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Professional Articles

Screenagers : Coping with the Intrusion of Tech into Everyday Life
Event Summary
By Mary Mulvihill

The May 13th  local showing of “Screenagers”, a new documentary on teen screen use, by pediatrician, Dr. Delaney Ruston, Seattle, was sponsored by Hannah’s House, a local non-profit. Hannah’s House serves dual custody  and high conflict families, often referred by family court for mandated treatment. Complex  co-parenting issues arise during these protracted custody battles. Susan Griffin LMFT, Director, put together the screenings (morning session for professional CEU’s and afternoon session for parents). CAMFT, San Diego Chapter and  San Diego Psychological Association were co-sponsors. After viewing the film, subject matter experts presented on their respective specialty areas, followed by a panel discussion.
 
Angie Coulter LMFT, MT-BC & Mark Rosenberg BCBA MFTI, personable young family therapists, presented  how they address the common  digital dilemmas in their Encinitas-based private practices and their work with charter schools.  They reviewed signs of screen addiction, including their impact on learning and provided excellent behavioral strategies to moderate screen use. Aggressive counter reactions are sometimes seen when device access is restricted. An interesting sub-group is teens on the autistic spectrum, who are drawn to  digital devices to cope with social awkwardness and where parents often appreciate the  peace and containment that comes from teens becoming absorbed in digital devices or games. There are many things parents can do, form being a good role model to providing alternate recreational activities. Mark & Angie provided down to earth advice about managing this issue within the family system
 
Mary Mulvihill Ph.D., Health Psychologist and  a Professor in the Graduate School of Public Health at SDSU, brought a public health approach, using the example of distracted driving, which is often modeled by parents, and picked up easily by teens without timely, thoughtful intervention. She presented a 5 Step Habit Breaker Intervention protocol, that is simple, specific yet flexible,  that can help break a bad habit. Based on operant behavior theory, this brief, 10-14 day protocol uses observations, education & goal setting, cue alteration, reinforcement and/or punishment, & coaching to rewire the brain and form a new  digital habit.  This protocol can be used in private practice with guidance from the therapist to promote behavior change or in a school setting. Changing one digital behavior, like distracted driving,  often generalizes to other digital behaviors (distracted walking, studying interference, bedtime social media, etc.), which can then, in turn, be focused on specifically to reduce screen exposure overall. Driver’s training or even before are the ideal time to instill safe driving behavior, which is not currently targeted by schools in the same way as, for example, drunk driving.
 
Ethan Marcus J. D., CFLS,  an expert in Family  Law (and former stand-up comedian), brought  in the legal perspective for families trying to work out custody arrangements in family court. Since the portion of assets assigned to the children are prorated to each parent depending on how much custodial time they have,  an adversarial element  can easily be activated. During family dissolution, often there is maladaptive mourning, which manifests in high conflict and other troublesome child or parent behaviors.  Kids who vent their feelings on social media, may find their posted comments used by counsel in court proceedings. Attorneys have to educate judges, one by one,  about what environmental supports, including digital device rules, are healthy for the child. Adherence to these can then form a basis for the court awarding more or less custodial time and financial resources to a particular parent. Digital device access is a new, potentially important area for the court to consider.
 
Panel Discussion: Moderator Susan Griffin LMFT, co-parenting expert,  brought up the importance of parental engagement in their children’s digital use, and a need for clinicians to assess that use. Important information can be gained about what is happening and affecting the child’s welfare. For example,  a case where a divorced father, anxious about losing connection to  his children, was found to be texting his daughter up to 80 times during the school day. There was a consensus that very often parents do not know what their children are really consuming online, and how important it is for them to become engaged in finding out.
 
Especially important is to maintain parent access to digital devices by knowing the passwords, so they can be accessed if needed. A school psychologist brought up a recent threat assessment involving a 5th grade girl, where the parents were not aware of her worrisome online communications, and deeply shocked to see them. Angie Coulter LMFT mentioned the potential utility of tracking apps for parents as an option. She reminded us that often parents are also unaware of cyberbullying that may be going on, which is distressing to their child.
 
Dr. Mulvihill clarified in response to a query the risk of hands free phone use while driving (as high as drunk driving, but lower than texting &driving) vs. talking to a passenger, listening to music or podcasts (all lower than hands free phone use and not thought to present a problem). Hands free and hands on use have a similar risk, both causing significant “inattention blindness”) – loss of automatic side to side visual scanning due to cognitive interference from the phone conversation. Visual perception of peripheral hazards is lost, which is extremely hazardous.
 
There was considerable interest in how  Mark Rosenberg LMFTI & Angie Coulter LMFT negotiate and implement parent-child behavioral contracts as one approach, which needs to be done with youth input, family discussion and good timing.  They noted that often parent’s also have a “screen addiction” issue, poignantly shown by a young child describing conversing with a parent on their device. Parents can get immersed  and  neglect kids, so they need to look at their own screen behavior, as well as their children’s screen behavior.
 
The Problematic and Risky Internet Use Screening Scale (PRIUSS) assessment tool for assessing screen use in an office setting was recommended. Susan Griffin LMFT also felt that some addiction measures, which could be modified for “process” addictions might be useful and appropriate. It was discussed that engaging with parents and teens to review phone content during sessions might be useful in some situations but this raises questions for informed consent (including office forms) and client privacy, which would need to be addressed.
 
A participant brought up a need to find a new discourse about digital devices, so it was not framed as an adversarial parent-child (or student/teacher situation) issue. A language with which to talk about this issue is still developing.
 
There was a concern raised about the teen drama series, 13 Reasons Why.  Dr. Mulvihill stressed the importance of watching shows with teens, or even playing their video games with them to see what they experience. This may open up discussion and be important training in media literacy, a  useful  skill, given the volume and intensity  of media, that must typically be digested by today’s youth. Guidance and support from engaged adults is needed.
 
 She also brought up the importance of clinician/parent awareness of viewing and  social media sharing of porn, particularly among ever younger boys (typically starts ages 9-11). The potential adverse impact on  brain circuitry for sexual functioning with porn overexposure is notable (violence, misogynistic images also detrimental). Erectile dysfunction in healthy youth men may result after frequent, prolonged porn consumption. This has become epidemic.
 
Note: Sexting was discussed informally after the event, with several participants sharing problematic examples. In the recent CICAMH Children’s Mental Health Conference, sex educator Dr. Janet  Rosenzweig discussed the widespread sharing of naked pictures among teens (the new “third base”) as the “new normal”, unwise though it may be in terms of consequences. Kids whose photos are shared without permission or posted online, endure betrayal, shaming, social ostracism, and regrettably, may have low support from shocked, angry parents or adults when they need it most.
 
The panel wrapped up with a request for comments from the sparse group of  professional attendees about why they thought only 10 professionals (vs. 60 parents) signed up for the  Screenagers event. It was felt that parents see the effects of screen overuse and must deal with these behaviors on a daily basis, while clinicians have to ask about it to even know what is going on. With the exception  of obvious sleep disruption, digital device overuse may not be on most clinician’s radar yet, as far as the importance to children’s well-being (sleep habits, study habits, social skills development, process addiction, etc.). The consensus was that digital device overuse is an important, new area,  not yet commonly viewed as part of the clinical domain until very problematic. Future trainings need to continue,  participants thought,  as technology evolves, affecting all of us  - clients  & therapists, every day in so many ways.
 
Overall, it was a stimulating and thought  provoking discussion about an emerging issue in clinical practice. Stay tuned for future CE trainings and public education events on this timely topic!
 
Thanks to Susan Griffin, LMFT, and her staff at Hannah’s House for planning & leading this interesting event!

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PROFESSIONAL ARTICLES
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SDPA (SAN DIEGO PSYCHOLOGICAL ASSOCIATION) CMHC (COMMUNITY MENTAL HEALTH COMMITTEE) REPORT ON THE SAN DIEGO COUNTY ADULT BEHAVIORAL HEALTH SYSTEMS OF CARE COUNCIL
 
By Don Miller, Ph.D.
I am the San Diego psychological Association Fee for Service representative to the adult council (Adult Behavioral Health System of Care Council) appointed by the SDPA Community Mental Health Committee. The MHSA (Mental Health Services Act) of San Diego County Behavioral Health Services budget for the coming fiscal year is 1.9 billion dollars. The purpose of the San Diego County HHSA (Health and Human Services Agency) Adult Behavioral Health Systems Of Care Council (ABHSOC or Adult Council) is to help facilitate the design and implementation of the adult system of care by providing feedback and recommendations to the Mental Health Director, Alfredo Aguirre, LCSW. The Behavioral Health Services’ role in the implementation of Live Well San Diego is to assure healthy communities by providing an array of state-of-the-art behavioral health services to children, youth, families, young adults, adults and older adults. Since the launch of Live Well San Diego, Mental Health Services Act (MHSA) funds have been leveraged within the behavioral health system to advance the integration of coordinated and seamless care for patients with substance abuse, mental health and physical needs through a paired provider model. The scope of behavioral health services and program in San Diego County is mind boggling with, as noted, a 1.9 billion dollar budget. Live Well San Diego is an innovative 10-year initiative that embodies the Health and Human Services Agency’s effort to achieve the County vision for healthy, safe and thriving communities. The initiative aims to advance the overall wellbeing of the entire community. Visit www.sandiego.camhsa.org To view the complete MHSA program for San Diego County. On their website, click the links on the left for detailed information about each of the MHSA program components.
 
At the 3/13/2017 Adult Council meeting Alfredo Aguirre, LCSW, Directors Behavioral Health Services, gave the Director‘s report: He noted that as new proposals are rolled out regarding the attempt to exchange ACA/Obamacare with some alternate plan, at its present stage of the plan, if implemented, ten to twenty-two million people in the U.S. will lose their insurance coverage and the costs to subscribe to whatever new health care plan exists, may go up. Many agencies are opposing the initial health care proposals, including the American Medical Association, the American Psychiatric Association, NAMI (National Alliance on Mental Illness)  etc. The Conservative component of Trump backers are also displeased with the new proposals, calling them “Obama-light,” wanting to reduce benefits even further. A cap on Medicaid could have rippling effects. Two-hundred-thousand (200,000) single adults are enrolled in ACA/Obamacare in San Diego County. Before ACA the single adults covered under ACA in San Diego County, for the most part, had no coverage and will lose their coverage if the rollback happens. Many homeless individuals in San Diego County are also accessing medical care in San Diego through the ACA. Though they are homeless, they have been receiving treatment for various medical conditions. Homelessness is a high risk life style and at least accessing medical care cuts the risk to some degree as untreated medical conditions have resulted in an increased mortality rate in the homeless population. There was CMS (County Medical Services) which was hard to get and keep and with ACA the CMS enrollment dropped to 100. If ACA is rolled back, CMS will have to pick up the slack.
 
 Exciting things are happening at the Community Mental Health Committee and the committee is accepting new members. There are representative positions to fill. The CMHC keeps track of mental health trends and activities in San Diego County and recommends action to the SDPSA board when necessary. Contact CMHC Chairman Dr. Steve Tess at 619-579-9346 for meeting times.
 
The 2nd Annual Critical Issues in Child & Adolescent Mental Health Conference Review
By Mary Mulvihill


The 2nd Annual: Critical Issues in Child & Adolescent Mental Health Conference (CICAMH), held Saturday, March 11 at Crowne Plaza Hotel was a huge success!
 
There were 400 attendees, 20 exhibitors (including SDPA) and a mental health bookstore on site. An art exhibit by ARTS: A Reason to Survive, was featured. The venue was pleasant and spacious.  The program was informative, uplifting and inspirational.

Program highlights:
  • Opening: Conference Chair, Jeff Rowe MD. welcomed Nick Macchione, Director, HHSA, San Diego County, the key conference sponsor, for introductory remarks.
The program began with an amazing original poem by National Student Poet, Maya Salameh, a San Diego International Baccalaureate high school student. She is a local treasure!
 
Featured Speakers:
  • Lisa Boesky Ph.D. , troubled teen expert, reviewed the challenges of suicide assessment in children & teens.  Rates are rising, especially among Latino kids and girls 10-14 years old. From risk factors to trust/communication challenges to the sheer unpredictability of kid’s behavior, it’s an area fraught with difficulty. Self-injury is now thought of as an additional risk factor.
From her perspective as an expert witness in post-suicide lawsuits, Dr. Boesky emphasized the importance of good clinical care, strong documentation and proof of recent, frequent suicide intervention training as the best liability protection for clinicians.  Many residential and juvenile justice facilities are lacking in both clinical care and staff training. for suicidal youth, she noted.
  • Kara Bagat M.D., UCSD Dept of Psychiatry, reviewed the recent stats on teen substance use (widespread, with vaping and hookah on the rise in high school). She described her research on the detrimental effect of regular cannabis use on youth mental health problems, especially psychotic disorders outcome.  Treatment research overwhelmingly favors family treatment, which varies in intensity and effectiveness. Kids also need to learn different coping skills for their life challenges as a key part of effective treatment and relapse prevention.
  • Youth Panel: Maya Salameh & 2 friends (coached by Jeff Rowe, MD, Conference Chair) from the San Diego International Baccalaureate High School. This was a terrific testament to the power of kids to use their perspective and creativity to think outside the box about teen problems. They were impressively smart, achingly honest and very funny with their quips and candor. They charmed the audience, adding tremendous positive energy to the day. The teen panel received a standing ovation from the impressed & delighted attendees.
?Casual Networking Buffet Lunch: The morning gave us lots to think about as well as, many new friends & colleagues were introduced. Lots of people came back from last years’ inaugural event, nice to see a community building on behalf of preventing kid’s mental health problems.
  • Janet Rosenzweig Ph.D. , child welfare advocate and sex educator (author How to Talk to Your Child About Sex), was dynamic in motivating attendees about the importance  of talking to kids about sex using accurate information and personal/family values.  Due to widespread consumption of contemporary porn, which tends to be violent and degrade women, corrective input is needed from influential guides. Girls, especially, need accurate information about sexual arousal, so they don’t confuse autonomic response with love, increasing risk for predatory seduction. 
Sharing of naked photos is becoming a part of normative sexual development in teens (the new “third base”), so adults must adjust. They need to be ready to support kids experiencing social humiliation, shunning, or bullying after a sexual mistake made public or an over sharing incident. Sexting prevention allows parents an opening to talk about their sexual values and lay out likely consequences for kids, so they are equipped to make good decisions in the moment.  Parents who went through limited “abstinence only” sex education may not be well equipped themselves to provide information for kids, so they may need information, assistance and moral support.
 
  • Cecil Steppe, President San Diego Urban League, Board Chair: Gompers Secondary School, talked about the long history of school inequality in SE San Diego, serving  low income kids of color.  He outlined the destructive effects of well-intentioned “top down” efforts, such as school busing (depleting the community of  its best students & role models, precluding extra- curricular activities) and making the local school a magnet school (influx of white students while local kids could not qualify for the program and were literally fenced off from the other kids). 
 
Creating a charter school run by local parents and teachers in collaboration with UCSD (Cecil Lytle Ph.D., former provost of Thurgood Marshall College, Bud Meehan Ph.D., former Professor of Sociology) has been an alternative model established after a long process of often contentious community activism/organization. Gompers School (grades 7-12, a community experiment, is a high quality, college prep environment that teaches respect, achievement and is values based. The current (4th) graduating class has 115 students. More special needs kids attend Gompers than any other school (14%), and many kids have been traumatized, given their environment.  Every day, students enter the “Gates of Wisdom”, greeted by staff with breakfast and are given a similar send off as they leave.  Spirit is high.
 
Students asked for some night classes since they live in environments not conducive to studying. On these nights, teachers drive them home, so they don’t walk through gang territory at night. Even gang members express respect for the Gompers daily uniform of suit & tie. Apparently, they often encourage the Gompers kids to make something of themselves while they have the chance - a chance they wish they might have had at their age.
 
This school boasts a 100% graduation rate, 70% of students get into colleges, 14% to UC schools. The first wave of UC graduates is arriving back into the community to strengthen and inspire others.  Despite a myriad of barriers, they are finding and nurturing local talent in staff & students.
 
Mr. Steppe, age 84, (sharp as a tack!), received a prolonged standing ovation in recognition of this work at Gompers on behalf of  “all our kids – kids belong to the community”, he says, “we are all responsible for them “  -  and his lifetime of community activism.
 
  • Tasreen Khamisa & Benita Page, Tariq Khamisa Foundation described the genesis of TKF’s work for violence prevention as the murder of Tariq, Tasreen’s brother, followed by her father’s outreach to the 14 year old shooter, Tony Hicks and his grandfather/guardian. Starting with this remarkable act of forgiveness and empathy for the life difficulties of the young shooter, the family wanted to work to reduce the seeds of community violence, as a good deed done in Tariq’s name, which birthed the foundation.
TKF Foundation has developed and implemented a well-received, effective curriculum teaching conflict resolution, mindfulness and a path of forgiveness to peace in 21 “at risk” middle schools in San Diego over the last 20 years. The training teaches kids how to go through the attitudinal and behavioral steps of forgiveness. The program also mentors problem kids referred by teachers for frequent disciplinary problems one to one. The program has been shown to reduce fights, truancy & suspensions.
 
The TKF program offers the schools a new approach using restorative justice practices (healing for the wounded offender along with consequences for their misguided actions, including apologies and making amends to heal the victim & school community). Tasreen ended with describing her family’s efforts to support Tony in prison and now, after 20 years incarcerated, in preparing for his first parole hearing. They hope to get him released in 2018.
 
Tasreen & Benita received the third standing ovation of the day! People seemed deeply touched by the heartfelt commitment & valuable work of this foundation which arose from a tragic loss.
 
Finale: San Diego Children’s Choir. The conference wrapped up with a brief but spectacular performance by the Girls Concert Choir of the San Diego Children’s Choir. The 45 tween girls in their red jackets were adorable. They sang beautifully. This terrific musical performance ended the day on a high note, with thunderous applause, hoots & whistles. Bravo!
 
Overall, it was a wonderful day!
 
Didn’t make it this year?  Join us next year – Save the Date:  March 9 & 10, 2018.
 
This event was sponsored by SD County Health & Human Services and collaboratively planned by representatives from HHS, the San Diego Academy of Child Psychiatrists, San Diego Psychiatric Society, CAMFT: San Diego Chapter, & San Diego Psychological Association – itself a remarkable and all too rare example of different professions in San Diego working together for the benefit of kids.  
 
(SDPA Planning Committee members : Annette Conway, Katherine Quinn, Ellen Colangelo, & Mary Mulvihill)