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Rebecca Resnik, PsyD  
Female
Bethesda, MD

Specialties: ADHD, dyslexia, developmental delays

Interests: Developmental Disabilities
MindWell Clinical Psychology
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Adult ADHD: A Common Source of Treatable Problems

Jul 15, 2009 - 6 comments
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Adult ADHD

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ADHD

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psychological testing

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Psychological Assessment



Adult ADHD: A Common Source of Treatable Problems

Attention Deficit Hyperactivity Disorder has generally been considered largely a disability of childhood, one that many people expect to leave behind as they grow to adulthood. Most of us think of ADHD as primarily a child’s problem that interferes with progress at school. We often picture hyperactive little boys with behavior problems. However, when an adult has trouble doing all the things he or she needs to get done at home, work, and in educational settings, doctors do not always consider that the culprit could be ADHD. Recent research suggests that as many as 3-5% of adults have ADHD. That could mean that up to 5 out of every hundred adults struggle with underachievement and frustration due to a very treatable disorder. This is a significant number of people, particularly when you consider that ADHD runs in families. This rate would mean that ADHD among the most common mental health disorders in adults. The research suggests that more adults have ADHD than have schizophrenia, bipolar disorder, and many other well known mental health problems (though depression remains more common).

As Dr. Larry Silver so eloquently described it, ADHD is not just a learning disability; it is a ‘life disability.’ The problems associated with ADHD do not just occur in the classroom or during childhood. In a recent online panel discussion lead by Dr. David Goodman*, researchers emphasized that the same symptoms we recognize in childhood ADHD also occur in adults. These same childhood symptoms take on different forms in adults with ADHD. For example, most adults with ADHD are not floridly hyperactive. Instead, an adult is more likely to report ‘inner restlessness’ or problems with impulsivity. Symptoms of ADHD impact important adult tasks such as remembering to pay the mortgage, paying attention while driving, or managing your children’s schedules. Studies have shown that people with ADHD have higher rates of underachievement, car accidents, career setbacks, and substance use. Adults with ADHD have significant problems functioning in their daily lives. These problems can ‘snowball’ as individuals take on increasing responsibility throughout adulthood, such as raising a family or being promoted at work.

Dr. Russell Barkley has written about the ‘core deficits’ of ADHD. The deficits most likely to be seen in adults include: problems with working memory, impulsivity, distractibility, trouble persisting through challenges, and trouble organization and planning. While these deficits may not sound serious on paper, they are a very big deal to those with the disability and their families. Because ADHD can be successfully treated, it is important to obtain an accurate diagnosis.

The adults I have seen who have ADHD report frustration with their lives. They often describe the sense that they are capable of doing more, but can not do what needs to be done to achieve their goals. Many adults with ADHD, particularly women, have other mental health problems related to their ADHD symptoms. As is the case with children who have ADHD, adults with ADHD are at higher risk for anxiety or depression. Because ADHD runs in families, coping with a child who has ADHD may be particularly difficult for a parent with the same disability. The relatively high rates of anxiety and depression are not surprising when you consider the unpleasant consequences of living with the symptoms of ADHD. Dr. Russell Barkley has reported on findings that adults with ADHD have higher rates of car accidents and driving violations than the general population. College students with ADHD are less likely to meet their educational goals, and more likely to underperform in the workforce. The impulsivity associated with ADHD can lead to unwise choices about sexual behavior, relationships, spending, or risk taking.

It is also common for individuals to be diagnosed later in life than we used to expect. Many people do not seek assessment or treatment until they are adults, when problems have become intolerable. Just because symptoms of ADHD could be kept at bay for years does not mean that the disorder is not present. Many bright individuals develop ways of compensating for their disabilities. I have tested adults and older adolescents who managed to hide their disability by never having to study, or charming their teachers or bosses into giving them leeway. Adults with ADHD typically find jobs that allow them to keep active, such as being a paramedic or artist. They may also seek out environments that are very supportive, or rely on loved ones to manage the organizational details of life (like filing the taxes on time). The key is that the symptoms of ADHD were always there, even if it took until adulthood for those symptoms to have a serious impact on a person’s success and happiness. If a person has a longstanding pattern of symptoms associated with ADHD, it is an excellent idea to seek assessment.

At this time, ADHD is diagnosed by assessing symptoms. Psychologists and neuropsychologists use tests to formally measure a person’s ability to pay attention, sustain focus, work efficiently, and be strategic. It is important for the diagnosing clinician, be it a psychologist, psychiatrist, or general practitioner, to gather data as part of the assessment. Symptoms of ADHD can also be caused by other mental health disorders, such as depression or anxiety, or even medical conditions. Many problems can superficially resemble ADHD. The doctor should be careful to consider other mental health disorders as well as ADHD, given the high frequency of ADHD occurring with other mental health problems such as anxiety. If you can not access a psychologist or psychiatrist, you may wish to complete a reliable, empirically-validated rating scale and bring it to your next doctor’s appointment to help your doctor determine your diagnosis. The Harvard School of Medicine has provided the World Health Organization’s Adult ADHD Self Report Scale online. It can be downloaded at:   http://www.hcp.med.harvard.edu/ncs/ftpdir/adhd/18%20Question%20ADHD-ASRS-v1-1.pdf

The good news about adult ADHD is that it is a disorder that typically responds well to treatment. A ‘multi-modal’ approach is often recommended, meaning that treatment includes both medication and psychotherapy combined. Stimulant medications or alternatives (e.g. Atomoxetine is a non-stimulant medication used to manage symptoms of ADHD) are considered among the safest of psychotropic medications. Side effects are common, yet a skilled prescriber can adjust the dose, choice of medication or how the medication is released to maximize patient comfort. In addition to medication, psychotherapy is invaluable in helping people overcome the problems that ADHD has caused in their lives. Psychotherapy can assist adults with ADHD in developing better habits, managing their mood, and improving important relationships. Obtaining an accurate diagnosis is an important first step towards improving quality of life for both the adult with ADHD and the people count on him or her.

To learn more:

Dr. Russell Barkley's ADHD report is an excellent resource for keeping up to date with the state of the art in ADHD, http://www.russellbarkley.org/clinical-newsletter.htm (also see www.russellbarkley.com)
ADHD in Adults: What the Science Says by Dr. Russell Barkley

Children and Adults with Attention Deficit Hyperactivity Disorder www.chadd.org

National Institute of Mental Health Information Page: http://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml

Dr. Larry Silver’s Advice to Parents on ADHD by Dr. Larry Silver

*June 2009, Medscape CME, Psychiatry and Mental Health, Dr. David Goodman, Dr. Anthony Rostan, Dr. Richard Weisler discuss: Adult ADHD and the DSMV, www.medscape.com    (This wonderful online training video lead me to the Harvard Medical School's posting of the ASRS, for which I am very grateful)





Spanking

Jun 29, 2009 - 43 comments
Tags:

punishment

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aggressiveness

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child behavior

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Spanking

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Parenting

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Discipline



Spanking

Once again, people are talking about spanking and physical punishments. This time, thanks to the reality television program “John and Kate Plus Eight.” I have not watched the show, so I am not writing about that family and their parenting practices. However, I am always glad to see people talking about parenting. A lot of parents wonder about spanking. All of us who care for children need to think about how we feel about spanking and other physical means of punishment. Spanking, especially among parents of young children, is still very common. There is no topic related to parenting that stirs up such intense controversy as spanking. Want to turn that friendly parenting-group potluck into a war zone? Just start loudly voicing your opinion on spanking. It seems that the more it is discussed, the more people become entrenched in their positions—everything from spanking is absolutely necessary, to spanking is needed sometimes, to spanking is always wrong no matter what.

No one enjoys spanking a child. Remember that moment you first held your child in your arms? No parent has ever spent that moment looking forward to a time when they would want to hurt that little person. Yet everyone who already has children knows that a child’s behaviors can create most intense frustration we have ever experienced. Those times happen for all of us, and we owe it to ourselves and our children to think in advance about we will respond. My goal in writing is to send a hopeful message-- that you can raise wonderfully behaved children without spanking, and to describe why it is a good idea to avoid it.

Of all the things we do for our children, discipline is one of the most important. Children desperately need limits and consequences. Taking the time and effort to discipline thoughtfully is a great act of love. But many people do not know that discipline and punishment are not the same thing. Discipline is teaching children to choose to do what is right, instead of what is easy or feels good. It includes all of our methods for teaching them control their own behavior. The goal of discipline is to teach children to become people of good character, not just to make them submit to our authority.

Punishment is different. Punishment is a specific act done to create unpleasant consequences (such as physical pain, shame, or discomfort in the case of spanking). The goal of punishment is to reduce or eliminate an undesirable behavior. Spanking is a form of punishment. Many people do not know that you can be a very effective disciplinarian without ever using harsh punishments or spanking.

This posting is organized as a discussion of arguments I hear in favor of spanking and physical punishment. The information below reflects scientific evidence about parenting and child development, my clinical experience as a psychologist, my work as a special educator, and undeniably my experiences as both a mother and daughter.*

1. “Spanking is the only thing that really works!”  
Many people who spank do it because they believe it is an effective tool for improving child behavior. Parents are surprised to find that this is actually not true. When scientists have compared spanking to other methods of changing behavior, they have found that spanking is actually not very effective. Scientists who study spanking have learned that parents believe spanking works because it often stops the unwanted behavior ‘right then and there.’ This sounds great; however, the important thing to know is that while spanking stops the behavior for the moment, it generally makes the problems worse. I liken spanking to scratching poison ivy. Spanking, like scratching poison ivy, does bring a moment of relief. Yet as anyone who has had poison ivy will tell you, the more you scratch it, the worse it gets. Spanking does little to eliminate or reduce problem behavior over time. Spanking does not teach the child to engage in better behaviors, it merely stops the behavior for the moment. Unfortunately, the unwanted behavior is very likely to return, and then it becomes harder to stop.

Scientists have been studying spanking for decades. Results across studies show that spanking and use of harsh punishments increases children’s level of aggression. Children who are spanked tend to become more defiant in response. This is not surprising. When a parent hits a child, she teaches him that it is ok to hit someone weaker than yourself as long as you feel you have a good enough reason. Children who are spanked are more likely to be physically aggressive towards others, including little brothers and sisters, teachers, friends, family pets, and even their parents. Psychologists others who work with children know that it is all too common for children and teens to hit their parents. Children who are hit learn to hit back, and they grow bigger and stronger each day.

In addition, just as with most punishments, children who are spanked get used to being spanked. It loses its effect. Over time, it can take more and more spanking (or spanking harder) to get the child to comply. Unfortunately, many parents find themselves rapidly depending on spanking once they start. They find that their kids are harder and harder to control. This is awful both for the children and their parents when everyone becomes stuck in a cycle of never-ending power struggles.

2. “Spanking works well if you do it in a controlled, loving, manner.”
I have heard this ideal of the ‘calm’ or ‘loving’ spanking held up as a ‘gold standard’ how to use this technique. However, this idea does not match what we know about human nature and how people behave when angry. In the real world, many parents can not meet the ideal of staying calm in the face of challenging child behavior. Studies show that many parents spank when they lose their temper. Multiple studies also show that when parents spank, the risk of crossing the line into abuse grows. Parents who spank more frequently or who spank with objects are at the highest risk. The reality is that parents who spank are at higher risk for going too far and harming the child as compared to parents who do not use physical punishments.

Our children can make us more angry, more afraid, and more frustrated than just about anything else in the world. As any parent knows, our children’s provocative behavior produces an extreme stress response. It certainly does not make us feel calm and loving. During emotional stress, our heart rates increase, we get an adrenaline rush; our bodies get ready for a ‘fight or flight.’ This is the time when we are least capable of thinking clearly. It is the time when we have the least self-control, when we risk going too far in punishing our children. It is easy to say “Oh that will never happen to me.” It is harder to face the idea that it could.

Surprisingly, releasing our anger physically tends to make us angrier and more aggressive. Scientists who study the human brain have learned that releasing aggression produces pleasure—it feels good to release pent up anger. The satisfaction we take in releasing anger makes it all the harder to stop. We all have it in us to do damage to others, and avoiding spanking is one way we can protect our children. Mixing messages about love with actions that cause shame and pain is very confusing to a child. The last thing we want to do is to teach our children, particularly our daughters, that it is fine for people who claim to love them to hit them.

3. “Spanking will help my child become a better person”
      
Many well-meaning parents use spanking in the hopes that it will help their children to acquire morals and values. While the goal is excellent, spanking teaches a very different set of lessons about how to treat those weaker than yourself. We can use pain and shame to force people to comply with our demands, but spanking does not teach our child how to be more loving, empathic, or considerate.

Imagine that you arrive home and tell your spouse that you forgot to make the bank deposit. Suppose your spouse then punches you in the face to ‘teach you a lesson.’ You might never forget the deposit again, but what would that punch do to your relationship? Would you ever feel the same about your husband or wife again? Would you gratefully accept that kind of treatment because you really did make a mistake? Human beings respond to punishment with anger, avoidance, and feelings of vengeance. Too often, people then turn that anger loose on whoever is available. Children may be afraid to hit the parent back, but they can hit the new baby, kick the dog, or beat-up the small kid in their class. As it is often said, children ‘learn what they live.’

I have often heard people argue that because spanking has been used in the past, that parents should keep doing it. However, people of the past did many things that we find unacceptable today, such as practicing racial segregation, allowing husbands to legally beat their wives, and abandoning children with Downs Syndrome and Autism in institutions. We have come a long way in our understanding of how such behaviors hurt people. Today’s parents are fortunate to have access to more effective means of changing behaviors. Every generation abandons practices when the research shows us better ways of living. For example, today’s doctors would never tell women that breast feeding is unhealthy for babies, or encourage parents not to hold and cuddle infants, but these were common child-rearing recommendations of years past. Today, we know better, and we can choose to do what works.

4. “If I don’t spank them, my kids won’t respect me.”
Parents do need to be authority figures. They do need to be in-charge if their children are to learn to self-control. However, parents are not in-charge when they are screaming at the kids, weeping with anger, or so angry they are ready to hit. Consider a work-place example. Employees are unlikely to respect a boss who has regular tempter tantrums. They might fear him, but he would not be likely get loyalty and devotion. Just as an adult would do with a punishing boss, research shows that children who are spanked learn to avoid their parent. Instead of learning to ask for guidance, these children learn to hide their mistakes, or plan revenge. Instead of creating respect, spanking is toxic to the parent-child relationship.

As tough as it is, the best way to teach our children to respect us and our rules is to ‘practice what we preach.’ Parents can demonstrate that even when you are furious, you do not lash-out at others. Parents can show that just because you feel like hurting someone, you do not give in to those feelings. We can teach children that being an adult means being able to master your impulses.

Finally, I have heard people make the argument that spanking is necessary because of “Spare the Rod, Spoil the Child.” Some believe that “Spare the Rod” is an essential directive for parenting. Clearly, I am a psychologist and not a theologian, but I would offer this thought about that idea. The ‘big picture’ of all religions is the message of self-control. Human beings are charged to rise above our fear, aggression, and other baser instincts. Every religion teaches the central tenet of “do unto others” we call the Golden Rule. There is much in religious texts about mercy, forgiveness, and turning the other cheek. These most important messages can serve as excellent guides for all of us making parenting decisions.



*Note: There are many excellent discussions of the scientific literature regarding spanking, and this post is intended to highlight a few of the key ideas in the debate regarding spanking. What I have written here summarizes ideas from many minds far greater than mine, and I would encourage anyone who is interested or skeptical to investigate further. The reader is directed to the following sources to learn more about managing difficult behavior:

The Kazdin Method for Parenting the Defiant Child by Dr. Alan Kazdin
The Men They Will Become by Dr. Eli Newberger
The American Academy of Pediatrics www.aap.org
The Explosive Child by Dr. Ross Greene
How to Talk so Kids will Listen and Listen so Kids will Talk by Adele Faber and Elaine Mazlish
Touchpoints by Dr. T. Berry Brazelton
To examine the research about spanking for yourself, go to PubMed, an online database of journal articles:  http://www.ncbi.nlm.nih.gov/pubmed/






Affordable Mental Health Care: How to find free or reduced-fee treatment in your area

Jan 14, 2009 - 20 comments

Affordable Mental Health Care: How to find free or reduced-fee treatment in your area

The following is a guide to finding affordable psychological and psychiatric services in your area. Many people call or write me asking how they can find treatment if they do not have insurance or can not pay their deductibles. It is extremely frustrating to need help and not be able to afford it, even if you have insurance. It is sad that many insurance companies do not cover psychological and psychiatric services to the extent that all of their subscribers can access care. Unfortunately, many psychologists can no longer afford to participate with insurance companies or Medicaid/Medicare. The reasons for this include low reimbursement rates, frequency of denied payment for services, and the burden of insurance related paperwork. While the situation is problematic, there is no reason to assume that you can not get the care you need.

On the bright side, if you can take the time and energy to search, you have a good chance of finding someone who can help. First, here are some terms to be familiar with:

Sliding Fee Scale—this means that the clinician will adjust the price of services in accordance with your ability to pay
Community Mental Health Center—a public, non-profit agency that provides mental health treatment
Pro Bono Services—Free services offered to those in need. The ethical code of the American Psychological Association encourages psychologists to do pro-bono work, and most do some form of uncompensated service.

Do not be shy about asking clinicians if they can accommodate your financial situation. If they can not, they should be able to refer you to someone who can provide you less expensive treatment that would meet your needs. You may also find that a psychologist will agree to conduct a short-term, focused treatment on a specific problem. Ask if you can come every other week or monthly. Ask if there is a payment plan. Some psychologists are willing to provide therapy over the phone or through the computer if your work schedule makes it difficult to attend sessions.

Here are some ideas for where you can find free and affordable mental health care:

1. Call your general practitioner. Your physician should have a list of places he or she is comfortable sending you.
2. Contact an advocacy group’s local chapter. Organizations such as the National Alliance on Mental Illness (http://www.nami.org/Template.cfm?section=your_local_NAMI, Alcoholics Anonymous (http://www.aa.org/lang/en/meeting_finder.cfm?origpage=29), or the Association of Retarded Citizens (ARC) in your area will be able to help find treatment for specific needs. Advocacy groups typically maintain lists of local community therapists and respite care providers.
3. Contact your local hospital. Hospitals take insurance, including medical assistance. Call the Behavioral Health or Outpatient Psychology/Psychiatry department. Teaching hospitals (those that train student psychologists and psychiatrists) may be particularly good sources of less expensive care.
4. For urgent matters, try a crisis hotline. Even if you are not in immediate danger of harming yourself, they can still help. The people who answer the phone will have lists of places you can go where you can be seen as quickly as possible, even if you can not pay.
5. Ask your child’s school guidance counselor or school psychologist. Part of that person’s job is to refer students and families to local mental health care services.
6. Contact your local division of social services. You can often find this through your county’s website, or through private social service organizations such as Jewish Social Services (jssa.org).
7. Private ‘find a therapist’ websites such as www.therapists.psychologytoday.com/ will let you search for providers who are willing to offer sliding scale or pro bono care.
8. Local colleges and universities often maintain clinics that provide care to the general public. These clinics can be contacted through the departments of Psychology, Counseling, or Social Work. For example, if you went to the George Washington University Center for Professional Psychology website, you would find a link to the Center Clinic (http://www.gwu.edu/~cclinic/PsydCenterClinicContactUs.html). The Center Clinic is an example of a training clinic staffed by doctoral students who are supervised by licensed psychologists.
9. If you are a member of a religious community, clergy members can often refer you to pastoral counseling or other mental health care providers who have a spiritual orientation to treatment.

Good luck!


Your Family’s Mental Health During an Economic Downturn

Jan 13, 2009 - 1 comments
Tags:

parenting anxiety depression

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children behavior



Developing Resilience in Tough Times

Everywhere we look these days, there is more stress-inducing news about the state of the economy. Many families are facing lay-offs, reduced hours, or loss of overtime, while some are losing their homes. This is a time of increased anxiety for some, grief and hardship for others. We are all looking for how to ‘cut-back’ to weather the economic storm. This article is written to provide information about how to protect your mental (and thereby physical) health during our economic downturn.

First: Take the best care of yourself that you can

This sounds obvious; of course all of us want to make our health a priority. However, recent data indicate that people are postponing or avoiding important medical and psychological care. It can be tempting to cut mental health care from the family budget, yet this can be a mistake with serious consequences. It is critical to consider your mental health as much a priority as your physical health. We often underestimate the impact of our mental health on our day-to-day functioning. People are often surprised to learn that according to the World Health Organization, the second greatest cause of missed work days across the world is depression*. The impact of mental health disorders on work exceeds that of many diseases and chronic conditions we typically associate with missed days, such as arthritis or asthma. Additionally, many physical problems have mental health components. Conditions such as fibromyalgia, migraines, back pain, obesity, and diabetes can respond well to combining psychological treatment and medical care.

Even without physical problems, the anxiety brought on by economic woes can be toxic. In times of increased stress, people are more likely to argue with spouses, physically abuse children, and turn to illicit substances or other destructive behaviors in an attempt to manage anxiety. Anxiety can bring out the worst in us. When we are overwhelmed, we may lack the resilience to meet the demands of bad economic times, such as working extra hours or caring for an aging parent at home. Anxiety and depression interfere with our sleep, leading us to be tired and irritable. When we are sleep deprived, we are more likely to do and say things that we would not if we were feeling better (e.g. lashing out at our little ones or driving aggressively). Such maladaptive behaviors only make our problems worse, which in times of economic depression can make the difference between being able to ‘sink’ or ‘swim.’ Anxiety and depression are conditions that respond best to a combined approach of psychotherapy and medication for most individuals.

We must not consider psychological care a luxury. It is far from selfish to make our own mental health care a priority, especially for those of us who have families. Our spouses and children are counting on us to function. Trying to ignore our own need for mental health care (or couples treatment) may save money in the short term, yet it will hurt everyone in our family if we are angry, depressed, anxious, or hopeless. I often use the analogy of the air masks on a plane. Remember how the flight attendant tells us to put our own mask on first before helping others? We can not help our loved ones if we do not take care of ourselves as well. Our children will benefit most from having parents who can cope, far more than they ever will from having expensive toys and outfits.

Second: Help your children become resilient

Your children are hearing the same media messages you are, yet they have limited understanding of what the information means. Children tend to have very concrete concerns in times of crisis. For example, they may see their parents fighting about money, and worry that they are going to get a divorce. A ‘tween’ girl may sulk about not being able to shop at the expensive, trendy store even after you explain that you cannot afford it. Children may ask if they will have to move out of their house, or worry that they will not be able to keep the family dog. When you talk to your children about economic matters, remember to address their very practical concerns using simple language. If you do not know how to answer a question (ones such as “Why are you and Mommy always fighting?” or “Why doesn’t daddy go to work anymore?”), ask your child what he thinks the answer is before you respond. You may find that your child knows what is going on, and just wants reassurance. You may also find that he has come to a completely illogical conclusion about events, such as believing that the problems are his fault. Reassure your child about irrational fears, and give very simple, basic answers about what is going to change or happen. Kids usually need more reassurance than they do details. Your child may need you to explain things again and again before they understand, so do not be afraid to repeat yourself often. Make sure to give extra affection to comfort him.

If you child is over five, he is likely to respond well to being able to do something to help. Kids will develop a sense of pride about pitching in to help the family. Children can perform helpful tasks such as clipping coupons, looking out for sales, or helping you make choices about what to buy in the grocery store. Children can do an excellent job playing detective by identifying wasted energy or water. Your children may surprise you with their tolerance for changing spending habits if they feel a part of the decision making process. For example, let older children determine how to spend money allotted for treats or entertainment. Instead of “No! I told you ten times that we can’t afford those cookies anymore!” try “Well, we can get that brand if we decide to go without chips. What do you think of that?” Children can help you select clothing or toys to consign and give to families in need. They can plan garage sales. They can help you fix things around the house. Older children can earn extra money by helping neighbors with pet care or lawn work. Ask your librarian for books about families going through tough times (the Ramona books by Beverly Cleary are terrific; those of us who were girls in the early 80’s remember Ramona ‘scrimping and pinching to make ends meet’). With the help of books and movies, you can help your children to develop an attitude of teamwork.

Finally, acknowledge that your children’s feelings about having less are ok. A child may not be happy about not getting an IPod, but that does not mean he is spoiled, just human. Nobody likes to do without. Let the kids do a little venting here and there while you listen without being judgmental. Encourage daydreaming. It can be fun to play the ‘what if we won the lottery tomorrow . . .” game. You, the parent, will set the tone for turning their attention away from material things and towards what is important in life, like play, friends, and family time. Many people who live through difficult times emerge with a sense of achievement, because they met and mastered a challenge. Tough economic times can force us to teach our children important lessons about their own abilities.


*http://www.who.int/mental_health/management/depression/definition/en/