NYU Psi Chi Journal of Psychology Research, Volume III

NYU PSI CHI

JOURNAL OF PSYCHOLOGY RESEARCH SPRING 2018 VOLUME III

NYU PSI CHI

JOURNAL OF PSYCHOLOGY RESEARCH SPRING 2018 VOLUME III

EDITOR-IN-CHIEF

Raven L. Lin

EDITORS

Ayesha Bharadwaj Das Deborah Adenikinju Elisabeth Andreeff Eleanor Harrison

PEER REVIEWERS

Allison Degen Danielle Miano Emily Rabinowitz Mollyrose Napolitano Simone Van Taylor Tianyun Zhang

LAYOUT DIRECTOR

Kayla Ying Yan Lim

FACULTY MENTOR

Dr. Andy Hilford

SPECIAL THANKS

NYU Psi Chi NYU Department of Psychology 2

CONTENTS 4

Letter from the Editor

CONTRIBUTOR ARTICLES 6

11

Head Trauma and Neuropsychiatric Complications: A Proposed Approach to Detect Warning Signs for Chronic Traumatic Encephalopathy in Living Athletes

Racheed Mani

The Effectiveness of Sensory-Based Interventions for Children with Attention- Deficit/Hyperactivity Disorder

Tiffany Davis, Jamie Tan, Nicole MacWhirter, Courtney Thomas

18

Understanding the Mental Health Risks and Clinical Needs of Immigrant and Refugee Women with a History of Trauma

Hanna Sharif-Kazemi

22

Stephanie J. Hauck

26

Barriers to Professional Help-Seeking in the Deaf Community

30 34 37 42

Sleep On It: The Impact of Sleep Deprivation on Decision-Making

Michelle Hansen

An Advocacy for Acceptance and Commitment Therapy

Rachna Sadhwani

Psychopaths and their Brain Differences

Leslie Locke

Recommendations for Gender Expression in Nick Jr. Television Programs

Julia Moses

Combating Eating Disorders: A Review of Etiology and Interventions

Caroline Zemsky

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LETTER FROM THE EDITOR Since its inception in the Fall of 2014, the NYU Psi Chi Journal of Psychology Research has pledged to provide a platform for the wealth of creativity, passion, and tenacity to advancing the field of psychology that radiates from our Psi Chi members. This volume, the third issue of its kind, reflects the myriad curiosities of undergraduate scholars who are uniquely diverse in their knowledge and experiences.

In this issue, you will encounter topics that seek to bridge the divisions between empiricism, clinical practice, and advocacy. From health barriers in the Deaf community to decision-making under sleep deprivation, the covered range is an especially multidisciplinary collection of enterprising visions for progress in psychological research and application.

This publication represents the scholarly contributions of our immensely talented writers, peer reviewers, editors, and designer with whom I had the utmost pleasure of spearheading this project. Thus, I take this opportunity to congratulate these student contributors, whose collaborative efforts made this journey possible, on their exceptional work for this edition. Additionally, I would like to extend my gratitude to our faculty advisor Dr. Andy Hilford and to the current Psi Chi executive board for their enduring support and guidance.

Thank you for reading, and I hope you enjoy this edition,

Raven Lin Secretary of Psi Chi Editor-in-Chief of the Journal 4

CONTRIBUTOR ARTICLES

MANI | Head Trauma and Neuropsychiatric Complications: Detecting CTE in Living Atheletes

Head Trauma and Neuropsychiatric Complications: A Proposed Approach to Detect Warning Signs for Chronic Traumatic Encephalopathy in Living Athletes Racheed Mani There is growing scrutiny regarding the link between head trauma and the acquisition of neurological and psychiatric conditions. Head trauma is associated with a significantly increased risk of unipolar and bipolar depression, schizophrenia, and mood disorders (Orlovska et al., 2014; Robinson & Jorge, 2002). Public attention has now focused on assessing head injuries in athletes participating in contact sports, many of whom have consequently exhibited chronic traumatic encephalopathy (CTE), a neurodegenerative condition resulting from repeated instances of concussions and traumatic brain injuries. CTE is characterized by neurological atrophy within the central nervous system (CNS), translating pathologically through deposition of the tau protein. Symptomatically, CTE presents in stages, starting with substantial memory disturbances, impulsivity, speech impediments, motor impairments, and depression, before eventually progressing to neurodegeneration in the form of dementia (McKee et al., 2009). CTE first came to light when many professional boxers exhibited dementia pugilistica, or ‘punchdrunk syndrome’, which manifested as dementia-like symptoms. Additionally, American football and soccer players who exhibit CTE have often gone on to suffer from dementia (Tartaglia et al., 2014). However, such conclusions have been drawn only from post-mortem analyses.

Researchers have the impetus to find means of detecting warning signs for CTE in athletes during their lives. This process should entail evaluation for biomarkers linked to short and long-term head traumas. Biomarker assessment, when supplemented with neuropsychiatric evaluations and timely medical interventions, will go a long way in preventing many athletes’ lives from being marred by the neuropsychiatric complications of CTE. One of the most well-documented cases pioneering early interest in the link between head trauma and compromised neuropsychiatric well-being involved Phineas Gage, the American construction foreman. Gage miraculously survived the ordeal of an iron bar thrust through his skull. Though he survived, Gage suffered from permanent frontal lobe damage, which manifested through marked changes in behavior, such as irreverence and inability to take responsibility for his actions (Damasio et al., 1994). A similar phenomenon is now being considered with respect to participants of contact sports. These sports, while integral parts of everyday recreation and entertainment, carry a high risk of concussion for their participants. Head trauma is a rampant occurrence in contact sports, whether from a blow of a boxing glove, to heading a soccer ball, to collisions with opposition players in strong football tackles. Athletes often experience repeated head impacts, each of which may not be as severe as Phineas Gage’s, but nevertheless, 6

MANI | Head Trauma and Neuropsychiatric Complications: Detecting CTE in Living Atheletes

carries its own incremental mark of potential damage. Recently, neuropathologist Ann McKee, upon examination of brains from 111 deceased American football players from the National Football League (NFL), confirmed that 110 players displayed the pathology of CTE, which was exhibited through the deposition of the tau protein as neurofibrillary tangles in the central nervous system (CNS) (McKee, Mez, & Abdolmohammadi, 2017).

Many of these symptoms have been reported in athletes afflicted by head trauma during their lives. NFL linebacker Fred McNeill was suspected of having CTE after brain scans suggested evidence of tau pathology, an observation validated by a subsequent post-mortem autopsy.

McNeill’s family members indicated that he had suffered from depression and dementia-like memory loss until his death in 2015 (Omalu et al., 2018). In soccer, a sport characterized by repetitive impacts to the head with the soccer ball, the plight of head trauma and subsequent brain injury has been well-documented. One of the most renowned cases is that of Jeff Astle, a former England and West Bromwich Albion striker. Astle suffered from marked cognitive decline later in his life before ultimately acquiring dementia. Dementia has also been reported in many other soccer players, including four members of England’s 1966 World Cup winning team. Furthermore, analyses from a cohort of soccer players from 1980 to 2010, all of whom also acquired dementia, indicated a significant prevalence of CTE (Ling et al., 2017).

These findings, while groundbreaking in bringing this phenomenon to public awareness, have all been discovered in post-mortem retrospect. The former players had already suffered from their plight long before their condition could even be detected. Many athletes who suffer from even acute head trauma have been impacted with neuropsychiatric complications. In 2017, Harvard Medical School psychiatrists diagnosed a living college soccer player, who had a history of concussion, with schizoaffective disorder. He exhibited frontal lobe dysfunction, impulsive behavior, and thought blocking (Adelsky et al., 2017). Given that athletes like him have suffered at such early ages, one can imagine how much of an impact chronic head trauma, culminating in acquiring CTE, can have on the neuropsychiatric well-being of athletes in the long run. An athlete’s career, even without considering the persistent risks of careerthreatening injuries, is truncated relative to other occupations, as athletes often retire in their 30s. However, CTE tends not to present until 5-10 years after repeated brain trauma. Once the athlete acquires CTE, they are consigned to progressively worsening symptomatology throughout the remainder of their lives.

Early intervention of CTE has been inherently limited due to a lack of in vivo methods to detect markers of CTE. In addition, CTE results from concussions, which often do not show on magnetic resonance imaging (MRI) or computed tomography (CT) scans, making immediate detection difficult. One key target in early intervention of CTE is timely detection of its tau neuropathology. This could be done using a radioactive tracer compound to probe for the tau protein on a positron-emission tomography (PET) scan. One such tracer is FDDNP, which can bind to tau prroteins. Moreover, [18F]-T807, a derivative tracer of FDDNP, has recently been found to exhibit highly specificity for the tau protein in in vivo autoradiography results.

[18F]-T807 shows great promise as a PET tracer for potential tau analyses going forward.

Ideally, provided that the value of [18F]-T807 is substantiated further, this tracer could be used clinically in the future. For now, FDDNP can more than suffice as an effective probe for the tau protein during PET scans. Alternatively, tau can be assessed by acquiring cerebrospinal fluid (CSF) from lumbar punctures (LPs) and subjecting the CSF to an antibody assay for the tau protein (Gandy et al., 2014).

One potential route worth pursuing is to periodically assess athletes for CTE biomarkers 7

MANI | Head Trauma and Neuropsychiatric Complications: Detecting CTE in Living Atheletes

during their involvement in contact sports. As members of professional sports teams, players are subject to regular fitness and medical testing. During such tests, players are assessed for hazardous conditions, such as heart arrhythmias, which, if present, often result in a precautionary termination of the player’s career. Such measures are taken to prolong the player’s life, as there are life-threatening risks like cardiac arrests, which may transpire under the rigorous physical exertion associated with professional sports. Similar precautions should be taken with CTE assessment. One way to test for tau (and potential CTE) is to have players undergo periodic PET scans and/or CSF-LPs as part of their medical examinations.

While assessing for the tau protein is useful in detecting CTE pathology, the most effective line of action is immediately assessing for biomarkers of traumatic brain injury (TBI) during any case of head trauma. Ultra-early detection and intervention for traumatic brain injury can prevent further exacerbation to the point of acquiring CTE. As of February 2018, the Food and Drug Administration (FDA) approved a novel blood test to immediately detect TBI: the Banyan Brain Trauma Indicator (Banyan BTI). The Banyan BTI identifies two brain-specific protein biomarkers: Ubiquitin Carboxy-terminal Hydrolase-L1 (UCH-L1), and Glial Fibrillary Acidic Protein (GFAP). These proteins have been detected in blood serum from people suffering from mild TBI within hours of sustaining head injuries. Such findings suggest that UCH-L1 and GFAP are ideal biomarkers for the near-immediate detection of TBI (Diaz-Arrastia et al., 2014; Papa et al., 2016). Given that CTE is a long-term manifestation of repeated occurrences of TBI, there is another potential assessment that could be administered immediately following a head injury: using the Banyan BTI blood test to assay for UCH-L1 and GFAP in athletes’ blood samples upon any instance of suffering a significant blow to the head.

While biomarkers may present a major sign of TBI or CTE, it must be noted that UCH-L1, GFAP, and tau may be detected in minute quantities in all athletes, even in those who are seemingly healthy. It is erroneous to suggest that the mere presence of such biomarkers would always require the drastic action of terminating athletes’ involvement in sport. The key is to support athletic well-being while enabling participation in sport. This is when the process of conducting regular neuropsychiatric evaluations in concert with biomarker assessment becomes essential. Examination for biomarkers of acute TBI (UCH-L1 and GFAP) or CTE (tau) should be supplemented with neuropsychiatric evaluations to provide an added dimension for athlete testing.

With respect to immediate response from a single head injury, the Glasgow Coma Scale (GCS) is a proven, highly intensive evaluation to administer in tandem with biomarker assessment. This is a complex test that assesses eye, verbal, and motor responses to stimuli, gauging head trauma severity. Scoring ranges from 3 (unconsciousness) to 15 (full alertness) with any score below 9 indicating severe brain injury. Following administration of the GCS, the next line of action involves carrying out requisite and timely intervention to treat cases of head trauma. The course of action is dependent on the severity of the injury. Treatment may range from simple rest to, in the process of more severe TBI, hyperbaric oxygen therapy, using sedatives or diuretics to reduce excess intracranial pressure (ICP), and/or cognitive rehabilitation in an inpatient setting (Morries et al., 2015). In any case, having a team of neurologists, Physical Medicine and Rehabilitation (PM&R) physicians, and mental health professionals working together is essential for efficient treatment of brain injuries.

After treatment, athletes should be re-evaluated, to determine whether they are ready to resume their involvement in their respective sports. The Rancho Los Amigos Scale, when used in tandem with the GCS, is an effective post-treatment evaluation, which assesses 8

MANI | Head Trauma and Neuropsychiatric Complications: Detecting CTE in Living Atheletes

neurocognitive, behavioral, and motor responses in the event of recovering from head trauma (Flannery et al., 1993). If, long after treatment, the athlete continues to present with CTE or TBI biomarkers, low scores on neuropsychiatric batteries, as well as a discernible decline in neurological and motor function, the medical staff should consult with the player and his coaching staff and take the necessary precaution in prematurely ending the athlete’s sporting involvement. Otherwise, if allowed to take part in sport, the athlete would face the prospect of his/her already compromised neurological function further worsening due to the inevitable fate of repetitive head trauma that would ensue.

To prevent the exacerbation of head trauma to the point of acquiring CTE and the irreversible neuropsychiatric complications that it imposes, it is essential to respond immediately to any instance of head trauma. Moreover, to monitor for potential CTE, all athletes - even those who have not experienced conspicuous head injuries - should also undergo periodic evaluations for biomarkers of acute and/or chronic head trauma. The tau protein, along with the pair of UCH-L1 and GFAP proteins, provide valuable insight into long- and short-term traumatic brain injury, respectively. Assessments should be accompanied with neuropsychiatric evaluations, and timely interventions should any major warning signs to athletes’ well-being present themselves. Implementing methods for early detection of traumatic brain injury is essential in preventing an array of potential neuropsychiatric conditions from worsening. Early analysis for biomarkers, coupled with neuropsychiatric assessments and requisite treatment, will enable current and future athletes to live healthier, more fulfilling lives, both during and beyond their involvement in sport.

REFERENCES Adelsky, S.J., Ducharme, S., Wilner, E., Yudkoff, B., & Lejeune, S. (2017). “Heads Up: The Presentation of Schizoaffective Disorder in an Elite College Soccer Player with Prior Concussion.” Harvard Review of Psychiatry, vol. 25, no. 6, pp. 302–310.

Damasio, H., Grabowski, T., Frank, R., Galaburda, A. M., & Damasio, A. R. (1994). The return of Phineas Gage: clues about the brain from the skull of a famous patient. Science, 264(5162), 1102-1105.

Diaz-Arrastia, R., Wang, K. K., Papa, L., Sorani, M. D., Yue, J. K., Puccio, A. M., McMahon, P., Inoue, T., Yuh, E., Lingsma, H., Valadka, A., Okonkwo, D., & Maas, A. I. (2014). Acute biomarkers of traumatic brain injury: relationship between plasma levels of ubiquitin C-terminal hydrolase-L1 and glial fibrillary acidic protein. Journal of neurotrauma, 31(1), 19-25.

Flannery, J., & Abraham, I. (1993). Psychometric Properties of a Cognitive Functioning Scale for Patients With Traumatic Brain Injury. Western Journal of Nursing Research, 15(4), 465-482.

Gandy, S., & DeKosky, S. T. (2014). [18F]-T807 tauopathy PET imaging in chronic traumatic encephalopathy.

F1000Research, 3, 229.

Ling, H., Morris, H. R., Neal, J. W., Lees, A. J., Hardy, J., Holton, J. L., Revesz, T., & Williams, D. D. (2017). Mixed pathologies including chronic traumatic encephalopathy account for dementia in retired association football (soccer) players. Acta Neuropathologica, 133(3), 337-352. doi:10.1007/s00401-017-1680-3 McKee, A.C., Cantu, R.C., Nowinski, C.J., Hedley-Whyte, E.T., Gavett, B.E., Budson, A.E., Santini, V.E., Lee, H.S., Kubilus, C.A., & Stern, R.A. (2009). Chronic Traumatic Encephalopathy in Athletes: Progressive Tauopathy following Repetitive Head Injury. Journal of Neuropathology and Experimental Neurology, 68(7), 709–735.

McKee, A. C., Mez, J., & Abdolmohammadi, B. (2017). Chronic Traumatic Encephalopathy in Football Players—Reply.

Jama, 318(23), 2353. doi:10.1001/jama.2017.16687 Morries, L.D., Cassano, P., & Henderson, T.A. (2015). Treatments for traumatic brain injury with emphasis on transcranial near-infrared laser phototherapy. Neuropsychiatric Disease and Treatment, 11, 2159–2175.

Omalu, B., Small, G. W., Bailes, J., Ercoli, L. M., Merrill, D. A., Wong, K.P., Huang, S.C., Satyamurthy, N., Hammers, J.L., Lee, J., Fitzsimmons, R.P., & Barrio, J. R. (2018). Postmortem Autopsy-Confirmation of Antemortem [F-18] FDDNP-PET Scans in a Football Player With Chronic Traumatic Encephalopathy. Neurosurgery, 82(2), 237-246. doi:10.1093/neuros/nyx536 Orlovska, S., Pedersen, M. S., Benros, M. E., Mortensen, P. B., Agerbo, E., & Nordentoft, M. (2014). Head Injury as Risk Factor for Psychiatric Disorders: A Nationwide Register-Based Follow-Up Study of 113,906 Persons With Head

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Injury. American Journal of Psychiatry, 171(4), 463-469. doi:10.1176/appi.ajp.2013.13020190 Papa, L., Brophy, G. M., Welch, R. D., Lewis, L. M., Braga, C. F., Tan, C. N., Ameli, N.J., Lopez, M.A., Haeussler, C.A., Mendez-Giordano, D.I., Silvestri, S., Giordano, P., Weber, K.D., Hill-Pryor, C., & Hack D.C. (2016). Time Course and Diagnostic Accuracy of Glial and Neuronal Blood Biomarkers GFAP and UCH-L1 in a Large Cohort of Trauma Patients With and Without Mild Traumatic Brain Injury. JAMA Neurology, 73(5), 551.

Robinson, R. G., & Jorge, R. (2002). Longitudinal Course of Mood Disorders Following Traumatic Brain Injury. Archives of General Psychiatry, 59(1), 23. doi:10.1001/archpsyc.59.1.23 Tartaglia, M.C., Hazrati, L.N., Davis, K.D., Green, R.E.A., Wennberg, R., Mikulis, D., & Tator, C. (2014). Chronic traumatic encephalopathy and other neurodegenerative proteinopathies. Frontiers in Human Neuroscience, 8, 30.

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DAVIS ET AL. | Effectiveness of Sensory-Based Interventions for Children with ADHD

The Effectiveness of Sensory-Based Interventions for Children with AttentionDeficit/Hyperactivity Disorder Tiffany Davis Jamie Tan Nicole MacWhirter Courtney Thomas INTRODUCTION Attention-deficit/hyperactivity disorder (ADHD) is a neurobehavioral disorder that affects approximately 5% of school-age children worldwide (Sayal, Prasad, Daley, Ford, & Coghill, 2017). The symptoms of ADHD include difficulty with focusing and regulating behaviors, as well as increased levels of hyperactivity, all of which may hinder a child’s ability to function physically, cognitively, and socially (Chacko, Kofler, & Jarrett, 2014). Due to the increased prevalence of ADHD in the past three decades, emerging literature has dedicated itself to investigating potential treatment options for children with this disorder (Polanczyk, Willcutt, Salum, Kieling, & Rohde, 2014; Safer, 2018). Common treatment options include use of stimulant medication, behavioral parent training, and behavioral therapy (Stubberfield, Wray, & Parry, 1999). While previous studies have found that stimulant medication is highly effective for reducing core symptoms of ADHD, potential adverse reactions, such as decreased appetite, difficulty sleeping, and stunted growth have caused parents to seek alternative treatment (Barbaresi, Katusic, Colligan, Weaver, & Jacobsen, 2007). Occupational therapy is one form of alternative treatment that has been proposed to reduce core symptoms of ADHD (Schaaf & Miller, 2005).

Current literature suggests that occupational therapy (OT) interventions could be effective for children with ADHD since many of these children have sensory processing problems in addition to their core symptoms of ADHD (Mangeot et al., 2001; Yochman, Parush, & Ornoy, 2004). Sensory processing describes the way individuals manage, integrate, and organize incoming sensory stimuli (Panagiotidi, Overton, & Stafford, 2018). Sensory processing problems include over- or under-sensitivity to sensory input, difficulty processing and integrating sensory information, or atypical responses to sensory input (Schoen, Miller, Green & Nielsen, 2009).

Mangeot et al. (2001) found that children with ADHD experience greater abnormalities in sensory processing as compared to those not diagnosed with ADHD. Furthermore, there were significant differences between children with ADHD and those without ADHD in regards to their auditory, visual, tactile, and oral processing (Yochman et al., 2004). OT is a common treatment for children who experience these sensory processing abnormalities.

Occupational therapy can be defined as the use of therapeutic interventions to enhance engagement in daily activities and performance in areas related to physical, psychosocial, cognitive, and sensory-perceptual development (Roley, DeLany, & Barrows, 2008). In regards 11

DAVIS ET AL. | Effectiveness of Sensory-Based Interventions for Children with ADHD

to the present study, OT is able to help children with sensory processing difficulties learn how to better integrate and process their senses in a more developmentally appropriate and healthy way (May-Benson & Koomar, 2010). Interventions used by OT practitioners for children with sensory processing problems can be organized into two categories: Ayres Sensory Integration (ASI) and Sensory-Based Interventions (SBIs). For the purpose of this paper, we will be focusing on SBIs. SBIs include sensorimotor activities, or techniques that seek to change the sensory system via adaptation, to promote sensory integration (Fraser, MacKenzie, & Versnel, 2017). SBIs are often implemented — usually by an adult — in a child’s natural environment throughout the day, as sensory input is needed for self-regulation (Watling & Hauer, 2015).

Examples of SBIs include weighted vests, bouncing on a ball, and use of movement-based seating equipment (Watling & Hauer, 2015).

Sensory-based therapy is frequently used for children diagnosed with autism spectrum disorder (ASD) since many children with ASD experience sensory processing abnormalities (Case-Smith & Miller, 1999). However, previous reviews have reported inconclusive or mixed findings on the effectiveness of sensory-based therapies for disruptive behavioral disorders, such as ADHD. Although a substantial amount of literature on SBIs appear to be promising for children with ASD, less is known about the effectiveness of SBIs for children with ADHD. Due to inconsistencies in current literature, we are seeking to answer the following research question: Are sensory-based interventions effective for children diagnosed with ADHD? We hope that addressing the insufficiency of literature in regards to this specific population and diagnosis within the field of OT will further encourage implementation of more evidence-based research and practice in the future. Moreover, we hope to inform practitioners and parents on alternative and successful forms of ADHD treatment.

METHODS An extensive literature search was conducted across four databases: PsycNET, CINAHL, Medline, and Embase. Search terms were established and compiled from existing systematic reviews on sensory therapy. Inclusion and exclusion criteria were established in order to offer guidelines for the content, quality, type, and year of the literature included within the review.

Inclusion criteria included peer-reviewed publications, formal diagnosis of ADHD, articles published between 1960 and 2018, children between the ages of 3 and 12, and pre-post study design. A study was excluded if a diagnosis of autism spectrum disorder, sensory processing disorder, developmental coordination disorder, or cerebral palsy was also present.

Initial screen was based on a brief reading of the title and abstract. After the initial screen, 3023 studies were recorded as irrelevant to the current review and removed. Each stage of article screening required at least two reviewers in order to maintain inter-rater reliability.

Conflicts between raters were resolved when necessary. After the initial screen, 262 studies were left for full text assessment of eligibility. Full text screening involved a more thorough and careful reading of the articles, primarily focusing on study design and population. After the full text screen, 255 studies were deemed irrelevant and excluded from the review. A total of seven studies were left for extraction for the present literature review.

RESULTS Results by Intervention Type A total of seven studies met the inclusion criteria for this study. Four intervention types 12

DAVIS ET AL. | Effectiveness of Sensory-Based Interventions for Children with ADHD

were identified and studies were sorted accordingly. Of the seven studies, two investigated the effects of weighted vests, two examined vestibular therapies, two examined metronome training, and one examined therapy balls.

Weighted Vests Previous research has indicated that deep-touch pressure input provided by weighted vests can reduce sensory processing problems by changing arousal levels in the central nervous system (Baranek, Wakeford, & David, 2008). Two studies included in this review investigated behavioral outcomes of using weighted vests. In the first study, Lin, Lee, Chang, and Hong (2014) used a randomized two-period crossover design to measure outcomes of attention, impulse control, and on-task behavior between two groups. Participants in the weighted vest condition showed significant improvements in measures of inattention, processing speed, responsiveness, and consistency of executive management as compared to the control group.

These participants were also less likely to fidget, look away from the computer, and leave their seats during the task. In other words, participants who wore a weighted vest were more likely to be on-task. No significant differences were observed in automatic vocalizations (meaningless utterances) and impulse control between the two groups. In the second study, VandenBerg (2001) used a single-subject design to similarly investigate the effect of weighted vests on participants’ on-task behavior. On-task behavior was defined as engagement in processes that are necessary for finishing an activity assigned by a teacher. For example, a child was deemed on-task if he/she was visually focused on the activity. Participants’ on-task behaviors increased by 18-25% after wearing a weighted vest. Overall, the studies supported use of weighted vests for children with ADHD to increase on-task behavior in school-based settings.

However, more studies are needed to confirm the effectiveness of weighted vest interventions.

Vestibular Therapy Two studies analyzed the effects of vestibular therapy on cognitive performance in children diagnosed with ADHD were used in this review. A between-group randomized controlled trial

by Haghshenas, Hosseini, and Aminjan (2014) studied the effects of vestibular stimulation on auditory comprehension in children with ADHD, using clinical exercises in the control group.

Vestibular stimulation was achieved through exercises involving jumping on a trampoline, walking on a balance beam, reaching on a therapy ball, and executing various movements on a swing. Clinical exercises included cognitive activities (e.g., a memory card game, massage therapy, proprioceptive activities, and visual attention training). Vestibular stimulation or clinical exercises were delivered twice a week for 10 weeks. The researchers used the Integrated Visual and Auditory Continuous Performance Test (IVA CPT) as a pre- and post-test to measure auditory comprehension based on errors of omission, errors of commission, and reaction times. The study found no significant difference between the intervention and control groups.

However, mean differences between pre- and post-tests using vestibular stimulation in the intervention group were significantly higher than those in the control group.

Lotfi et al. (2017) conducted a between-group randomized controlled trial measuring the effect of vestibular rehabilitation on cognitive performance in children with combined ADHD and vestibular impairment. Comprehensive vestibular rehabilitation therapy (VRT) was implemented in 45-minute sessions, twice weekly, for 12 weeks and included exercises for balance and gait, postural stability, and eye movements. The outcome measures of the study included attention, measured by choice reaction time (CRT); and spatial memory capacity, measured by spatial 13

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working memory (SWM). Balance and vestibular function was also observed. Results from this study indicate a significant difference in pre- and post-test balance scores in the treatment group but not the control group. In comparing the post-tests of the groups, no significant differences were reported for all vestibular evoked myogenic potential (VEMP) scores. However, in the intervention group, vestibular exercise significantly improved attention to tasks but not spatial working memory. It also shortened reaction times of participants in the intervention group. Thus, it is evident that vestibular rehabilitation improved several aspects of balance, cognitive performance, and vestibular impairment in children with ADHD. Metronome Training Two studies examined the effects of interactive metronome training in children with attentional deficits and developmental coordination disorders. Cosper, Lee, Peters, and Bishop (2009) operated a within-subjects design, in which participants completed weekly hourlong sessions of metronome training for 15 weeks. The Bruininks-Oseretsky Test of Motor Proficiency-Short Form was used to measure motor control and coordination. Additionally, the Gordon diagnostic system was administered to assess sustained attention. Each measure was administered to participants before and after the intervention. The researchers found that metronome training improved reaction time, visual motor speed, and battery composite score, but not attention or motor control of inappropriate behavior (Cosper et al., 2009).

The second study, conducted by Shaffer, Jacokes, Cassily, Greenspan, Tuchman, and Stemmer (2001), administered a randomized controlled trial consisting of an interactive metronome treatment group, a video group, and a control group. Participants in the video group were instructed to play a PC-based nonviolent video game and the control group did not receive any treatment. Each participant was assessed before and after the intervention on attention and concentration, clinical functioning, academia, and cognitive skills. Participants who received interactive metronome training showed significant improvement in identifying similarities and differences, as well as a reduction of aggressive behaviors, as compared to the video and non-intervention control groups. Furthermore, five tests measuring reading and attention revealed a significant improvement only in the interactive metronome group.

Although the articles produced positive results on certain measures and reduced undesired characteristics of ADHD, further research is needed to support the application of interactive metronome training as a treatment for this disorder.

Therapy Balls One study conducted by Schilling, Washington, Billingsley, and Deitz (2003) examines ways in which the use of therapy balls, as compared to normal classroom chairs, has an effect on in-seat behavior and legible word productivity for children diagnosed with ADHD. Current literature has provided evidence that sitting still in chairs and paying attention during class time is often a challenge for children diagnosed with ADHD. Therefore, therapy balls are proposed as a potential alternative.

Outcomes of this study demonstrated that therapy balls improved in-seat behavior.

More specifically, all three participants who had previously struggled with distractions and remaining in their seats for long durations of time reported stronger preference for therapy balls and remained seated for longer periods. Similarly, all participants’ legible word productivity on the therapy balls was greater than that of their legible word productivity when they were seated in chairs. This study demonstrated the potential positive implications for therapy balls in 14

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classrooms. While the researchers reported improvements in both in-seat behavior and legible word productivity, limitations must be considered when interpreting these findings, which will further be disseminated in the discussion section.

DISCUSSION AND IMPLICATIONS While the reviewed studies show initial evidence of the effectiveness of SBIs for children with ADHD, the literature is still quite limited and methodologically weak. Therefore, much of the existing literature regarding the effectiveness of SBIs for children with sensory processing problems is either inconclusive or contains too much variability in diagnosis and symptom severity among participants. In addition, only a handful of studies have focused exclusively on the ADHD population. For example, within the present review, Schilling et al. (2003) presented a variability in diagnosis and symptom severity among participants, including oppositional defiant disorder and comorbid diagnosis of severe behavior disorders. Additional studies examining the effectiveness of sensory-based treatments also frequently group together diagnoses such as autism spectrum disorder or developmental coordination disorder, which creates a heterogeneous sample. As a result, parsing out specific treatment effects for specific populations or diagnoses is very difficult.

More specifically, the articles utilized in this review contained many evident limitations. For instance, both studies involving interactive metronome training had a limited variety of patients and age ranges. Furthermore, Shaffer et al. (2001) only used male participants and overlooked factors that could contribute to improved attention, such as planning and sequencing. In addition, Cosper et al. (2009) and Lin et al. (2014) conducted experiments in which each participant acted as their own control, failing to present a no-treatment control group.

However, on a broader scale, major limitations and methodological weaknesses within literature surrounding OT interventions in regards to ADHD include low sample size, overrepresentation of male participants, heterogeneity of ADHD symptoms, variability in the duration and frequency of interventions, medication effects, lack of standardized outcome measures, lack of control or alternative intervention groups, and lack of evaluation on delayed intervention effects. The key limitations are expanded upon below.

A major limitation in the literature has been the use of low sample sizes. Of the seven studies included in this review, sample sizes ranged from three participants to 110 participants. Over half of the studies had a sample size of 20 or less participants. Having a low sample size can result in low statistical power and a greater tendency for type II error, or false negative findings.

For this reason, significant positive treatment effects may be underreported. Another limiting factor is the potential effects of medication on treatment outcomes. Only one study prevented medication use during the intervention in order to reduce the likelihood that medication may influence treatment outcomes (Lin et al., 2014). While some studies mentioned the type of medication used by participants, the dosage intake was not monitored during the intervention process. As a result, it is difficult to determine whether the findings are due to the intervention or the medication. The overrepresentation of males in study samples has also been a major limitation in current literature. This can result in gender bias because the effects for one sex may not be generalizable to both sexes. Lastly, although all reviewed studies contained participants who were formally diagnosed with ADHD, subtypes of ADHD were not considered during the randomization process, which could have resulted in nonequivalent groups for between-group studies. Previous research has found that certain subtypes may react differently to treatment due to differences in symptoms and symptom severity (Dunn & Bennett, 2002). More studies 15

DAVIS ET AL. | Effectiveness of Sensory-Based Interventions for Children with ADHD

are needed to further examine differences in reactivity to intervention between ADHD subtypes.

CONCLUSIONS This systematic review aims to address the existing research on SBIs for children with ADHD. Results of this review suggest that utilizing SBIs is a potential alternative form of treatment that can be effective for children diagnosed with ADHD. This review suggests that core symptoms of ADHD, as well as sensory processing abnormalities, can be improved in terms of on-task behavior, cognitive performance, and attention. More specifically, improvements in hyperactivity, auditory comprehension, balance, visual motor speed, legible word productivity, and in-seat behavior have been observed within this review. While preliminary findings for utilizing SBIs are positive, caution should be taken when forming any conclusions regarding the efficacy of these interventions, as explained in the discussion section.

Future research should focus on improving the quality of studies by including more randomized controlled trials in order to avoid non-randomized controlled trial (RCT) biases.

These studies should also aim to address the methodological limitations and weaknesses, as outlined earlier. With these commitments, future OT practitioners, physicians, psychologists, and parents can be better informed about the effectiveness of these interventions and utilize them as alternative forms of treatment for children with ADHD.

REFERENCES Allardyce, J., Suppes, T., & van Os, J. (2007). Dimensions and the psychosis phenotype. International Journal of Methods in Psychiatric Research, 16, 34-40.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Arlington, VA: American Psychiatric Publishing.

Angermeyer, M. C., Dietrich, S., Pott, D., & Matschinger, H. (2005). Media consumption and desire for social distance towards people with schizophrenia. European Psychiatry, 20, 246-250.

Angermeyer, M. C., & Schulze, P. (2001). Reinforcing stereotypes: How the focus on forensic cases in news reporting may influence public attitudes towards the mentally ill. International Journal of Law and Psychiatry, 24, 469-486.

Bjerregaard, B., Smith, M. D., & Fogel, S. J. (2005). Benefits and risks of using “diminished capacity” mitigation in death penalty proceedings. In S. W. Hartwell (Ed.), Research in social problems and public policy, vol. 12: The organizational response to persons with mental illness involved with the justice system (pp. 111-134). New York: Emerald Publishing.

Daalman, K., Zandvoort, M., Bootsman, F., Boks, M., Kahn, R., & Sommer, I. (2011). Auditory verbal hallucinations and cognitive functioning in healthy individuals. Schizophrenia Research, 132, 203-207.

De Leede-Smith, S., & Barkus, E. (2013). A comprehensive review of auditory verbal hallucinations: Lifetime prevalence, correlates and mechanisms in healthy and clinical individuals. Frontiers in Human Neuroscience, 7, 1-25.

Gillespie, L. K., Smith, M. D., Bjerregaard, B., & Fogel, S. J. (2014). Examining the impact of proximate culpability mitigation in capital punishment sentencing recommendations: The influence of mental health mitigators. American Journal of Criminal Justice, 39, 698-715.

Granello, D. H., & Pauley, P. D. (2000). Television viewing habits and their relationship to tolerance toward people with mental illness. Journal of Mental Health Counseling, 22, 162-175.

Johns, L. C., Nazroo, J. Y., Bebbington, P., & Kuipers, E. (2002). Occurrence of hallucinatory experiences in a community sample and ethnic variations. The British Journal of Psychiatry, 180, 174-178.

Krabbendam, L., Myin-Germeys, I., & van Os, J. (2004). The expanding psychosis phenotype. International Journal of Psychology and Psychological Therapy, 4, 411-420.

Larøi, F. (2012). How do auditory verbal hallucinations in patients differ from those in non-patients? Frontiers in Human Neuroscience, 6, 1-9.

Lawrence, C., Jones, J., & Cooper, M. (2010). Hearing voices in a non-psychiatric population. Behavioural and Cognitive Psychotherapy, 38, 363-373.

Linden, D. E., Thornton, K., Kuswanto, C. N., Johnston, S. J., van de Ven, V., & Jackson, M. C. (2011). The brain’s voices: Comparing nonclinical auditory hallucinations and imagery. Cerebral Cortex, 21, 330-337.

Linscott, R. J., & van Os, J. (2010). Systematic reviews of categorical versus continuum models in psychosis: Evidence

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for discontinuous subpopulations underlying a psychometric continuum. Implications for DSM-V, DSM-VI, and DSM-VII. Annual Review of Clinical Psychology, 6, 391-419.

McCarthy-Jones, S. (2012). Hearing voices: The histories, causes and meanings of auditory verbal hallucinations. New York, NY: Cambridge University Press.

Rascon, J., & McClam, E. (2015, February 15). ‘American sniper’ trial: Eddie Ray Routh believed Kyle was a ‘pig assassin,’ doctor says. NBC News. Retrieved from http://nbcnews.com Ravven, S., & Kapoor, R. (2014). Heat-of-passion manslaughter and the mentally ill defendant. Journal of the American Academy of Psychiatry and the Law, 42, 115-117.

Tien, A. Y. (1991). Distributions of hallucinations in the population. Social Psychiatry And Psychiatric Epidemiology, 26(6), 287-292. van Nierop, M., van Os, J., Gunther, N., Myin-Germeys, I., de Graaf, R., ten Have, M., … van Winkle., R. (2012).

Phenotypically continuous with clinical psychosis, discontinuous in need for care: Evidence for an extended psychosis phenotype. Schizophrenia Bulletin, 38(2), 231-238.

Verdoux, H., & van Os, J. (2002). Psychottvic symptoms in non-clinical populations and the continuum of psychosis.

Schizophrenia Research, 54, 59-65.

Vilhauer, R. P. (2014). Depictions of auditory verbal hallucinations in news media. International Journal of Social Psychiatry, 61, 58-63.

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SHARIF-KAZEMI | Mental Health Risks of Immigrant and Regufee Women

Understanding the Mental Health Risks and Clinical Needs of Immigrant and Refugee Women with a History of Trauma Hanna Sharif-Kazemi Seeking safety, shelter, food, farmable lands, and freedom, people have sought to escape hunger, incarceration, torture, and oppression for millennia. However, the amount of refugees and rates of immigration to the United States have drastically increased in the past few decades (Foster, 2001). A large number of these immigrants and refugees are at significant risk for poor living conditions, economic exploitation, and racist or prejudicial treatment in their host locations (United Nations High Commission of Refugees, 1993). The continuous arrival of immigrants and refugees to the United States must encourage the American social service and mental health systems to generate new services, new sensitivities, and new interventions for a large population that is recognizably in need, but whose traumas are foreign to the lives of most American citizens (Foster, 2001). People who immigrate to the United States have encountered traumatic events unlike the average citizen of the United States, such as witnessing extreme violence or war, as well as facing prejudice in the United States due to their immigrant status.

Clinicians and researchers should thus begin to understand how best to serve the nation’s new immigrants and refugees, as well as investigate the following questions: How compromised are people who have been forced to leave behind all they know? What role does past trauma of war, disaster, and oppression have on an immigrant or refugee’s mental health? What current systematic and oppressive forces pose risks to the mental health of immigrants and refugees?

What role does gender play when assessing their mental health risks and experiences? How do clinicians intervene insomuch that people ultimately adjust to new host environments, while simultaneously avoiding ethnocentric bias when making diagnoses? This article will consider some of the pertinent knowledge that has been generated to answer these questions, and will seek to suggest clinical approaches to assess the complex experiences of immigrant patients.

Past research has conveyed the great number of complex emotional and physical tasks that must be accomplished by people who leave their homelands. A immigrant and refugee’s loss of family, community, and physical environment are common stressors found within clinical reports. Additionally, reports have identified the cumulative effects of specific stressors as precipitants of mental health issues such as Post-Traumatic Stress Disorder (PTSD), anxiety, and depression which are associated with immigrant and refugee trauma. Desjarlais et al.

(1995) concluded that it is not migration alone but rather, the traumatic or derailing events before, during, or after dislocation that lead to psychological mental distress for immigrant and refugee patients. Examples of pre-migratory traumatic events can be found in the common narratives that have circulated throughout our media since World War II. The United States has received, among many other groups, Jews who were tortured in the Holocaust camps, Syrians who have escaped war, and Haitians who have lost their homes due to the devastating earthquake of 2010. The pre-migration trauma literature illuminates the long-term effects 18

SHARIF-KAZEMI | Mental Health Risks of Immigrant and Regufee Women

such traumatic experiences have on daily life while settling in to a new country. For example, Chung and Kagawa-Singer (1993) found that among several Southeast Asian groups, premigration trauma exposure remained predictive of psychological distress five years or more after migration. Narratives of traumatic events during dislocation are also now told by women who are crossing the borders from Central to North America unaccompanied by partners or families. Engaging “coyotes” (illegal travel brokers) for passage, some have been subjected to months-long sexual assaults and forced labor as forms of “added payment” before reaching their destinations (Martin, 1999). Hundreds of Haitians and Cubans have been lost crossing the Caribbean Sea to the United States every year, and those who survive may witness the drowning of loved ones or the terror of being adrift at sea before being rescued (Bragg, 1999).

Historically, and at present, we have seen large groups of forced or voluntary immigrants transported between continents and confined to small, squalid quarters for months at a time.

In the seventeenth and eighteenth century United States, when West Africans were forced to migrate on slave ships, a tradition of cumulative trauma began, and many groups immigrating to the United States today have similar experiences.

Although traumatic events may happen before and during immigration, the experience of new traumatic instances is still likely to occur once the migrant has entered their new host country. Host countries are not always the most hospitable environments for newcomers, especially if they themselves are economically hard-pressed and are now subject to receive immigrants in large numbers as a result of some environmental or geopolitical crisis. Thus, residence in temporary resettlement areas such as refugee camps or detention centers can be a harrowing experience, with overcrowding, fear, and lack of provisions exacerbating the existing stressors of forced migration. Reports from these areas indicate a common atmosphere of anxiety, fear of loss, or the threat of repatriation. The process of seeking permanent, legal asylum in a host country carries its own set of acute stressors, as applicants can be held in detention centers for months or even years, before finally being formally processed (Postero, 1992). At this stage of the immigration or refugee process, individuals are in a state of limbo; conditions of quasi-imprisonment often fuel existing symptoms of isolation and anxiety. Many detainees at an immigration center had been imprisoned and abused in their own countries. For many, the atmosphere and treatment at the center aroused disturbing memories of their earlier trauma and served as contextual cues for awakening of trauma symptoms (Middleton, 2007).

The acute symptoms of PTSD may be interpreted by correctional guards as “uncooperative behavior”, and maltreatment from guards only makes the environment more stressful.

The Diagnostic and Statistical Manual of Mental Disorders’ definition of PTSD focuses on traumatic experiences that involve actual or threatened death or injury, or witnessing such events (American Psychiatric Association, 2013). However, scholars have advocated for an understanding of traumatic experiences that is ecosystemic, meaning that changes in behavior can be attributed to changes in environment. This would enable researchers and counselors to identify and address the complex sources of trauma that may not clearly fall within the DSM5 definition. This is relevant for immigrant and refugee trauma research and clinical practice, as even when immigrants or refugees begin to settle in their host country, they are likely to experience discrimination, racism, or systemic oppression. This is confounded by the fact that immigrants and refugees may experience the trauma of poverty, language barriers, difficulty accessing resources, and difficulty obtaining employment (Carter, 2007; Goodman & WestOlatunji, 2008). Emigrating in the hope of finding work and a new life in an adopted land, only to find themselves confronting isolation and exploitative living conditions, leaves immigrants and 19

SHARIF-KAZEMI | Mental Health Risks of Immigrant and Regufee Women

refugees at significant risk. These post-migration conditions painfully compound the distress experienced by many who may have already suffered persecution in their homelands, followed by the myriad risks of difficult transit and relocation (Foster, 2001).

Although research has demonstrated the numerous possible traumatic events immigrants and refugees are prone to experiencing, it is important to note the greater risk of trauma posed to immigrant or refugee women. Of the approximately forty million immigrants in the United States, 51% are women with varying statuses, including naturalized citizens, lawful permanent residents, refugees/asylees, persons on temporary visas, and undocumented immigrants (Zong, Batalova, & Hallock, 2018). However, less is known about refugee and undocumented women immigrants who are particularly vulnerable to trauma because of their marginalized social positioning as women, women of color, refugees, or undocumented (Clarke & Borders, 2014; Goodkind & Deacon, 2004). If clinicians can adopt an ecosystemic lens, we can begin to understand how certain systematic oppressors in the host country, such as racism and sexism, can pose an especial risk for immigrant and refugee women, as oppression may reawaken past trauma or create new ones. The research literature on the mental health of immigrant and refugee women remains slim, with the only prevailing research focusing on specific ethnic groups like Carribean and China (i.e Ali, 2004), leaving vast ethnic groups’ such as Iranian, Syrian, and African narratives yet to be explored. However, Goodman, Vesely, Letiecq, and Cleaveland (2017) found that many of the immigrant and refugee women from varying ethnic backgrounds shared both structural stressors (e.g., poverty, lengthy family separation) and situational stressors (e.g., perceptions of discrimination). Structural and situational stressors intersected, which led to an accumulation of stressors. For example, language barriers, employment challenges, and economic marginalization were connected to women’s perceptions of discrimination. All undocumented immigrant and refugee women in this study were also experiencing significant structural stressors related to their inability to meet the economic needs of their families. The chronic stress of living in poverty was evident in every interview the researchers conducted; thus, for many of these women, addressing traumatic experiences was often secondary to their concerns about their families’ financial security.

Clinicians who work with immigrant and refugee populations must be aware of the three stages of migration and the potential risk of trauma that a female immigrant or refugee patient may have in order to become adept at dealing with ethnological sources of trauma.

Yet, the need of this knowledge poses the question of how clinicians should intervene so that people adjust to new host environments, yet simultaneously avoid any ethnocentric bias that can affect diagnosis. In order for clinicians to make sense of this inherently complicated juxtaposition, they should avoid making diagnoses too soon, if at all. Clinicians must ask openended questions which would allow their immigrant women patients to construct their own immigrant narratives. Asking questions, such as “What does your race mean to you?”, “What did your immigration process look like?”, and “What has your experience in America looked like so far?” are all examples of questions that open an opportunity for the patient to convey where her trauma as a immigrant or refugee woman lies. It is also important for the clinician to develop skills to counter the ill effects of ethnocentric bias and develop multicultural counseling competencies, such as identifying the appropriate time and ways to talk about race with clients.

Educators can work with emerging professionals to identify ways to introduce race as part of processing the therapeutic relationship, especially when discussing trauma with immigrant or refugee women. Although it is challenging to consider the numerous intersecting facets of a patient’s experiences, taking on this challenge is crucial to the provision of care that facilitates 20

SHARIF-KAZEMI | Mental Health Risks of Immigrant and Regufee Women

an immigrant or refugee woman’s recovery and growth after experiencing any form of trauma.

REFERENCES Ali, A. (2004). The intersection of racism and sexism in psychiatric diagnosis. In P. Caplan & L. Cosgrove (Eds.), Bias in psychiatric diagnosis. New York: Rowman & Littlefield Publishers.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Bragg, R. (1999, December 4). Cuban boy is smiling, but no one else is. New York Times.

Carter, R. T. (2007). Racism and psychological and emotional injury: Recognizing and assessing race-based traumatic stress. The Counseling Psychologist, 35, 13–105.

Chung, R.C., & Kagawa-Singer, M. (1993). Predictors of psychological distress among Southeast Asian refugees. Social Science and Medicine, 36, 631–639.

Clarke, L. K., & Borders, L. D. (2014), “You got to apply seriousness”: A phenomenological inquiry of Liberian refugees’ coping. Journal of Counseling & Development, 92, 294–303.

Desjarlais, R., Eisenberg, L., Good, B., & Kleinman, A. (1995). World mental health: problems and priorities in lowincome countries. New York: Oxford University Press.

Foster, R. P. (2001). When immigration is trauma: Guidelines for the individual and family clinician. American Journal of Orthopsychiatry, 71(2), 153–170.

Goodkind, J. R., & Deacon, Z. (2004), Methodological issues in conducting research with refugee women: Principles for recognizing and re-centering the multiply marginalized. Journal of Community Psychology, 32: 721–739.

Goodman, R. D., & West-Olatunji, C. A. (2008). Transgenerational trauma and resilience: Improving mental health counseling for survivors of Hurricane Katrina. Journal of Mental Health Counseling, 30, 121–136.

Goodman, R. D., Vesely, C. K., Letiecq, B., & Cleaveland, C. L. (2017). Trauma and resilience among refugee and undocumented immigrant women. Journal of Counseling & Development, 95: 309–321.

Martin, D. (1999). The new faces of immigrant trauma: Women crossing borders alone. Paper presented at the annual meeting of the American Orthopsychiatric Association, Washington, DC. Postero, N. (1992). On trial in the promised land: Seeking asylum. Women & Therapy, 13, 155–172.

United Nations. (1993). Yearbook of the United Nations 1993: Part 3 Chapter 15 - Refugees and Displaced Persons.

Retrieved from http://www.unhcr.org/excom/yearbook/4e1ee783b/yearbook-united-nations-1993-part-3-chapter15-refugees-displaced-persons.html.

Zong, J., Batalova, J., & Hallock, J. (2018, February 8). Frequently requested statistics on immigrants and immigration in the United States. Retrieved from https://www.migrationpolicy.org/article/frequently-requested-statisticsimmigrants-and-immigration-united-states/.

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HAUCK | Sleep Deprivation and Decision Making

Sleep On It: The Impact of Sleep Deprivation on Decision-Making Stephanie J. Hauck Sleep is a vital part of overall health and well-being, yet many Americans report that they do not get enough sleep. The American Academy of Sleep Medicine recommends adults sleep for at least 7 hours each night for optimal health outcomes (Watson et al., 2015), but in 2014 the Centers for Disease Control found that one-third of American adults do not meet that standard (Liu et al., 2014), indicating that a sizable percentage of the U.S. population is deprived of sleep. Sleep deprivation occurs for a variety of reasons, including irregular work shifts, emotional stress, and career or academic demands (Lund et al., 2010; Bonnet & Arand, 1995; Killgore, 2010). Because sleep loss affects a significant portion of the population, it is crucial to fully understand the impacts it can have on cognitive processes that are used on a daily basis. One such cognitive process is the decision-making used in dynamic, real-world situations.

Decision-making is a process that integrates several cognitive components such as attention, risk evaluation, working memory, innovative thinking, inhibition of emotional responses, and assessment of rapidly changing situations (Harrison & Horne, 2000). Previous research has largely focused on how sleep deprivation affects the simplest cognitive processes involved in decision-making, such as attention and alertness (Killgore, 2010). In their study on the attentional abilities of sleep-deprived subjects, Lim and Dinges (2008) found that performance on the Psychomotor Vigilance Test (PVT), which measures reaction time, worsened as a result of sleep deprivation. In this experiment, sleep-deprived participants displayed longer reaction times to visual cues and were more likely to not respond to these cues at all, as compared to non-sleep-deprived participants. Previous researchers have stated that a decline in attention is the main consequence of sleep deprivation and is the principal factor in impairments in cognitive performance, as individuals may be incapable of employing higher-order cognitive processes if they are unable to attend to a task in the first place. However, this theory contributes to the misconceptions that more complex cognitive abilities, such as decision-making, are relatively unaffected by sleep deprivation, and therefore do not contribute to overall failures in task performance.

There is sufficient evidence to suggest that sleep deprivation can in fact negatively impact the higher-order processes involved in making decisions. Many cognitive processes involved in decision-making are mediated by the prefrontal cortex (PFC), an area largely responsible for executive functioning, which allows individuals to plan, control actions, and reason (Diamond, 2013). Previous studies have suggested that the PFC is sensitive to the effects of sleep loss.

In one study by Harrison, Horne, and Rothwell (2000), young adults that had been deprived of sleep for 36 hours showed impairments on neuropsychological tests that required the use of the higher-order cognitive functions linked to normal PFC functioning. These findings imply that the higher-order processes necessary for decision-making are vulnerable to sleep deprivation. Further evidence from neuroimaging studies support the claim that the PFC is 22

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sensitive to sleep loss. One fMRI study aimed to find differences in PFC activation between well-rested individuals and individuals who had been deprived of sleep for 24 hours. In Schnyer et al.’s study (2009), both simple and complex decision tasks were administered to sleepdeprived and well-rested individuals. They found that while activation of the PFC and task performance remained relatively unchanged for sleep-deprived participants during a simple decision task, significant impairments in performance accompanied by decreases in neural activation of the PFC were seen in complex decision tasks. These findings indicate that higherorder cognitive processes and executive functioning housed in the PFC may be impacted by sleep deprivation, contrary to the belief that basic cognitive functions like attention are the only operations affected by sleep deprivation.

While general decrements of brain activation in areas linked to complex cognitive processes can be observed in neuroimaging studies, it is important to understand how this can impact specific behaviors exhibited during the decision-making process. The ability to monitor taskrelevant information is crucial, as failures to keep track of changing information can impede on an individual’s ability make decisions based on the current circumstances. In a study conducted by Whitney et al. (2014), in which the fundamental rules of a reversal learning task were switched unpredictably, sleep-deprived individuals had difficulty learning the initial rules and adjusting to the new ones, contributing to poor performance even as the task continued for several trials after each rule reversal. This suggests that sleep-deprived individuals struggle when confronted with abrupt situational changes, reflecting an inability to keep track of task stimuli, previous choices, and outcomes. Difficulties in adjusting to a dynamic situation can hinder the ability of a sleep-deprived individual to choose the best solution given the current problem, as they may be unable to rely upon accurate and up-to-date reservoirs of information related to the decision task.

In addition to reducing accurate tracking of task-relevant information, sleep deprivation reduces an individual’s ability to think innovatively and develop novel solutions. Innovative thinking is a necessary skill in the decision-making process, as individuals must think beyond obvious solutions and come up with creative ones to achieve positive outcomes. However, sleep-deprived individuals may have difficulty inventing new strategies and might be reluctant to try new solutions. In a study by Harrison and Horne (1999), both sleep-deprived and wellrested participants played a competitive business strategy game that required increasingly flexible thinking in order to succeed. Rather than approaching the problem from a different perspective, sleep-deprived participants were more likely to perseverate, or insistently repeat, old strategies, even when these strategies did not result in desired outcomes (Harrison & Horne, 1999). The rigidity in game strategy of sleep-deprived participants produced severe losses throughout the game (Harrison & Horne, 1999). The implications of these findings are serious, as many real-world situations require individuals to create novel solutions to challenging problems. If sleep-deprived individuals are unable to use innovative thinking to devise creative methods, they may continually use failed strategies and thus never reach satisfactory outcomes.

Additionally, sleep deprivation impairs an individual’s ability to assess the amount of risk associated with different solutions. The ability to perform a costs-benefits analysis is crucial to the decision-making process, as it helps individuals minimize the loss of resources and maximize gains. When well-rested, individuals often choose options with low risk if the outcome is framed as an overall gain but choose options with higher risk if the outcome is framed as a loss (McKenna et al., 2007). However, as demonstrated by McKenna et al. (2007), when 23

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sleep-deprived individuals completed the Lottery Choice Task, a decision task that assesses the amounts of risk and ambiguity a subject is willing to accept, they were more likely to accept greater risk for options associated with gains and avoid risk for options associated with losses — a reversal of the risk acceptance behavior seen in well-rested individuals. These findings suggest that sleep-deprived individuals are more susceptible to the effects of framing and will choose an option that seems beneficial despite the risk associated with it. There are several real-world situations when a diminished ability to appraise and avoid risk is potentially harmful, such as in healthcare settings where doctors debate on performing risky procedures that might prolong a patient’s life (McKenna et al., 2007), in business negotiations with high financial stakes, and in other situations when risky decisions have a lasting impact on others.

Aside from causing decrements in the cognitive abilities crucial to the decision-making process, sleep deprivation hampers an individual’s ability to process emotions and inhibit emotional responses. Emotions play a crucial role in decision-making due to their influence on cognitive processes, such as situation evaluation (Schwarz, 2000). Sleep loss has been shown to impact mood and emotional reactivity to both positive and negative events. In a study by Zohar et al. (2004), medical residents who had been sleep-deprived reacted more negatively to negative events during their work days and displayed blunted affect in response to positive events. A greater tendency to react negatively to events indicates that sleep-deprived individuals have a reduced ability to regulate their emotional responses, leading to intolerant responses to problems they face. Deficits in emotional processing can amount to difficulties in making decisions (Killgore, 2010) because they can reduce an individual’s willingness to address the problem and prevent them from taking steps to develop practical solutions.

Decision-making calls for the integration of several cognitive and emotional processes, both simple and complex, including attention, risk evaluation, information tracking, and emotional inhibition — all of which are susceptible to the detrimental impacts of sleep deprivation. While these processes are seemingly distinct, their interactions are crucial to the decision-making process, and deficits in all of these processes result in failures to accurately assess situations and make rational decisions. The real-world implications of poor decisionmaking are widespread and can impact several different professions in which people must make snap decisions about considerable problems. Researchers should continue to focus on decision-making in real-world contexts and further elucidate the full range of effects that sleep deprivation has on higher-order cognitive processes. This research is important, as it brings to light the serious impacts that sleep deprivation can have on daily functioning.

REFERENCES Bonnet, M. H., & Arand, D. L. (1995). We are Chronically Sleep Deprived. Sleep, 18(10), 908-911. doi:10.1093/ sleep/18.10.908 Diamond, A. (2013). Executive Functions. Annual Review of Psychology, 64(1), 135-168. doi:10.1146/annurevpsych-113011-143750 Harrison, Y., & Horne, J. A. (2000). The impact of sleep deprivation on decision making: A review. Journal of Experimental Psychology: Applied, 6(3), 236-249. doi:10.1037//1076-898x.6.3.236 Harrison, Y., & Horne, J. (1999). One Night of Sleep Loss Impairs Innovative Thinking and Flexible Decision Making.

Organizational Behavior and Human Decision Processes, 78(2), 128-145. doi:10.1006/obhd.1999.2827 Harrison, Y., Horne, J. A., & Rothwell, A. (2000). Prefrontal Neuropsychological Effects of Sleep Deprivation in Young Adults—a Model for Healthy Aging? Sleep, 23(8), 1-7. doi:10.1093/sleep/23.8.1f Killgore, W. D. (2010). Effects of sleep deprivation on cognition. Progress in Brain Research, 105-129. doi:10.1016/ b978-0-444-53702-7.00007-5 Lim, J., & Dinges, D. F. (2010). A meta-analysis of the impact of short-term sleep deprivation on cognitive variables.

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HAUCK | Sleep Deprivation and Decision Making Psychological Bulletin, 136(3), 375-389. http://dx.doi.org/10.1037/a0018883 Lim, J., & Dinges, D. F. (2008). Sleep Deprivation and Vigilant Attention. Annals of the New York Academy of Sciences, 1129(1), 305-322. doi:10.1196/annals.1417.002 Liu, Y., Wheaton, A. G., Chapman, D. P., Cunningham, T. J., Lu, H., & Croft, J. B. (2016). Prevalence of Healthy Sleep Duration among Adults — United States, 2014. MMWR Morb Mortal Wkly Rep 2016;65, 137-141. doi: http:// dx.doi.org/10.15585/mmwr.mm6506a1 Lund, H. G., Reider, B. D., Whiting, A. B., & Prichard, J. R. (2010). Sleep Patterns and Predictors of Disturbed Sleep in a Large Population of College Students. Journal of Adolescent Health, 46(2), 124-132. doi:10.1016/j. jadohealth.2009.06.016 Mckenna, B. S., Dickinson, D. L., Orff, H. J., & Drummond, S. P. (2007). The effects of one night of sleep deprivation on known-risk and ambiguous-risk decisions. Journal of Sleep Research, 16(3), 245-252. doi:10.1111/j.13652869.2007.00591.x Schnyer, D. M., Zeithamova, D., & Williams, V. (2009). Decision-making under conditions of sleep deprivation: Cognitive and neural consequences. Military Psychology, 21(Suppl 1). doi:10.1080/08995600802554607 Schwarz, N. (2010). Emotion, cognition, and decision making. Cognition and Emotion, 14:4, 433-440, doi: 10.1080/026999300402745 Watson, N. F., Badr, M. S., Belenky, G., Bliwise, D. L., Buxton, O. M., Buysse, D., Dinges, D., Gangwisch, J., Grandner, M., Kushida, C., Malhotra, R., Martin, J., Patel, S., Quan, S., Tasali, E., Twery, M., Croft, J., Maher, E., Barrett, J., Thomas, S., & Heald, J. L. (2015). Joint Consensus Statement of the American Academy of Sleep Medicine and Sleep Research Society on the Recommended Amount of Sleep for a Healthy Adult: Methodology and Discussion. Sleep, 38(8), 1161-1183. doi:10.5665/sleep.4886 Whitney, P., Hinson, J. M., Jackson, M. L., & Dongen, H. P. (2015). Feedback Blunting: Total Sleep Deprivation Impairs Decision Making that Requires Updating Based on Feedback. Sleep, 38(5), 745-754. doi:10.5665/sleep.4668 Zohar, D., Tzischinsky, O., Epstein, R., & Lavie, P. (2005). The Effects of Sleep Loss on Medical Residents’ Emotional Reactions to Work Events: a Cognitive-Energy Model. Sleep: Journal of Sleep and Sleep Disorders Research, 28(1), 47-54. doi: 10.1093/sleep.28.1.47

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HANSEN | Barriers to Professional Help-Seeking in the Deaf Community

Barriers to Professional Help-Seeking in the Deaf Community Michelle Hansen INTRODUCTION Audism, coined in 1977, is the prejudice and discrimination against people who are deaf by the hearing majority (Eckert & Rowley, 2013). Audism is apparent in education (i.e., the forced integration of English into deaf schools) and employment (e.g., 52% of Deaf individuals were unemployed in 2014) (Garberoglio, Cawthon, & Bond, 2016), but it is also apparent in the lack of health services for the Deaf, specifically in regards to mental health services (Garberoglio et al., 2016). This article will examine the following question: what barriers currently exist that impede Deaf individuals from seeking help from professionals for issues involving mental health?

Approximately 0.38% of the adult American population is functionally deaf (Mitchell, 2005), and 10.9 % of all U.S. adults had at least one diagnosable major depressive episode in 2016 (Blackwell, Lucas, & Clarke, 2014). Based on these statistics, approximately 1.3 million people are comorbidly deaf and depressed in the United States. However, this number does not take into account the psychological consequences of being deaf.1 Studies have shown that Deaf individuals are more than twice as likely to have experienced sexual abuse as children than their hearing counterparts (Black & Glickman, 2006; Kvam, 2004). Lack of communication with hearing parents and punishment for using sign language in oral schools are additional types of trauma unique to Deaf individuals (Anderson, Craig, Hall & Ziedonis, 2016). Deaf junior high school students were diagnosed with depression 30% more often than their peers (Watt & Davis, 1991). Moreover, deaf individuals are about four times more likely to suffer from an anxiety disorder, when compared to their hearing compeers (Black & Glickman, 2006).

For these reasons, it is crucial that mental health services are available to serve and assist the Deaf. However, literature has identified several pervasive issues that impede the helpseeking behavior of members of the Deaf community.

Main Concerns of Deaf Individuals Seeking Mental Health Services Lack of Accessible Mental Health Services One of the most dire issues inhibiting Deaf people from receiving psychiatric treatment is the absence of readily available psychological resources that cater to the Deaf. 56% of Deaf individuals cannot find accessible mental health services for the Deaf and upwards of 90% of Deaf adults believe that there are not enough existing mental health services that benefit the For the purpose of this article, Deaf with a capital “D” will signify people who have profound or complete hearing loss and use American Sign Language (ASL) as their primary means of communication, and deaf with a lowercase “d” will signify the difficulty or inability to hear.

1

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HANSEN | Barriers to Professional Help-Seeking in the Deaf Community

Deaf population (Feldman & Gum, 2007; Steinberg, Sullivan, & Loew 1998). This can be attributed to the overall scarcity of psychiatrists and psychologists who accommodate to the Deaf community, as fewer than three percent of all mental health service providers offer their services to Deaf individuals (Raifman & Vernon, 1996). A lack of accessibility could also be due to several logistical problems, including distance from a provider who offers mental health services to Deaf clients, a lack of finances, and a lack of interpreters or other translational services (e.g., teletypewriters, videochat programs).

Lack of Trust in Confidentiality Parameters.

A general mistrust of hearing people within the Deaf community is even more visceral for hearing mental health service providers (Anderson et al., 2017; Meador & Zazove, 2005). Among the main ways that mistrust can be fostered in a clinical setting is by breaching confidentiality.

With few mental health services in place for the Deaf in a close-knit Deaf community, there is a fear of being recognized by other individuals who are a part of that community (Anderson et al., 2017; Meador & Zazove, 2005; Steinberg et al., 1998). Recognition in itself can feel like a breach of confidentiality in that others become aware that a person is seeking help for mental health issues when that person did not consent to informing them of such. Furthermore, concerns that ASL interpreters and clinicians that work with Deaf people within group therapies will either know about other Deaf people who their client may have discussed in confidence, or consciously or unconsciously breach confidentiality through discussion with others outside of the realm of therapeutic settings (Mastrocinque, Thew, Cerulli, Raimondi, Pollard, & Chin, 2015).

Lack of Diagnostic Explanation.

Many Deaf people have trouble understanding the technical terms and diagnoses that frequently accompany a visit to a mental health professional (Anderson et al., 2017; Briffa, 1999; Meador & Zazove, 2005). One Deaf patient in particular simply stated, “the therapist never explained my diagnosis” (Anderson et al., 2017, p. 242). Deaf individuals are frequently given their diagnosis and an explanation of said diagnosis in written form, using what they describe as “big words” and “psychiatry words” (Briffa, 1999, p. 9). Though seemingly straightforward, written diagnoses can be troublesome for Deaf patients, as the average reading comprehension level of Deaf students at age 17 was at the same level as hearing students in the fourth grade (Holt, 1993). This suggests it is more difficult for Deaf individuals to understand written language than it is for hearing individuals, especially when more complicated vocabulary is involved (Kelly, Albertini, & Shannon, 2001; Marschark, Sapere, Convertino, Mayer, Wauters, & Sarchet, 2009). Additionally, written modes of diagnosis do not give Deaf patients the chance to inquire about possibly confusing terms. This can be problematic in that medical professionals, clinical psychologists included, tend to use patient education handouts, which are not available for translation into ASL (Meador and Zazove, 2005).

Lack of Interpreters Trained in Mental Health.

The majority of interpreters in therapy settings do not have any mental health training whatsoever, and some have no experience working with individuals with mental illnesses (Briffa, 1999). This has the potential of leading to uncomfortable and awkward experiences in a therapeutic setting, as well as a struggle in properly translating what physicians say.

Interpreters are crucial in bridging the gap between two different languages and cultures, 27

HANSEN | Barriers to Professional Help-Seeking in the Deaf Community

and consequently, when Deaf clients were asked what they would change about their current mental health providers, several responded that they would want their providers to only hire interpreters who were rigorously trained in mental health and confidentiality law (Anderson et al., 2017).

Lack of Knowledge of Deaf Culture Amongst Mental Health Providers.

Deaf culture is comparable to a national culture in that it is composed of unique histories, experiences and traditions (Sparrow, 2005). However, the most prominent trait of Deaf culture is the native language of ASL. There is a language barrier in place that makes it difficult for most hearing and non-ASL speaking psychologists to properly communicate with Deaf patients who are seeking treatment. Furthermore, there are two main concepts in Deaf culture that hearing medical professionals often do not address: the need to be included in conversational information and the need to wind down conversations (Meador & Zazove, 2005). The need to be included in conversation refers to a clinician communicating to a Deaf patient through his or her interpreter, rather than having a conversation exclusively with the interpreter. The need to wind down conversations has to do with a common practice in Deaf culture in which people spend a great deal of time saying goodbye, in opposition to English where conversations take a longer time to begin then to end (Swota & Hester, 2011). An abrupt ending to a conversation may be perceived as rude or thoughtless to a member of the Deaf community (Meador & Zazove, 2005).

This causes a unique dilemma in the need for psychologists who intend on working with Deaf populations to be both culturally and linguistically competent. Deaf individuals appreciate when hearing therapists learn basic signs (e.g., greeting signs) and how to fingerspell their names, which is one way in which service providers can combat linguistic and cultural barriers, and demonstrate an attempt to meet their Deaf clients where they are at (Munro et al., 2005).

DISCUSSION These five issues are among the key barriers that stand between the Deaf and the professional mental health treatment they deserve. Policymakers can better cater mental health services to the Deaf community by encouraging more clinical settings to provide access to interpreters who are specifically trained in mental health and are competent in confidentiality laws, as well as discourage the use of written documents to explain diagnoses. In general, further research should be done regarding the efficacy of current mental health services for the Deaf nationwide. If these crucial needs of the Deaf are met by the professionals who provide mental health services for them, members of the Deaf community may be more open to seeking formal sources of help in the future.

REFERENCES Anderson, M. L., Craig, K. S. W., Hall, W. C., & Ziedonis, D. M. (2016). A pilot study of deaf trauma survivors’ experiences: Early traumas unique to being deaf in a hearing world. Journal of Child & Adolescent Trauma, 9(4), 353-358.

Anderson, M. L., Wolf Craig, K. S., & Ziedonis, D. M. (2017). Deaf people’s help-seeking following trauma: Experiences with and recommendations for the Massachusetts behavioral health care system. Psychological Trauma: Theory, Research, Practice, and Policy, 9(2), 239-248.

Black, P. A., & Glickman, N. S. (2006). Demographics, psychiatric diagnoses, and other characteristics of North

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HANSEN | Barriers to Professional Help-Seeking in the Deaf Community American deaf and hard-of-hearing inpatients. Journal of Deaf Studies and Deaf Education, 11(3), 303-321.

Blackwell, D. L., Lucas, J. W., & Clarke, T. C. (2014). Summary health statistics for US adults: national health interview survey, 2012. Vital and Health Statistics. Series 10, Data from the National Health Survey, (260), 1-161.

Briffa, D. (1999). Deaf and mentally ill: Are their needs being met?. Australasian Psychiatry, 7(1), 7-10.

Eckert, R. C., & Rowley, A. J. (2013). Audism: A theory and practice of audiocentric privilege. Humanity & Society, 37(2), 101-130.

Feldman, D. M., & Gum, A. (2007). Multigenerational perceptions of mental health services among deaf adults in Florida.

American Annals of the Deaf, 152(4), 391-397.

Garberoglio, C.L., Cawthon, S., & Bond, M. (2016). Deaf People and Employment in the United States: 2016.

Washington, DC: U.S. Department of Education, Office of Special Education Programs, National Deaf Center on Postsecondary Outcomes.

Holt, J. A. (1993). Stanford Achievement Test—8th edition: Reading comprehension subgroup results. American Annals of the Deaf, 138(2), 172-175.

Kelly, R. R., Albertini, J. A., & Shannon, N. B. (2001). Deaf college students’ reading comprehension and strategy use.

American Annals of the Deaf, 385-400.

Kvam, M. H. (2004). Sexual abuse of deaf children. A retrospective analysis of the prevalence and characteristics of childhood sexual abuse among deaf adults in Norway. Child Abuse & Neglect, 28(3), 241-251.

Marschark, M., Sapere, P., Convertino, C. M., Mayer, C., Wauters, L., & Sarchet, T. (2009). Are deaf students’ reading challenges really about reading?. American Annals of the Deaf, 154(4), 357-370.

Mastrocinque, J. M., Thew, D., Cerulli, C., Raimondi, C., Pollard Jr, R. Q., & Chin, N. P. (2017). Deaf victims’ experiences with intimate partner violence: The need for integration and innovation. Journal of interpersonal violence, 32(24), 3753-3777.

Meador, H. E., & Zazove, P. (2005). Health care interactions with deaf culture. The Journal of the American Board of Family Practice, 18(3), 218-222.

Mitchell, R. E. (2005). The severely to profoundly hearing impaired population in the United States: Prevalence and demographics. Project HOPE Policy Analysis Brief.

Munro, L. E., Philp, K. M., Lowe, R. D., & Biggs, H. C. (2005). Counselling deaf clients: Politics, practice and process.

Raifman, L. J., & Vernon, M. (1996). Important implications for psychologists of the Americans with Disabilities Act: Case in point, the patient who is deaf. Professional Psychology: Research and Practice, 27(4), 372.

Sparrow, R. (2005). Defending deaf culture: The case of cochlear implants. The Journal of Political Philosophy, 13(2), 135-152.

Steinberg, A. G., Sullivan, V. J., & Loew, R. C. (1998). Cultural and linguistic barriers to mental health service access: the deaf consumer’s perspective. American Journal of Psychiatry, 155(7), 982-984.

Swota, A. H., & Hester, D. M. (2011). Providing culturally effective health care. Pediatrics in Review, 32(3), e39.

Watt, J. D., & Davis, F. E. (1991). The prevalence of boredom proneness and depression among profoundly deaf residential school adolescents. American Annals of the Deaf, 409-413.

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SADHWANI | Acceptance and Commitment Therapy

An Advocacy for Acceptance and Commitment Therapy Rachna Sadhwani In an increasingly competitive and volatile world, the number of stressors people face living in urbanized societies has risen exponentially. Our minds constantly drown in an ocean of clutter. While we are fighting to stay afloat, we fail to realize that we are not allowing our minds to simply observe and not judge. As a result, more often than not, this constant need to criticize takes a toll on our bodies. Whether rushing to a meeting with a client, scrambling to finish that paper due tomorrow, or struggling to keep our children out of trouble, our minds are always thinking, planning, and judging. We have been programmed to keep fighting and moving forward despite the circumstances. We are convinced there is no time to stand still to fully face and feel the stressor. However, is this always the healthy option?

In the United States, 1 in 5 adults, upwards of 43 million American adults and youths (aged 13-18), suffer from serious mental disorders in a given year (SAMHSA, 2017). With these statistics, the availability of mental health care has become more important than ever, yet the proportion of actual treatment given is still insufficient (SAMHSA, 2017). Only 40% of the American adults suffering from mental disorders receive treatments in a year (SAMHSA, 2017).

Moreover, suicide is the 10th leading cause of death in the U.S. (CDC, 2015). From these statistics we can imply that people need new hope for managing and treating their mental disorders.

There are multiple types of therapy that have helped people manage and overcome mental health issues, including the increasingly popular use of mindfulness techniques. These powerful techniques help us engage with the present without acting on our cognitions, as we usually take action based on how we judge our lives, emotions, and thoughts. By reducing judgment, we observe our emotions and thoughts at face value, and pursue our lives based on the true status of our existence. Within these techniques, Acceptance and Commitment Therapy, or ACT (Hayes, 2006), is becoming increasingly established as more people desperately try to ease their pain.

Dr. Steven Hayes, a revolutionary clinical psychologist, pioneered Acceptance and Commitment Therapy, which is based on the notion that people can lodge themselves in the cycle of “seeking happiness�. In a world that is often perceived as dangerous and stressful, many of us yearn to see the world through rose-colored glasses. Sometimes, the pursuit of happiness can be counterproductive, because we set personal expectations of happiness.

When events do not meet those expectations, we fall deeper into a negative state of mind.

When we experience negative emotions, we anxiously eradicate them because we think we do not have time or energy to really experience these sensations, thus we throw ourselves into the cycle of searching for happiness again (Harris, 2008). ACT teaches us when it is acceptable to stop running after a brief sensation of happiness, and to simply accept our emotions and thoughts for what they are: a few sensations and strings of words. We learn not to surrender to our thinking self and to get in touch with our observing self, and through this acceptance of 30

SADHWANI | Acceptance and Commitment Therapy

our cognitions, pleasant and unpleasant, we can set goals and take actions to still live a truly meaningful life (Harris, 2008).

ACT can bring us a step closer to dealing with the problem of increased prevalence of mental disorders. In order to take this step, we must first ask - what has caused the increased prevalence of mental disorders today? One possible explanation is our sluggish ability to keep up with the world’s advancements (Harris, 2008). Before urbanization and civilization, our ancestors were solely focused on survival. Their stressors involved avoiding predators and finding food to sustain themselves for the day. While our world has rapidly evolved, our minds have evolved at a much slower rate. Today, some of us perceive an intimidating meeting with our boss or public speaking as major stressors. Although they are stressful situations, most of them are not always life-threatening, yet our minds perceive them to be (Harris, 2008). We burden ourselves by labeling our thoughts and emotions as “bad”. As a result, we search for happiness in an attempt to eliminate these painful sensations. As former primates, while we now experience a wider range of emotions, happiness as a key one, our minds are still programmed to perform instinctual actions to help us increase chances of survival. Therefore, due to our former, more instinctual, motivations, our search for happiness stops abruptly when we fail to find it, and thus begins the vicious cycle - the happiness trap.

There are 6 guiding principles in ACT, as defined by Hayes (2006): 1. Acceptance is the backbone of any mindfulness technique. It is the process of accepting and allowing our minds to bring us whatever it pleases. Through acceptance, we reduce the amount we fight with our automatic emotions and thoughts, which leads us to feel and think without judgment. This is not to say that we should accept ALL automatic thoughts that could potentially lead to detrimental behaviors; however, we can identify the ones we should ruminate on and the ones to let go.

2. Cognitive Defusion focuses on a set of techniques that reframe how we react to our thoughts, emotions and sensations. It is the process in which we remove judgment, and observe our thoughts and emotions from a more realistic perspective.

3. Being Present helps us remain receptive of the given moment without attaching any evaluation to our situations or cognitive regurgitations. One of the ways we stay in the present is to describe environmental contingencies using our five senses.

This step allows us to truly stay in touch with our lives, and not deflect the present because of our perceptions.

4. The Self As Context step in ACT teaches us that we are not defined by our experiences and cognitions; we can detach ourselves from the experiences that we think are tightly tied to us. We realize that we can define who we are, and once we are aware of our power, we start to feel a burden lift.

5. Next comes the Values step. This is when we develop a stronger connection to our values. This is when we are reminded of who we are and why we make our decisions. Living by our values helps us perceive our lives to be more meaningful.

6. Once we master these techniques and are more attached to our values, we take Committed Action to achieve the goals we set for ourselves to live that meaningful life. Taking action allows us to live the lives we have dreamed, which can minimize incidences of “negative” emotional perceptions, and we ensure we commit to achieving our goals. With these techniques, we learn to take steps towards living a 31

SADHWANI | Acceptance and Commitment Therapy

more abundant life without letting our negative thoughts and emotions consume our motivation to move forward.

An empirical study conducted by Smout et al. (2012) illustrates the efficacy of ACT in treating various mental disorders. The study compared participants with depression, anxiety, eating disorders, substance abuse disorders, borderline personality disorder, psychosis, and pain symptoms in two groups. One group received ACT, while the other received the standard treatment specific to the disorder. In the ACT group, the data showed a decrease in expressed symptoms and duration of observed symptoms compared to the group receiving standard treatments. This study suggests that ACT has greater efficacy in treating mental disorders compared to other standard treatments.

Although studies on the effectiveness of ACT across multiple cultures are still underway, one other study suggests that ACT can be implemented and practiced among diverse groups (Woidneck et al, 2012). Due to the flexibility within each of the six processes, people from different cultures can practice these steps however they see fit. The guidelines can be implemented according to each culture’s values. ACT is a form of therapy that can be standardized while preserving cultural differences, thus pioneering a revolutionized perspective of clinical psychology.

Another study by Vakili et al. (2015) tested the efficacy of three treatments: ACT, SSRIs, and combined ACT-SSRIs treatment to determine the most effective treatment in reducing obsessive-compulsive (OC) symptoms and experiential avoidance (EA) in participants from Tehran, Iran. The results showed decreased symptomatic expression in participants receiving ACT and combined treatment compared to those receiving only SSRIs. There was no significant difference between participants in the ACT and combined treatment groups (Vakili, Y., Gharaee, B., & Habibi, M., 2015). From these findings, we can reason that ACT is an effective form of treatment (with or without additional medication) and can be effective in cultures outside of America too.

Looking at treatment findings and literature, we can hypothesize that more than a treatment, Acceptance and Commitment Therapy is a way of living that brings people hope.

We often forget to live in the present, as we are inundated with daily struggles and worries about the past and the future. We tend to fall deeper into an abyss of negative emotions and thoughts, without realizing that we attribute too much importance to them. We perceive these cognitive states to be true, however, they are simply a string of words or images produced by our minds. These negative emotions and thoughts are not always life-threatening, unless we turn them into life-threatening actions. The key to mastering ACT is to realize that we are in control of how we react to any type of adversity. In the direction where our world is headed, we need to implement mindfulness techniques that will guide us through the day and empower us to fulfill our dreams. What life is worth living without total realization of precious moments?

To live is to ACT.

REFERENCES Acceptance And Commitment Therapy (ACT): The Psychology Of Acting Mindfully. (2017, August 01). Retrieved January 20, 2018, from https://positivepsychologyprogram.com/act-acceptance-and-commitment-therapy/.

National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. (2015). 10 Leading Causes of Death, United States. Retrieved March 24, 2018, from https://webappa.cdc.gov/cgi-bin/broker.exe Harris, R. & Hayes, S. (2008). The Happiness Trap. London: Robinson. (2016, February 22). Retrieved January 20, 2018, from https://youtu.be/o79_gmO5ppg.

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SADHWANI | Acceptance and Commitment Therapy Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and Commitment Therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44(1), 1-25. doi:10.1016/j.brat.2005.06.006 Mental Illness. (n.d.). Retrieved January 20, 2018, from https://www.nimh.nih.gov/health/statistics/mental-illness. shtml#part_154785 Stockman, J. (2012). Lifetime prevalence of mental disorders in U.S. adolescents: Results from the national comorbidity survey replication–adolescent supplement (NCS-A). Yearbook of Pediatrics, 2012, 385-387. doi:10.1016/j. yped.2011.04.014 Smout, M. F., Hayes, L., Atkins, P. W., Klausen, J., & Duguid, J. E. (2012). The empirically supported status of acceptance and commitment therapy: An update. Clinical Psychologist, 16(3), 97-109. doi:10.1111/j.17429552.2012.00051.x.

Substance Abuse and Mental Health Services Administration. (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA 175044, NSDUH Series H-52). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/ Vakili, Y., Gharaee, B., & Habibi, M. (2015). Acceptance and commitment therapy, selective serotonin reuptake inhibitors, and their combination in the improvement of obsessive–compulsive symptoms and experiential avoidance in patients with obsessive–compulsive disorder. Iranian Journal of Psychiatry and Behavioral Sciences,9(1). doi:10.5812/ijpbs.845 Woidneck, M. R., Pratt, K. M., Gundy, J. M., Nelson, C. R., & Twohig, M. P. (2012). Exploring cultural competence in acceptance and commitment therapy outcomes. Professional Psychology: Research and Practice, 43(3), 227233. doi:10.1037/a0026235.

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LOCKE | Psychopaths and their Brain Differences

Psychopaths and their Brain Differences Leslie Locke Psychopaths are characterized as a complete anomaly of the human condition and have long fascinated the general population as well as psychologists. Psychopathy is a personality disorder that is defined as consisting of social and emotional traits such as glibness, lack of empathy, remorse, shallow affect, and irresponsibility, in addition to behavioral characteristics, such as promiscuity, impulsivity, and low behavior controls (Kiehl, 2006). Those afflicted with psychopathic personality disorder lack many of the characteristics that most people consider vital to being human: empathy, emotional attachment, and a basic level of respect for other people (Anderson & Kiehl, 2012). Because these characteristics come naturally to the vast majority of the population, many people take these characteristics for granted. While much is known about the behavior of psychopaths, there is still relatively little information on the brain structures that correspond to these behaviors (Kiehl, 2006). However, several researchers have tried to remedy this situation by studying the brains of psychopaths to see where their brain abnormalities lie.

Psychologists have successfully identified psychopathy. Information on how to assess psychopathy is readily available, with Hare’s Psychopathy Checklist-Revised (PCL-R) as the most widely used method of assessment (“Hare’s Psychopathy Checklist”). The PCL-R has proven itself to be an excellent test of a person’s psychopathic behaviors for research, legal, or clinical reasons. The test consists of 20 items that are meant to measure personality traits and behaviors in a given individual (“Hare’s Psychopathy Checklist”).

Psychopathy is currently believed to affect 1% of the general population (Kiehl, 2006).

Though few in number, psychopaths manage to make up approximately 25% of the prison population (Kiehl, 2006). Psychopaths commit a disproportionately higher number of violent crime as opposed to the percentage of non-psychopaths that also commit violent crimes (Anderson & Kiehl, 2012). Since the relatively small population of psychopaths commit so many of these crimes, they are a burden on society not only in the chaos and tragedy they create, but also economically.

This statistic stating that psychopaths comprise 1% of the population also includes nonviolent psychopaths, which are sometimes not taken into the equation. The stereotypical serial killer psychopath is often apprehended and included in statistics, but what about the icy-eyed, heartless CEO? The corporate psychopath is very much like the violent psychopath, aside from a few traits. These so-called successful psychopaths often have realistic long-term goals and good behavioral controls, which are aspects often not found in criminal psychopaths.

These psychopaths tend to fly under the radar of most people because the vast majority think of psychopaths only as the caricature that is often painted of them in Hollywood movies. The reality is quite far from the truth. Psychopaths hide in a variety of different positions, though many of the ‘successful’ psychopaths gravitate towards jobs that give them power over others.

Others behave entirely differently, choosing to lives their lives in a more parasitic way towards those around them.

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LOCKE | Psychopaths and their Brain Differences

It is clear that psychopaths function differently than everybody else, but the current question revolves around the physical brain differences. There have been studies that have attempted to pinpoint the brain regions that are involved in psychopathy, and in doing so, have discovered that several parts of the brain are different in psychopaths. Kiehl’s (2006) study included an investigation of how people with brain injuries to certain areas of the brain began to show certain psychopathic traits, which would point to the brain regions involved in psychopathy.

The regions that are implicated in most studies are orbitofrontal cortex, amygdala, anterior and posterior cingulate, and adjacent paralimbic and limbic structures (Anderson & Kiehl, 2012).

These specific parts of the brain and the abnormalities present are important, because they deal with items such as fear, decision making, and emotional regulation (Anderson & Kiehl, 2012). All of these mental functions are problematic for psychopaths.

Marsh (2017) found that psychopaths have substantially smaller amygdalas than the rest of the population. Additionally, there is an even larger difference between psychopaths and people who behave altruistically. Research has shown that the response in the amygdala, which is partially responsible for the body’s fear response, is lowered in psychopaths. This lowered amygdala response helps explain why psychopaths lack fear and and do not seem to worry about the repercussions of their actions.

Other research, however, has suggested that it is actually the white matter connections linking the previously named structures that accounts for aberrant psychopathic behavior.

A study by Craig et al. (2009) found that this atypical connectivity present in the amygdala– orbitofrontal cortex limbic network might contribute to the neurobiological systems supporting the impulsive, antisocial behaviour and emotional detachment that is so often seen in psychopaths.

There are striking differences in the appearance of a psychopath’s brain compared to the brain of a non-psychopathic person (see Figure 1). Recent research has shown that psychopaths have a decreased amount of gray matter in their limbic and paralimbic areas and that these structural abnormalities may be contributing to their aberrant behavior (Craig et al., 2009). Having less grey matter is problematic, because the psychopath’s brain structures are not as connected as the average person’s, and this research is saying that their aberrant behavior is related to this.

Though there is still some difference of opinion on whether psychopaths have problematic brain regions or less neural connectivity, it is clear that psychopaths have a fundamentally different brain structure. The reality is probably a mix of both theories. It is crucial that people incorporating this knowledge into their daily lives. While psychopaths make up a minority of the population, they can make the lives of the people around them much more difficult. Instead of assuming that everyone will respond to situations with empathy and respect for others, it is important to be aware that a subset of the population will behave in unexpected ways characteristic of psychopaths as a result of brain abnormalities. Future research will hopefully provide a more precise view on the biological reasons behind dangerous psychopathic behaviors, so it is known exactly which brain regions or connections are at the root of the problem.

REFERENCES Anderson, N., & Kiehl, K. (2012). The psychopath magnetized: Insights from brain imaging. Trends in Cognitive Sciences, 16, 52-60.

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LOCKE | Psychopaths and their Brain Differences Craig, M. C., Catani, M., Deeley, Q., Latham, R., Daly, E., Kanaan, R., Picchioni, M., McGuire, P., Fahy, T., & Murphy, D. (2009). Altered connections on the road to psychopathy. Molecular Psychiatry, 14, 946-953.

“Hare Psychopathy Checklist.” The Gale Encyclopedia of Mental Health. Retrieved February 2018 from Encyclopedia. com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/hare-psychopathychecklist Kiehl, K. (2006). A cognitive neuroscience perspective on psychopathy: Evidence for paralimbic system dysfunction.

Psychiatry Research, 142, 107-128.

Marsh, A. (2017). The fear factor: How one emotion connects altruists, psychopaths, and everyone in-between. New York, NY: Basic Books.

FIGURES

Figure 1. Positron emission tomography (PET) scans of a normal brain compared to a psychopathic brain. Adapted from “The Psychopath Magnetized: Insights from Brain Imaging,” by N.E. Anderson and K.A. Kiehl, 2012, Trends in Cognitive Sciences, 16(1), p. 52-60. Copyright 2011 by Elsevier Ltd.

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MOSES | Recommendations for Gender Expression

Recommendations for Gender Expression in Nick Jr. Television Programs Julia Moses INTRODUCTION Until the mid-twentieth century, traditional gender roles, such as sensitive and weak women and strong and emotionless men, were seen as necessary parts of childhood development. Findings suggest that kindergarten-aged children will try to predict a person’s gender on television by employing gender stereotypes (Durkin & Nugent, 1998). In the 1960s, researchers began to define societal precepts of the characteristics that were considered male and female. Widespread agreement emerged of women as considerate, emotional, and gentle, while men were active, dominant, and rough. Despite intense political activism from the women’s rights movement to change these gender roles, gender stereotypes still seem to stay more or less unchanged (Lueptow, Garovich, & Lueptow, 2001; Ruble, Martin, & Berenbaum, 2006; Vonk & Ashmore, 2003).

Children use gender roles as a way to make sense of the world. They commonly use heuristics, or mental shortcuts, to make initial judgements about a person. Gender stereotyping is one way of using heuristics. Preschoolers usually rely on an individual’s perceived gender to make judgements and tend to ignore other conflicting information that may lead them to question their first impressions (Biernat, 1991; Martin, 1989). Heuristics have been found to be accurate in many cases, yet they almost always miss certain elements due to their surface judgements. However, the media, especially television (T.V.) programs, often portray women and men in ways that reinforce non-representative, stereotypical, and potentially harmful gender norms. According to social learning theorists, gender stereotyped knowledge and behaviors are transmitted to children through direct learning, which involves the use of straightforward teaching techniques. From an early age, children learn long lasting lessons from television programs. In a longitudinal study of a small Canadian town, researchers observed social differences in the participants before and after they had access to television reception.

Behaviors of school-aged children changed significantly over time, including increased aggression, reduced creative thinking, and increased gender stereotyping. (Williams, 1986).

Today, 8- to 18-year-old Americans devote an average of 7.5 hours each day to various kinds of entertainment media, approximately 53 hours a week. (Rideout, Foehr, & Roberts, 2010). In addition, the number of children that regularly watch T.V., rises from about 40% at 3-month-olds to 90% by age 2. By ages 2 to 6, a typical preschooler spends 1.5 to 2.7 hours a day watching television programs (Rideout & Hamel, 2006; Scharrer & Comstock, 2003; Zimmerman, Christakis, & Meltzoff, 2007). These staggering numbers reflect the importance of television on the development of children’s minds, opinions, and concepts, especially at very young and malleable ages.

Unsurprisingly, researchers have been concerned about television’s influence on the cognition and behaviors of young children. More specifically, they found that television has 37

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the power to teach harmful gender stereotypes. Women often have less screen time and are less likely to act as main characters when compared to men. In addition, they are often sexualized or portrayed as attractive, emotional, and victimized (Collins, 2011; Signorielli, 2001).

In recent years, these harmful stereotypes, however, may be changing. Female characters are progressively portrayed as more independent, assertive, intelligent, less emotional, and less sensitive. (Thompson & Zerbinos, 1995). Despite this progress, television viewing is still linked to negative gender stereotypes in children, which can lead to reduced self-esteem, lowered career aspirations, and negative body image (American Psychological Association, 2010; Cole & Daniel, 2005; Rivadeneyra & Ward, 2005). While television’s portrayal of gender has significantly changed since the 1950’s, progress still needs to be made. In a study by Thompson and Zerbinos (1995), lead male characters were observed with twice as many lines as the lead female characters. Similarly, initial tests on the behavior and communication variables indicated that male characters, when compared to their females counterparts, were more involved, because they simply appeared more often. In the present study, I analyzed the role of of gender stereotypes in three current children’s television programs. I aim to provide Nick Jr. with recommendations on how they should change, if at all, their television programs.

METHODS I watched three current Nick Jr. television programs that are recommended for ages 3 to 7: Peppa Pig, Ni-Hao, Kai-Lan, and The Backyardigans. These specific programs were picked since they all included an approximately equal amount of male and female characters. This way, I was able to identify the differences, if any, between the two genders’ portrayal. Peppa Pig (Astley, Barker, & Hall, 2004) follows the main character Peppa, an anthropomorphic pig, through adventures with her friends and family (three boys, five girls). Ni-Hao, Kai-Lan (Paladino, 2007) is about a girl named Kai-Lan who helps her friends solve their problems while teaching Mandarin and sharing Chinese culture (four boys, two girls). The Backyardigans (Burgess, Peltzman, Giggie, Shiell, & Palmer, 2004) tells the story of five friends (three boys, two girls) and their imaginary adventures in their backyard. The lack of a main character distinguishes this program from the other two programs studied. I noted the differences in gender portrayal, such as character appearances and interests, from each television program.

RESULTS Appearances of the Characters I believe the characters of the three T.V. programs had very different appearances in order to simplify the storyline for young children. In Peppa Pig, the female characters (Peppa Pig, her mother, and some of Peppa’s friends) all wore dresses. Distinctively, the male characters were drawn with more rounded shirt/pants combinations. In addition, the male and female characters were presented in stereotypical colors, with many main female characters in pink or red dresses and the main male characters in blue or green clothes. This was not a coincidence, as seen in the tenth episode of season three, the “Washing” (2009). In this episode, Peppa places her red dress and her father’s white football jersey into the washing machine, accidentally turning the jersey pink. The father exclaims that the jersey can no longer be worn due to its pink color.

In Ni- Hao, Kai-Lan, Kai-Lan, the main character, was the only character with flowers 38

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in her hair. Lulu the hippopotamus, the only other main female character, was drawn in pink.

Although Kai-Lan’s other friends are anthropomorphic animals like Lulu, the male characters were displayed in the natural colors of the animals that they representing. Kai-Lan and Lulu, the only female main characters, were drawn with long lashes, while the male characters visibly did not have eyelashes.

The third program, The Backyardigans, portrayed, albeit not to the extent of the previous programs, male and female characters differently. One of the main female characters named Uniqua is a pink bug, and like Lulu the hippopotamus in Ni-Hao, Kai-Lan, she is not the natural color of the species that she depicts. But unlike Ni-Hao, Kai-Lan, Uniqua is not the only character who was represented in this manner; in fact, all of the characters were displayed in unnatural colors. As for their clothing, the hippopotamus named Tasha, was represented in an orange dress with flowers on it. On the other hand, Uniqua may be pink, but she wore overalls, a traditionally unisex clothing item. The male characters were shown in very diverse clothing items. A penguin named Pablo wore a bow-tie and hat, a kangaroo named Austin was pictured in jeans, and a moose named Tyrone was dressed in a striped shirt.

Interests and Attributes of Characters A television character’s interests and attributes can reveal the fashion in which their genders will be portrayed in the program. In Peppa Pig, the characters all display distinct interests. Peppa enjoys splashing in muddy puddles, playing dress up, and has a teddy bear named “Teddy.” Her younger brother, George, always carries around a toy dinosaur that he called “Mr. Dinosaur.” Mummy Pig is a homemaker, while Daddy Pig regularly works at a job outside of the family home.

In the Ni-Hao, Kai-Lan, Kai-Lan is playful and adventurous. Kai-Lan is a natural leader and always solves her friends’ problems with the help of Ye-Ye, her grandfather. Ye-Ye, who is calm and peaceful, grew up in Hong Kong. When faced with trouble, Lulu, the energetic and sweet rhinosirous, tends to remain calm and positive. She is happiest when dancing, playing house, having tea parties, and dressing up as a fairy during playdates with Kai-Lan. For the male characters, Tolee, a gray koala who loves pandas and fruit, is intelligent and worries profusely. On the other hand, Hoho, the white monkey and the youngest of the friends, has a lot of energy and enjoys being the center of attention. Rintoo, another friend of Kai-Lan, is a rambunctious tiger who does not think before he acts, works on impulse, and likes to play rough.

In The Backyardigans, Uniqua is curious and confident but is stubborn and holds strong opinions. During their imaginary adventures, she sees herself in roles that require brains and fortitude, such as a scientist (Burgess et al, 2004). Tasha is sweet, more rational, and can be stubborn. For the male characters, Pablo, the male penguin, is easily excitable and tends to become very nervous, while Tyrone, the male moose, tends to be cool-headed and easygoing.

DISCUSSION While the three programs all have certain elements that portray gender in a strict binary fashion, there is an overall shift in traditional gender roles from early cartoons. Peppa Pig displays some gender stereotypes, which are expressed through the appearance and the personalities of the characters. The program supports traditional stereotypes of a breadwinner 39

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man and a domestic woman. Researchers found that male characters tend to display negative emotions more than female characters in T.V. programs since, stereotypically, females tend to not be as aggressive as males. (Thompson & Zerbinos, 1995). In “Washing” (2009), George and Peppa’s father claim that they detest pink unlike Peppa. This is not a coincidence since pink is usually seen as a “female” color. Peppa Pig supports the stereotype that only girls are allowed to enjoy games like tea parties. In “The Treehouse” (2004), Peppa refused to let her male friends into her treehouse, because she hosted a “girls only” tea party. These instances may give the impression to male viewers that they should not play in this fashion, even if they enjoy traditional female activities.

In Ni-Hao, Kai-Lan, I found less evidence of gender stereotyping, but it was nevertheless present. During Lulu and Kai-Lan’s playdate, they use glitter, put on princess costumes, and dance, but the male characters engage in play with blocks and toy cars (Paladino, 2008). This perpetuates the stereotype about how boys and girls should play. Despite Kai-Lan as a strong lead character, she still displays many stereotypical “female” traits, such as sensing problems, empathizing, and attempting to selflessly help others (Thompson & Zerbinos, 1995). Like KaiLan, the other female character, Lulu, is very mild mannered, calm, and rarely becomes upset.

However, the male characters, Tolee, Hoho, and Rintoo, tend to become angered and frustrated much easier and displayed more aggressive emotions than the two female characters.

The final program, The Backyardigans, exhibited the least gender stereotyping of the three. The characters imagine themselves in different scenarios with different roles. All of the characters are fairly equally represented as a new character takes the lead role for each episode. Uniqua usually imagines herself in roles that require thinking and finds herself in roles that are not stereotypically female. For example, in “The Heart of the Jungle” (2004), Uniqua plays a doctor-scientist who is inspecting the “jungle” that the characters created. Regarding appearances, Uniqua and Tasha have the least gender stereotyping of the female characters in the three programs. Uniqua is depicted in pink, but she wears unisex overalls. Tasha, on the other hand, wears a dress with flowers but is illustrated in unisex colors, orange and yellow.

The boys are not overly masculine, but they do not display feminine qualities either.

Overall, my findings revealed that these current Nick Jr. programs display certain gender stereotypes; however, each program exhibited equal representation of both males and females as well as strong female leads. One way to reduce gender stereotypes in T.V. programs would be to introduce more female characters dressed in clothing and colors beyond stereotypical female styles. It would be beneficial to destress the colors to not perpetuate the idea that certain colors are for boys and girls. Moreover, Nick Jr. should display the characters engaging in activities beyond their stereotypical gender roles, such as male and female characters playing with dolls or trucks, respectively. This way, Nick Jr. television programs will not alienate children who may not enjoy their gender appropriate toys.

Despite these minor flaws, there has been improvement in children’s T.V. programs since 1950’s. Women are not solely portrayed as housewives, unintelligent, or overly emotional in programs, such as The Flintstones (Hanna & Barbera, 1960) or The Jetsons (Hanna & Barbera, 1962) . Improving the gender representations in television even more will help eliminate gender stereotypes and will benefit the current generation and the next ones to come. More diverse gender representation is displayed in the evolution of children’s T.V. throughout the decades, but there are still some aspects of these programs as stated previously that need to be addressed to disintegrate the strict binary representations of gender.

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REFERENCES Astley, N., Baker, M., & Hall, P. (Writers). (2004, May 31). Peppa Pig [Television series]. United Kingdom: Nick Jr. Astley, N., Baker, M., & Hall, P. (Writers). (2004). Mummy pig at work [Television series episode]. In Peppa Pig. London, United Kingdom: Nick Jr. Astley, N., Baker, M., & Hall, P. (Writers). (2004). The tree house [Television series episode]. In Peppa Pig. London, United Kingdom: Nick Jr. Astley, N., Baker, M., & Hall, P. (Writers). (2004). Very hot Day [Television series episode]. In Peppa Pig. London, United Kingdom: Nick Jr. Astley, N., Baker, M., & Hall, P. (Writers). (2007). Dens [Television series episode]. In Peppa Pig. London, United Kingdom: Nick Jr. Astley, N., Baker, M., & Hall, P. (Writers). (2009). Washing [Television series episode]. In Peppa Pig. London, United Kingdom: Nick Jr. Barbera, J., & Hanna, W. (Writers). (1960, September 30). The Flintstones [Television series]. United States: HannaBarbera Productions.

Barbera, J., & Hanna, W. (Writers). (1962, September 23). The Jetsons [Television series]. United States: Hanna-Barbera Productions.

Berk, L. E. (2006). Child development (9th ed.). Boston, MA: Pearson/Allyn and Bacon. Burgess, J., Peltzman, A. (Writers), & Giggie, B., Shiell, M., & Palmer, D. (Directors). (2004, October 11). The Backyardigans [Television series]. United States: Nick Jr. Burgess, J., Peltzman, A. (Writers), & Giggie, B., Shiell, M., & Palmer, D. (Directors). (2004). The heart of the jungle [Television series episode]. In The Backyardigans. Los Angeles, California: Nick Jr. Burgess, J., Peltzman, A. (Writers), & Giggie, B., Shiell, M., & Palmer, D. (Directors). (2005). Polka palace party [Television series episode]. In The Backyardigans. Los Angeles, California: Nick Jr. Burgess, J., Peltzman, A. (Writers), & Giggie, B., Shiell, M., & Palmer, D. (Directors). (2007). Into the deep [Television series episode]. In The Backyardigans. Los Angeles, California: Nick Jr. Burgess, J., Peltzman, A. (Writers), & Giggie, B., Shiell, M., & Palmer, D. (Directors). (2009). Escape from fairytale village [Television series episode]. In The Backyardigans. Los Angeles, California: Nick Jr. Durkin, K., & Nugent, B. (1998). Kindergarten children’s gender-role expectations for Television Actors. Retrieved October 30, 2015.

Paladino, S. (Writer). (2007, November 5). Ni-Hao, Kai-Lan [Television series]. United States: Nick Jr. Paladino, S. (Writer). (2008). Tolee’s rhyme time [Television series episode]. In NiHao, Kai-Lan. Los Angeles, California: Nick Jr.Paladino, S. (Writer). (2008). Beach day [Television series episode]. In NiHao, Kai-Lan. Los Angeles, California: Nick Jr.Paladino, S. (Writer). (2009). Kai-Lan’s big play [Television series episode]. In Ni-Hao, Kai-Lan. Los Angeles, California: Nick Jr. Paladino, S. (Writer). (2008). Lulu day [Television series episode]. In Ni-Hao, Kai-Lan. Los Angeles, California: Nick Jr. Thompson, T. L., & Zerbinos, E. (1995). Gender roles in animated cartoons: has the picture changed in 20 years?

Retrieved November 2, 2015.

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ZEMSKY | Combating Eating Disorders: A Review

Combating Eating Disorders: A Review of Etiology and Interventions Caroline Zemsky Over the past 50 years, the United States has seen a historically high - 3-10% - increase in the prevalence of eating disorders, with approximately 30 million people having received diagnoses for eating disorders at present (NIMH, 2016; Polivy & Herman, 2002). Past research supports that 50-75% of adolescent girls display body and weight dissatisfaction (Polivy & Herman, 2002); however, knowledge about the effects of eating disorders, which are frequently comorbid with anxiety and/or depression, on mental health is limited (NIMH, 2016). When the term “eating disorder� comes to mind, popular culture disseminates images of morbidly underweight women purging food after consumption (American Psychiatric Association, 2013). Undoubtedly, the influences of eating disorders are much broader than this stereotyped assumption, and in fact, manifest differentially among individuals (American Psychiatric Association, 2013). Therefore, it is often difficult to recognize when someone struggles with the disorder. For instance, an individual who suffers from an eating disorder may appear underweight, obese, or perfectly healthy.

Eating disorders feature symptoms that are far more complex than purging after food consumption. In fact, clinicians recognize three major types of eating disorders. Bulimia Nervosa, commonly known as bulimia, is characterized by purging, or forced vomiting, after episodes of binge eating, in which an individual uncontrollably and recurrently consumes large quantities of food (DSM-5, 2013). Next, Anorexia Nervosa, or simply anorexia, is clinically diagnosed in individuals who are significantly underweight for their age, height, and gender (NIMH, 2016). Typically, anorexic patients consume disportionately fewer calories, nowhere near their recommended daily intakes (Troscianko, 2004). Lastly, Binge Eating Disorder occurs when patients exhibit recurrent episodes of unusually excessive food consumption in short periods of time and continue to eat despite feeling satiated (NIMH, 2016).

To better understand eating disorders, the etiologies must be examined. Some psychologists associate the development of the disorder with societal standards and sociocultural constituents, including Western culture, media, and peer influences (Owen & Laurel-Seller, 2000; Rubinstein & Caballero, 2000). Others believe that biological influences like genetics and family history precipitate the emergences of these disorders (Polivy & Herman, 2002). However, a combination of biological and environmental factors likely cause eating disorders. In accordance with the nature versus nurture theory, eating disorders may arise from environmental and sociocultural factors but only when individuals are already biologically predisposed (Mazzeo & Bulik, 2009). Essentially, environmental circumstances have the ability to transform a genetic predispositions into a disorder (Mazzeo & Bulik, 2009).

The onset of eating disorders, specifically, may involve environmental factors that tend to contribute to societal ideals and expectations of healthy and attractive figures, which young women are increasingly likely to fall victim to the disorder (Keel & Klump, 2003; Owen & Laurel42

ZEMSKY | Combating Eating Disorders: A Review

Seller, 2000; Rubinstein & Caballero, 2000). Historically, media has differentially impacted beauty standards (Spettigue & Henderson, 2004). Traditionally, heavier builds suggest signs of wealth (Bushak, 2015), as these individuals are more likely capable of paying for substantial amounts of food. In the 19th century, society glamorized curves, fuller figures, and weight gain.

Paintings from the early 1800s, such as works by Rubens, portrayed and idealized heavier naked women with body rolls. Newspapers and magazines even criticized slenderness with headlines, such as “Men Wouldn’t Look at Me When I Was Skinny” and “Skinny Girls Are Not Glamour Girls” (Bushak, 2015). Society’s definitions of beauty and health appears subjected to present sociocultural values.

In the contemporary society, media culture defines conventional beauty standards with slim, perfectly contoured bodies seen in magazines, television, Instagram, and advertisements (Morris & Katzman, 2003). Unsurprisingly, media problematically and pervasively promotes unrealistic and unattainable bodies of models who are airbrushed and digitized to achieve just that: tiny waists, sculpted figures, and the absence of any visible fat. Mobile apps, including Selfie Gym, Make Me Thin, Absmatic, and Six Pack Abs, are publicly available to photoshop digitized muscles onto images of the user’s body. Makeup artists and Youtube bloggers even produce tutorials on contouring artificial abdominal muscles, simulating enlarged breasts, and changing bodily features to achieve the unrealistic model figure (e.g., Cosmopolitan, “How to Contour Your Abs”). It is inevitable that these societal pressures and expectations are such major contributing factors to the development of eating disorders, as these disorders may manifest when individuals fall short of these standards (Morris & Katzman, 2003).

The drive to achieve societal standards of beauty may potentially lead to maladaptive self-hatred, body image issues, and in extreme cases, eating disorders (Morris & Katzman, 2003; Rubinstein & Caballero, 2000). Women deemed attractive, such as models in beauty pageants and magazines, are often malnourished, with body mass indexes (BMI) as low as 16.9, compared to a healthy BMI range of 18.5 to 24.9 (Rubinstein & Caballero, 2000).

Moreover, previous empirical findings suggested that increased media consumption promoting thinness is associated with the development of eating disorders (Hawkins, Richards, Granley & Stein, 2004). Media influences attractive qualities as well as predict abnormal eating patterns in both men and women (Hawkins, et al. 2004). When exposed to excessive media, women showed reduced body image satisfaction, while men exhibited stronger desires for thinness and dieting (Hawkins, et al. 2004). Even healthy dietary fads may pressure individuals towards body dissatisfaction when they fail to comply with the lifestyle (Thomas, Hyde, Karunaratne, Kasuman & Komesaroff, 2008). For example, when someone consumes unhealthy junk foods instead of allowing personal indulgence, the individual may reprimand and feel negatively about themselves, increasing the likelihood of developing an eating disorder (Morris & Katzman, 2003).

When failure to comply with this strict lifestyle leads to extreme disappointment, individuals may subsequently force themselves to purge (Grabe, Ward & Hyde, 2008). Similarly, a history of eating disorders may induce more susceptibility to the tribulations of maintaining a healthy diet.

Fortunately, there are several psychosocial interventions for treating eating disorders.

Cognitive Behavioral Therapy (CBT), Interpersonal Psychotherapy (IPT), and family based therapy/peer support are the most common techniques for treatments; however, more severe cases call for inpatient care and hospitalization (Brown & Keel 2012). For individuals suffering from Binge Eating Disorders, both CBT and IPT are effective treatment options. Previous research demonstrated that CBT reduces binging episodes from pre- to post-treatment by 43

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96%, while IPT reduces the incidences by 94% (Wilfley, Welch & Stein, 2002). Similarly, CBT is recommended as a treatment option for bulimia nervosa. Through CBT, 40% of patients achieved remission through the course of the therapy and significantly reduced episodes of binging and purging (Brown & Keel, 2012). Additionally, for those suffering from anorexia nervosa, 41% of patients achieved normal weight through supportive family-based therapies (Brown & Keel, 2012).

Moreover, combinations of treatments promote high recovery rates. For example, many psychologists advocate for family therapy or the combination of CBT and family support in treating eating disorders (Bulik, Baucom, Kirby & Pisetsky, 2010). Furthermore, a new program named Uniting Couples in the treatment of Anorexia Nervosa (UCAN) integrates spousal participation into therapy to support his or her afflicted partner (Brown & Keel, 2012; Bulik et al., 2010). This treatment alternative maximizes social support and heavily caters to resolving personal issues that increase susceptibility to the disease (Brown & Keel, 2012). Not only does UCAN help the afflicted individual for faster recovery, but it also supports the family and loved ones. This program offers CBT and familial support to combat the disorder and ultimately strengthens social ties.

The increasingly pervasive and negative impacts of contemporary Western culture increase attention to eating disorders. Education on mental wellbeing and eating disorders should be encouraged, especially with the high prevalence of eating disorders and persisting influences of media in the current society. Spreading awareness about the prevalence and consequences of the issue can address stigmatization and offers access to a broader range of support to affected individuals. Understanding the biological and sociocultural factors contributing to the onset and development of eating disorders is also vital in successfully targeting and combating the disorder. Although previous research has analyzed the efficacies of various treatment options, the effects of combined treatment methods have not been addressed.

Future research may want to consider this alternative and other ways that may prevent and treat the consequences of eating disorders.

REFERENCES American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Brown, T. A., & Keel, P. K. (2012). Current and Emerging Directions in the Treatment of Eating Disorders. Substance Abuse: Research and Treatment, 6, 33–61.

Bulik, C. M., Baucom, D. H., Kirby, J. S., & Pisetsky, E. (2010). Uniting couples (in the treatment of) anorexia nervosa (UCAN). International Journal of Eating Disorders, 44(1), 19-28.

Diagnostic and statistical manual of mental disorders: DSM-5. (2013). Arlington, VA: American Psychiatric Association.

Grabe, S., Ward, L. M., & Hyde, J. S. (2008). The role of the media in body image concerns among women: A metaanalysis of experimental and correlational studies. Psychological Bulletin, 134(3), 460-476.

Harrison, K., & Cantor, J. (1997). The relationship between media consumption and eating disorders. Journal of Communication, 47(1), 40-67.

Hawkins, N., Richards, P. S., Granley, H. M., & Stein, D. M. (2004). The Impact of Exposure to the Thin-Ideal Media Image on Women. Eating Disorders,12(1), 35-50.

Morris, A. M., & Katzman, D. K. (2003). The impact of the media on eating disorders in children and adolescents.

Paediatrics & Child Health, 8(5), 287–289. National Institute of Mental Health (2016). Eating Disorders. Retrieved April 2018, from http://www.nimh.nih.gov/health/topics/eating-disorders/index.shtml.

Owen, P. R., & Laurel-Seller, E. (2000). Weight and shape ideals: Thin is dangerously in. Journal of Applied Social Psychology, 30(5), 979-990.

Polivy, J., & Herman, C. P. (2002). Causes of eating disorders. Annual Review of Psychology,53(1), 187-213.

Rubinstein, S., & Caballero, B. (2000). Is Miss America an undernourished role model?. Journal of the American Medical Association, 283, 1569.

Spettigue, W., & Henderson, K.A. (2004). Eating disorders and the role of the media. The Canadian Child and

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ZEMSKY | Combating Eating Disorders: A Review Adolescent Psychiatry Review, 13(1), 16–19.

Thomas, S. L., Hyde, J., Karunaratne, A., Kausman, R., & Komesaroff, P. A. (2008). “ They all work... when you stick to them”: A qualitative investigation of dieting, weight loss, and physical exercise, in obese individuals. Nutrition journal, 7(1), 34.

Wilfley, D. E., Welch, R. R., Stein, R. I., Spurrell, E. B., Cohen, L. R., Saelens, B. E., Dounchis, J.Z., Frank, M.A., Wiseman, C.V., & Matt, G. E. (2002). A randomized comparison of group cognitive-behavioral therapy and group interpersonal psychotherapy for the treatment of overweight individuals with binge-eating disorder. Archives of general psychiatry, 59(8), 713-721.

Yager, J., Devlin, M. J., Halmi, K. A., Herzog, D. B., Mitchell, J. E., Powers, P., & Zerbe, K. J. (n.d.). Treatment of Patients With Eating Disorders, Third Edition. APA Practice Guidelines for the Treatment of Psychiatric Disorders: Comprehensive Guidelines and Guideline Watches.

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