recovery of function. Medication is the corner stone on which recovery is nurtured. In the absence of medication frequent relapses and recurrences disrupt basic functions that protect the individual from the illness producing effects of daily stressors.

2. Home

A stable and safe place to live.

In daily practice we see persons with the most severe mental illnesses putting aside their disturbing thoughts, controlling their behaviours and getting back to school or work; while others with a milder illness are unable to leave their preoccupations and move ahead with life. Trusting relationships are quite often what they lack. Trust makes the home feel safe.

3. Purpose

Meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and the independence, income and resources to participate in society.

A person needs something to recover to. Amazing recovery can be sustained in a supportive job environment. Some bosses give this support naturally. It may be it is in their outlook; they see the illness as just one aspect of the persons identity. Vice versa, others with good symptom recovery without stigmata are unable to function in a hostile work place, and are unable to integrate with society  and lead meaningful lives.

4. Community

Relationships and social networks that provide support, friendship, love, and hope.

From volunteering at the community bookshop to joining a local football team; community interactions bring many otherwise isolated individuals into useful contact with others. These valued interactions are based on a personal identity which is not connected to their mental illness.

Recovery is a process towards achieving ones potential. The first small steps result in giant gains. Without them the individual is unable to reach any level of meaningful recovery. The first step for persons with serious mental illness is medication. Without medication, recovery from serious mental illness is long-drawn, stigmatising, and characterised by frequent relapses. Medication is the pillar around which recovery is fostered. A supportive home, work-place and community further augments this process. Recovery from severe mental illness is a process, it does not happen overnight, but for those who stay the course it brings the meaning back to life.

References

1. SAMHSA’s Definition and Guiding Principles of Recovery – Answering the Call for Feedback
    Accessed 04-Jan-2012

Drinking and driving

Alcohol and driving don’t mix. In a flashback to Alex’s drug influenced joyride in A Clockwork Orange, a Pune youth bumped into four people at different points on his late night drive through the city. When chased and caught he was found to be under the influence of alcohol.

In this post we take a look at the effects of alcohol on driving. We have already discussed some of the long term effects that necessitate imposing legal age limits for alcohol consumption in order to mitigate its neurotoxic effects on the developing brain.

30mg% is the legal blood alcohol concentration (BAC) limit for driving. Limits are a safety requirement to counter the adverse effects of alcohol on driving ability. The 30mg% level is often panned as being too low. Most countries have settled at a 50mg% threshold, some at 20mg%, others (considered very liberal) at 80mg%. Lets take a look at the effects on driving at these various blood alcohol concentrations (CDC 2011).

---

BAC	Effect on driving
20mg%	Visual deficits (problems with tracking of a moving object), Decline in multitasking ability (talking to a passenger while driving)
50mg%	Reduced coordination, difficulty steering, increased reaction time for braking by more than a second (Siliquini 2011)
80mg%	Problems with concentration, short term memory loss, reduced information processing capacity, impaired perception

---

How long after drinking alcohol is it safe to drive?
You need to wait at least as many hours as the ‘chota pegs’ (1oz or 30ml) you consumed. Alcohol is digested by the liver. The liver has a fixed capacity to metabolise about 8gms of alcohol in an hour. This is the amount of alcohol in 30ml of whisky, vodka, rum or gin. The equivalent dose is 250ml of beer or a glass (150ml) of wine. Each of these is considered as a ‘unit’ of alcohol.  However, consuming any quantity of alcohol within 6 hours prior to driving is associated with a doubling of the risk for a road traffic accident (Di Bartolomeo 2009). This effect of alcohol is present even at intake of 1-2 units which works out to a BAC of approximately 50mg%.

Blood alcohol levels as low as 20mg% impair driving ability under test conditions in a simulator. At 50mg% the impairments more than double the risk of an accident. The present 30mg% level may be legal but it remains impairing. Better to have a ‘designated driver’ - the person who does not drink for that particular evening. In case you want to we have already studied how to refuse alcohol.

DONT drink alcohol and drive

References

1. Anthony Burgess. A Clockwork Orange. 1962. (Various publishers including Penguin)
2. CDC. http://www.cdc.gov/motorvehiclesafety/pdf/BAC-a.pdf. Accessed 15-Dec-2011.
3. Stefano Di Bartolomeo Francesca Valent, Rodolfo Sbrojavacca, Riccardo Marchetti and Fabio Barbone. A case-crossover study of alcohol consumption, meals and the risk of road traffic crashes. BMC Public Health 2009, 9:316 doi:10.1186/1471-2458-9-316
4. Roberta Siliquini, Fabrizio Bert, Francisco Alonso, Paola Berchialla, Alessandra Colombo, Axel Druart, Marcin Kedzia, Valeria Siliquini, Daniel Vankov, Anita Villerusa, Lamberto Manzoli and TEN-D Group (TEN-D by Night Group). Correlation between driving-related skill and alcohol use in young-adults from six European countries: the TEN-D by Night Project. BMC Public Health 2011, 11:526 doi:10.1186/1471-2458-11-526.

Hope for dementia caregivers - ARDSI Conference Pune 2011

Training for caregivers of persons with Alzheimer's disease helps address the distressing behaviours that arise in the affected person. Caregiver training also promotes wellness in caregivers by giving them the skills to  handle the relentless stress. Unfortunately most caregivers are unaware of the need or the availability of resources. The Alzheimer’s and Related Disorders Society of India (ARDSI) held its 16th conference in Nov 2011 at Pune. This significant event marked Pune’s arrival on the national dementia caregiver stage. Pune is now the 16th Indian city with an ARDSI chapter of its own. How does this help people with dementia (PwD) and their caregivers? The ARDSI Pune chapter “develops, coordinates and renders services in the field of dementia care, support, and training”.

The training aspect is particularly interesting. Conversations with caregivers at the clinic usually swing around to the day-to-day nitty-gritty of dealing with dementia, the impaired activities of daily living (ADLs) - keeping the person engaged, getting them to bathe, preventing them from wandering. Members of other fully functioning chapters whom I met at the conference animatedly discussed the caregiver training workshops and courses they held on a regular basis. These local courses are exactly what the doctor ordered - education for understanding and hands-on caregiver training.

The Dementia India Report 2010 was extensively quoted by many of the conference speakers. This document has dementia related statistics specifically for India and its states, and is an essential resource to leverage for obtain funds for dementia related activities. It also has details of services available for people with dementia - unfortunately data on support groups is as yet not available.

Caregiver training is a thrust area in dementia management. The 10/66 Dementia Research Group has developed a training package with a set of manuals, detailed instructions and a training video for caregivers and caregiver training. These are available for anyone to download after providing an email id. They provide a template that can be used by any individual or organisation involved in caring for persons with dementia.

The ARDSI conducts two geriatric care training courses; a six month certificate course and a one year post-graduate diploma course at its centre in Cochin. The number of persons with dementia in India is assessed to be 3.7 million in 2010. The ARDSI and similar courses will provide a pool of trained workers to care for the needs of people with dementia and their caregivers. This pool of personnel is not just on paper. The conference was over-booked. Extra seating had to be provided to accommodate the 100+ last minute attendees in the 400 seater main auditorium. Most of them were trainee social workers entering the field in time to meet the growing demand for their services.

References

1. 10/66 Dementia Research Group. Resources for caregivers and caregiver trainers. 
2. Alzheimer’s and Related Disorders Society of India (2010). The Dementia India Report: prevalence, impact, costs and services for Dementia. (Eds) Shaji KS, Jotheeswaran AT, Girish N, Srikala Bharath, Amit Dias, Meera Pattabiraman and Mathew Varghese. ARDSI, New Delhi. ISBN: 978-81-920341-0-2 

Talk - not TV - for your toddler

Turn off the television and speak to your toddler. Talking is the best thing you could do today for your child’s psychological development. Talking is an interactive process in which your child exercises a core feature of being human - communicating through speech. Your child's vocabulary is directly proportional to the amount of time you spend talking.

Talking primes your child for independence. Speech evolves through attempts to communicate needs and feelings. Infants and toddlers are driven by evolution to master this complex process. You, the parent, play a key role in this two-way interaction. Infancy and toddler-hood are stages for developing secure bonding and attachment. The child is primed to bond with the mother or caregiver. The initial bond is secured by direct contact with the caregiver - through warmth, touch and voice. A secure attachment bond enables the infant seeks to explore the environment by attempts to crawl and later walk. The exploring toddler returns often to the parent to re-experience attachment security. It is here that talking plays a crucial role in maintaining the attachment bond at a distance. The child is then able to explore the environment away from direct contact with the parent.

Your one-year-old is psychologically unable to follow or learn from video. Some parents are convinced that certain TV channels are ‘educational’ for their toddler. The ability to comprehend video arises between 18 to 24 months of age (Pempek 2010). Prior to 2 years of age TV has little or no educational impact on the child, whatever the claims by media groups vying for their ‘eyeballs’. TV programming meant for 2-year-olds delays language and vocabulary development (AAP 2011, Zimmerman 2007).

Television is not a substitute for parenting. Parents leave the TV on to distract the child while they are engaged otherwise. Television holds the toddlers attention through its series of changing visual stimuli. This visual stimulus is powerful and distracting. While interacting with parents with the TV on in the background, the toddler is forced to shift attention to the TV once every 20 seconds. Even in adolescents, background TV adversely affects mental processing, memory and comprehension. Having the TV always on in the toddlers home interferes with unstructured play time that is critical to developing problem-solving skills and creativity. Repeated research has shown no developmental benefits for television exposure in infancy (Schmidt 2009, ).

Talk to and play with your children. Television is a medium that encourages passivity. TV delays vocabulary growth and language development in toddlers. Turn off the TV.

References

1. Academy of Pediatrics. Policy Statement. Media Use by Children Younger Than 2 Years. Council on Communications and Media. PEDIATRICS Vol. 128 No. 5November 1, 2011. pp. 1040 -1045 (doi: 10.1542/peds.2011-1753)
2. Pempek TA, Kirkorian HL, Richards JE, Anderson DR, Lund AF, Stevens M. Video comprehensibility and attention in very young children. Dev Psychol. 2010 Sep;46(5):1283-93. 
3. Schmidt ME, Rich M, Rifas-Shiman SL, Oken E, Taveras EM. Television viewing in infancy and child cognition at 3 years of age in a US cohort. Pediatrics. 2009 Mar;123(3):e370-5. 
4. Zimmerman FJ, Christakis DA, Meltzoff AN. Associations between media viewing and language development in children under age 2 years. J Pediatr. 2007 Oct;151(4):364-8. Epub 2007 Aug 7. 

Diet and mental health

Mental health and diet quality are closely linked. The food choices you made as a teenager affect the development of conduct and emotional problems that continue into adulthood. Lifestyle diseases such as heart disease, diabetes and obesity are attributed to changes in diet and exercise habits. Recently there is increasing evidence that diet and exercise also have a major influence on mental health. Dieting peaks after the festival season. This post will help you avoid the 'isms' and fads and point you in the direction indicated by current research.

A good quality diet predicts better mental health

Evaluating the quality of the complete diet provides a better and more consistent picture of nutrition status than focusing on individual nutrients like magnesium or food groups like various fatty acids (omega, polyunsaturated). A traditional diet of vegetables, fruit, meat, fish, and whole grains is associated with lower risk for depression and for anxiety disorders as compared to a "western" diet of processed or fried foods, refined grains, sugary products, and beer (Jacka 2010).

Switching to a high quality diet improves mental health

Switching to a healthy diet improves mental health. Unhealthy diets are associated with lower scores on mental health tests. The best part is that improvements in diet quality are mirrored by improvements in mental health (Jacka 2011). Also the reverse, when diet quality deteriorates psychological functioning is adversely affected.

What constitutes a high quality diet?

The quality of diet is assessed using food frequency questionnaires. Points are allotted for each type and frequency of food consumed. For example one point is allotted for each of at least two fruit servings per day, at least four vegetable servings per day; using reduced fat or skimmed milk, using soy milk, consuming at least 500mL of milk per day; using high fibre, wholemeal, rye or multigrain breads; having at least four slices of bread per day; using polyunsaturated or monounsaturated spreads or no fat spread; having one or two eggs per week, using cottage cheese, using low fat cheese. Out of a maximum possible score of 74, the average is about 33.0 (+9.0).You can get some idea of your diet quality score from this chart (Collins 2008).

Preventive psychiatry

Improving diet quality improves mental health outcomes. Especially for adolescents this is an important preventive intervention. Three quarters of all long term psychiatric illness manifest during adolescence and early adulthood (Kessler 2005) . These illness are among the most disabling. They occur with a high enough frequency to contribute a major portion of life years lost due to disability. Mental health illnesses cause long-term problems at work and at home. They usually persist over the lifetime and require medication and support at various stages. Adopting a high quality diet is an important primary preventive intervention for improved mental health - easy to implement and proven to be effective.

References

1. Collins CE, Young AF, Hodge A (2008). Diet quality is associated with higher nutrient intake and self-rated health in mid-aged women. J Am Coll Nutr 27: 146–157.
2. Jacka FN, Pasco JA, Mykletun A, Williams LJ, Hodge AM, O'Reilly SL, Nicholson GC, Kotowicz MA, Berk M. Association of Western and traditional diets with depression and anxiety in women. Am J Psychiatry. 2010 Mar;167(3):305-11. Epub 2010 Jan 4.
3. Jacka FN, Kremer PJ, Berk M, de Silva-Sanigorski AM, Moodie M, Leslie ER, Pasco JA, Swinburn BA.A prospective study of diet quality and mental health in adolescents. PLoS One. 2011;6(9):e24805. Epub 2011 Sep 21.
4. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, et al. (2005) Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62: 593–602.