Is your child ready to speak?

Is your child ready to speak?

Jarrisvette Villarreal, is from South, Texas in the United States. She worked as a Speech language Pathologist Assistant in Brownsville, Texas and then moved to Spain to pursue a Masters in Bilingual and Multicultural Education at la Universidad de Alcala in Alcala de Henares. She has been living in Span for 4 years and working as an English Language assistant with a variety of ages within the school system. She is currently working as a Speech therapist at Sinews and is excited to be a part of the team.

Do you notice that your little one is not yet speaking? Are you asking yourself why? Have you done a lot of research on how to promote talking, but can’t quite make it happen? Maybe we should take a step back, and ask ourselves if they are ready to talk? Have they acquired the pre-language skills that set the foundation for words?

As babies grow, their abilities change. Babies are like sponges; they absorb so much during their first years of life. They go from newborns who mostly sleep to walking, talking toddlers. This doesn’t happen overnight; there is a lot that happens in between these two phases, called “baby steps.” Little by little, they are going through minor changes every day and learning how to become these walking, talking toddlers. We always celebrate the big changes, like them producing their first word or taking their first steps. It’s incredible to witness the little ones learning and growing, but it’s easy to overlook the minor changes. These minor changes are what lead to their walking and talking, they are the skills that build the foundation for words and steps to happen.

We know that each baby is different and develops at their own pace, so maybe not every single one of them will hit that milestone mark at the, “said age.” However, there are still certain skills that a baby should acquire before they reach that milestone. Some children might need some extra help and guidance to gain these skills.

¿Está su hijo preparado para hablar?

Pre-language skills

Pre-language skills are prerequisites for speech and language. They are a set of skills that should develop alongside one another in both normal developing children and children with language disorders. These skills might not show up in the same order in every toddler, but they will show up before language emerges. These skills are what children use to communicate before they are able to form words. Pre-language skills must be consistently present, and stable in order for the child to be ready to talk.

How will I know if my child is ready to talk?

Lucky for us, Laura Mize, Speech Language Pathologist, has an awesome detailed podcast series that thoroughly describes pre-language skills. She talks about “11 skills a toddler must use before words emerge.” She helps us understand what they are, how to identify them and why they are important.

The pre-language skills mentioned in her podcast are:

  1. Responds to events in the environment: do they notice things around them? Children must be able to process things they hear and see. They must be aware of their surroundings, and react to it.
  2. Responds to people: are they interested in people? Children should interact with people. They’ll respond when you call them by name, or look for you, so you can play with them.
  3. Develops an attention span: attention spans in toddlers are typically 3-6 minutes long. They can notice something and are interested in it. They stay with it for a while and give themselves the chance to see how it works.
  4. Exhibits joint attention: they can share the moment. They can use a toy with you, and shift their attention from the toy to you.
  5. Plays with toys: toddlers learn through play and using toys. Toys are meaningful to them. Do they know how to appropriately play with the toys? For example: rolling a toy car on the ground.
¿Está su hijo preparado para hablar?
  1. Understands and uses early gestures: Do they communicate with their bodies? Can they wave bye-bye, nod yes or no, follow a point?
  2. Understands early words and follows simple directions: Do they recognize names of familiar people or things they use every day? If you say “Where’s dad?” or “Do you want water?” they will understand.
  3. Vocalizes: Are they noisy? Toddlers should make intentional and purposeful sounds with their voice, before they can even speak.
  4. Imitate actions, gestures, and words: They copy what you are doing. They use a toy the same way you use it, they clap when you clap.
  5. Initiates interaction: They take the lead to try and get your attention. They want to play with you, they try to get you to look at them or grab something for them.
  6. Turn taking: They are able to play back and forth. They can roll a ball or a car back and forth.

These are the 11 skills a toddler must develop before they start talking. Each one of these skills are essential to language development. Toddlers must have these skills firmly established in order for words to flow.

You can listen to the first part of the podcast clicking here and to the second one clicking here.

How can I help prepare my child for words?

As a parent you know your child best. You know what they are able to do and what they are not. You must be able to identify if these skills are present, consistent and strong in order for language to emerge. If one of these skills is missing, or isn’t strong, those are the skills you need to target and strengthen to prepare your child for words.

Questions we should ask ourselves when trying to determine how to help our children talk:

  • Which of these skills are present in my child? Which aren’t?
  • Which of these skills show up consistently? Which of them only every once in a while?
  • Which of these skills are strong? Which need some extra work?

We must determine which of these skills need reinforcement and which ones need to be introduced. Once we know what to target, we can work with our little ones to prepare them for words.

Should we go to a speech therapist?

¿Está su hijo preparado para hablar?

Some people will tell you “don’t worry words will come on their own, he/she is still young”. While that might be true sometimes, that is definitely not always the case. It’s great that you’re getting informed and learning more about how to help your child. You are the expert on your child and know them best, so if you have a gut feeling to seek help, there is no harm in that. The earlier children get the support they need, the better their outcomes.

Pre-language skills play a key role in language development. Children must go through all these skills before they start talking. If our little ones are late talkers, we must look at this list and determine what is missing, and work on those skills with them, or seek help from a speech therapist . It is important for us to not skip any steps that will lead to communication. We don’t want to push for words when our little ones aren’t ready yet. We need to set them up for success, by giving them the tools they need for language. Once we attain these eleven skills, we can focus on speaking words.

Sinews, Hacemos Fácil lo Difícil
Sinews MTI
Multilingual Therapy Institute
Psychology, Psychiatry and Speech Therapy
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Film review: God's Crooked Lines (2022)

The successful novel written by Torcuato Luca de Tena in 1979 has reached the big screen taking the same name of the book that has managed to hook readers since it was first published. Luca de Tena, with Los renglones torcidos de Dios or God’s crooked lines, takes us into a psychological thriller in which the reader will not be able to stop reading as questions will swirl around in his mind and he would hardly be able to leave those questions unsolved for the next reading. The film, on the other hand, engages the audience with the main character’s discourse -logical and very organised, which will generate new inquiries. Flashes from the past will make us reflect on the veracity of the facts.

Synopsis of the movie

The novel, and its eponymous film, tells the story of Alice Gould, a private investigator, who is admitted to a mental asylum on behalf of a client in order to clarify the circumstances of a murder. To do so, Alice documents herself about a mental illness, paranoia, and she pretends she is suffering from that illness. Recall that in the era in which the novel is set, wives had to ask their husbands for permission on certain things, getting Alice to trick her husband into signing the application for her admission to the sanatorium.

Throughout the pages and minutes of the film, readers and audiences will be making decisions about the reliability of what at one point seemed very obvious, the sanity of the main character of this story. But for the author of the book and the director of the film, sanity and insanity are separated by a very thin line.

Comparison with reality

According to the author of the novel himself, in order to write the book he had to voluntarily commit himself for 18 days in a psychiatric institution to be able to adjust to the reality of what was really living within those walls. Finally, in the dedication included in the book, he wants to thank the entire medical community for their work and tenacity to «straighten out» those crooked lines of God, the patients. Those patients who met himself and on whom he got inspiration from.

The main interest that this novel can generate in society lies not only in a simple leisure activity, but also in the progress that psychiatry and psychology have experienced since the time in which this thrilling story is framed. The different illnesses or conditions of the patients shown in the film and the book, bring mental health closer to anyone outside the field of health, although in some cases not in the most accurate way. The reader or the audience will be able to experience the close relationship between mind and physiology, the different techniques that were used for different disorders and even how patients were treated in these institutions. Nowadays, all of it may seem abusive or unacceptable for the audience but we shouldn’t put the spotlight on that. On the contrary, we should focus on the advances that have been experienced in those fields to preserve dignity and security of patients without depriving them of the inherent freedom to the human condition.

Sinews, Hacemos Fácil lo Difícil
Sinews MTI
Multilingual Therapy Institute
Psychology, Psychiatry and Speech Therapy
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A Superhero therapy tool kit to help your children cope with difficult situations

A Superhero therapy tool kit to help your children cope with difficult situations

Superhero therapy, is that a thing?

Janina Scarlet PhD, adapted an evidence-based therapy called Acceptance and commitment therapy (ACT) and turned it into the superhero lover’s dream. To help children and adults manage their symptoms of depression, anxiety, post-traumatic stress disorders and other mental health conditions. ACT and Superhero Therapy’s objective is to help people learn to have a healthier, more flexible relationship with their thoughts, feelings and other significant private events. Which in turn will allow them understand who they want to be and to move towards what is truly valuable to them. 

Working on values with children can be a very challenging task given its abstract background. Asking children or teens to do what is important above all pain or discomfort might seem impossible. Fortunately, That is where superheroes come in handy. Using an ACT framework, a therapist can help a patient relate to a fictional superhero, understand that superhero’s origin story and discuss how that superhero has overcome many of their own challenges (probably social, emotional or psychologically related) by taking actions toward their values (Washington, 2019). Prompting children to connect with a superhero’s story will allow them to play with different perspectives which can help them clarify what is important to them. 

So how can we use superhero therapy in our everyday life?

Ideally, superhero therapy should be used as a guideline for evidence-based therapists to use with children or adults in session. However like Marvel Comics creator Stan Lee said, “The person who helps others simply because it should or must be done, and because it is the right thing to do, is indeed, without a doubt a real superhero.” So grab your cape and lets bring out our superhero within.

1 – Find a superhero your children can relate to. Can you think of a superhero or a character your child can relate to? It can also be their favorite character, it does not have to be a superhero in a strict sense of the word. It can be any character in their favorite book, movie or series. It can even be a family member or a person in their life they admire. A character that might have an origin story or a struggle they can relate to. 

For example, for Dr. Scarlet it was Storm from X-Men. When she was very young, Dr. Scarlet was exposed to a nuclear explosion because she lived in a small town near Chernobyl. This had incredibly debilitating effects on her health. To make matters worse, her symptoms where heavily influenced by the weather, if it was hot outside she would get severe nose bleeds, if it was humid she would get migraines or seizures and so on. When she was twelve her family decided to move to the United States, thinking the situation would get better being away from radiation but there she faced other types of struggles. In school her new classmates could not understand what she had gone through. She had to endure intense bullying, she was called radioactive or contagious, her peers were afraid to touch her or be near her. This made her feel completely alone and depressed but it all changed when she watch X-Men. The “Super mutants” made her feel less lonely specially when she discovered Storm a superhero who could control the weather. A superpower she always wished to have since her own struggles depended on the weather. 

Is there any superhero that could make your child feel a little less alone in the world. A character they love or admire? It can be Batman, Ironman, Hulk, Harry Potter, Katniss Everdeen, even a Disney princess, a character from Encanto, Frozen and anime series. Anything you can think of. 

2 – What is their superpower? Try to find out what is it that your kid loves so much about this character. What superpowers do they have. What struggles have they faced and what have they needed to overcome them. What are they like, what characteristics have hook you child to this character. This is a conversation you can have with younger children too, they might not be as clear as older children but if they tell you they like batman because he is good at getting out of trouble there are a couple of characteristics you can take away from that, like smart, problem solving, quick, strong. There is always something behind the obvious answer, this superpowers might be the window to your children’s values. 

3 – Superhero diary. Once you have found the superpowers your child looks up its important they are translated into actions. Find a way you and your child can be a little bit more like Superman, Batman, Elsa, Katniss or whoever you have chosen. To make it more fun think of them as special missions and write them down in a Superhero Diary where your child can draw or write all the things they have done like their superhero so they can come back in difficult times and remind themselves all they are capable of. 

4 – Find a Superhero Mentor. Every Superhero has a sidekick or a mentor who supports them during their missions. Batman has Alfred, Harry Potter has Ron and Hermione, Ironman has Jarvis, Katniss has Haymitch. Encourage your child to find a sidekick or a mentor it can be a family member, a friend, a pet or even a therapist or a counselor. Sinews can be a great source for counseling, we great group of child therapists that will gladly jump at the chance to be a superhero mentor. 

5 – Every superhero journey starts with a struggle. Last but not least remind your children that all superheroes have an origin story that usually involve some kind struggle. Batman lost his parents, Harry Potter not only lost his parents he had to endure the horrible family he had left, Hulk was exposed to radiation. This stories turned them into the superheroes they are, the struggles helped them develop the incredible superpowers that we all admire. So if your children feel like life is a little daunting remind them it will turn them into amazing superheroes. 

References:

Scarlet, J. (2017). Superhero Therapy: Mindfulness skills to help teens & young adults deal with anxiety, depression and trauma. New Harbinger. 

Washington, K. (2019, April 25). What is superhero therapy?. Denver Health Blog. https://www.denverhealth.org/blog/2019/04/what-is-superhero-therapy

Sinews, Hacemos Fácil lo Difícil
Sinews MTI
Multilingual Therapy Institute
Psychology, Psychiatry and Speech Therapy
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Maneras de amar, un libro para entender mejor tus relaciones amorosa

Attached, a book to better understand your love relationships

Love is, without a doubt, one of the subjects that have fascinated us most (and tortured us, in equal parts) since the beginning of civilization, but also one of the great scientific questions: how does love work and, above all, why do we fall in love with whom we fall in love? In psychology, one of the theories seeking explanations, investigating, and solving, in part, these enigmas is the attachment theory.

The beauty of this theory is that if we know our attachment style, we can also resolve some of the love contradictions we fall into and make better romantic decisions. For example, «Why is it that if, in general, I consider myself a confident person, the moment the guy I like behaves distantly with me, I feel terrible and like I’m worthless?». Perhaps someone else is wondering: «I normally have no problem falling in love, but why is it that when the relationship becomes steady, I start to find they have too many flaws and decide to break up quickly?»

First, let’s put this theory in context: Initially, the study of attachment was not related to romantic relationships but to the bond that arises between infants and their parents or affectionate caregivers. In 1958, Bowlby, an English psychiatrist working in a hospital with children, coined this term when studying the effects of the mother-child relationship on the infant’s cognitive, emotional, and social development. Even if their physical and nutritional needs were met, the babies who had been prematurely separated from their mothers (because, for example, they were orphans during the Second World War) suffered serious consequences in their cognitive development due to the absence of contact with their attachment figure.

Thanks to this theory, we learned that when we are born, we need the protection of an adult to meet our physical needs – such as food and shelter – but, above all, we need the bond to feel loved, cared for, and comforted when our nervous system and stress response are activated.

It was not until much later, in the late 1980s, that Cindy Hazan and Philip Shaver helped us understand that the need for attachment is not unique to children. The security we feel or don’t feel in our romantic relationship also awakens our attachment styles. To put it simply, the bond created in our relationship with our parents functions as the blueprint for understanding our expectations in our future intimate and social relationships.

In this book, ‘Attached’ by Levine and Heller (2010), they take an in-depth look at how our attachment style influences the romantic decisions we make.

As children, people with a secure attachment style learned that the world was a stable, predictable place. They felt they could trust the people around them to be available whenever they needed them. That is why they tend not to feel much doubt in their romantic relationships. They feel comfortable showing themselves vulnerable to the person they love. In general, they feel deserving of such affection.

In contrast, people with an anxious attachment style grew up in an environment in which their physical and emotional needs were met ambivalently or intermittently: at times, they were there to care for them, and their affectionate caregivers understood what they needed, and at other times, they were not there or did not feel available to them. As we know, infants’ primary goal is to ensure their proximity to their attachment figure. That’s why children with an insecure-anxious attachment developed a very adaptive strategy to achieve this: to get even closer to their attachment figure especially when their caregiver moved away. As an adult, if you identify with this style, you probably criticize yourself a lot. When the person you like is distant or ambivalent, their attitude generates a lot of anxiety within you. To calm yourself down, you seek to get even closer to them. Please do not criticize yourself or call yourself «desperate» remember, in the past; this was an adaptive way to survive.

People with an avoidant attachment style learned that their caregivers might reject them or be distant from them. Therefore, they learned to rely only on themselves and not count on anyone else because if they were too trusting, they were afraid of being hurt later on. In their romantic relationships, they say they want intimacy and closeness, fall in love easily, and have no difficulty having intimate sexual relations. However, as soon as they deepen a relationship, they are afraid of losing their independence and become distant.

This book helps us identify our attachment styles and, from that knowledge, to take steps to find relationships that «heal» us. Specifically, it explores in depth the affective needs that each style possesses. For example, people with an anxious attachment style will need frequent contact, stability, clarity about what the other person feels, etc. Having these needs is valid, and more than that, it is essential to be aware of them and seek romantic relationships that are aligned with those needs. If we validate our own needs and communicate them openly, we will observe how our partner reacts and if they are ready to meet our needs (or not). From there, it will be easier to decide to prioritize relationships with people who offer us a secure base and transmit the affection and trust we need so much.

In ‘Attached’, we can have a first approach to attachment theory and how it influences our romantic relationships. But, in this book, several issues are left out; for example, the book does not reflect examples of LGTBQ+ relationships. Nor does it attempt to explain how attachment styles would influence polyamorous or non-monogamous relationships.

In any case, I think this book is an excellent start to reflect on your romantic choices and catch yourself on toxic patterns before they happen.

Good luck on this journey finding healthier relationships!

Lucía Largo
Division of Psychology, Psychotherapy and Coaching
Lucía Largo
Psychologist
Adults and adolescents
Languages: English and Spanish
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Movie Review: The Break-up (2006)

Movie Review: The Break-up (2006)

“The Break-Up” is an ideal movie to understand the inner workings of relationships. It is about Brooke (Jennifer Aniston) and Gary (Vince Vaughn), a couple who decide to put an end to their relationship after some years together, which then leads to a series of circumstances: the fight for who keeps the apartment they shared, and later, the way they both go through this breakup.

A scene that is key happens at the beginning of the movie, where the couple has an argument over superficial matters. Brooke accuses Gary of not helping her wash the dishes, and then continues saying that he never buys her flowers or takes her to the ballet. Gary then responds in a frustrated manner, saying he feels like nothing is ever good enough for Brooke and that she will never be happy with it.

This kind of argument can often happen within relationships, and there are times where the couple may not realize the message that is behind the superficial talk.
Within this couple’s dynamic we can observe how one’s thoughts and actions can feed into the other person’s, and viceversa, therefore creating a vicious cycle (or how we call it in therapy: circularity). In this case, if we reduce this dynamic to a simple mechanism, we would see it this way:

Brooke thinks “Gary doesn’t appreciate me”, therefore she feels like she isn’t valued, frustrated and demotivated. Consequently, she tells Gary that he doesn’t do anything for her. This leads to point number 2.

Gary thinks “Whatever I do, Brooke will never see it as enough”, therefore he feels incapable, frustrated and defensive. Consequently he doesn’t try to do things that Brooke would like. And this leads to point number 1.

Within this circularity, it would be necessary to make changes in order to create a new and healthier dynamic.

Moreover, later we see how Brooke does just this, by communicating exactly what she was meaning to get across in the first argument: she doesn’t feel valued or appreciated by Gary. In fact, we can see how Gary is much more receptive to this kind of vulnerable and direct communication, and therefore doesn’t act defensive because he doesn’t feel like it is an attack.

All in all, this romantic comedy is a tool that can show us how a relationship can become complicated due to dynamics that they can get stuck in and can tend to become chronic. But it can also show us how a small change in the dynamic can open new doors towards change and evolving within the relationship.

You can see the clip of the fighting scene here:
The Break-up Movie (2006)

Alexia Kelsey Roncero Penistone
Division of Psychology, Psychotherapy and Coaching
Alexia Kelsey Roncero Penistone
General Health Psychologist
Adults, adolescents, couples and families
Languages: English and Spanish
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Queridos Reyes Magos

Dear Santa...

As the song says: «Santa Claus is comming to town!» Another year of crossing off his wish list and wrapping packages. Few things are as magical as seeing the excitement in their eyes when they wake up on Christmas morning and see all the presents under the Christmas tree.
However, while we love to satisfy their desires, we would also like them to learn by playing. Many families have asked us for our professional opinion on this topic. That’s why we’ve dedicated a blog post to a short list of games that are both fun and help stimulate their cognitive functions.
  • LINCE (Lynx): We start with an ideal game to stimulate the selective attention of the little ones of the house. It consists of a round board with images and cards on which only one image appears. The game consists of removing a card and finding the image that appears on it as quickly as possible. The first one to find it wins the round. Ideal for an afternoon with the family! (4-7 years old).
  • CUBEEZ: Imagine a hybrid between Mr. Potato and a Rubik’s cube and you will get a glimpse of how Cubeez works. Each player has three cubes with different eyes and mouths. The player who can create the face on the card first wins the game. In addition to having a fun time, we will get to work a variety of cognitive functions such as visual selective attention, spatial orientation and fine motor skills.
    (From 6 years old).
  • JUNGLE SPEED KIDS: The children’s version of this classic board game is perfect to stimulate the reflexes and visual memory of the little ones. The objective of the game is to remember the position of the animal cards in order to form as many pairs as possible and save them from the lion’s claws. The winner is the player who has managed to turn over the most pairs. Another interesting aspect of this game is that it will allow us to work on behavioral inhibition, since when a player picks up two cards and they do not have the same animal, he/she cannot participate in the game until it is his/her turn again. (From 5 years old).
  • CONCEPT KIDS: This game is, without a doubt, one of the most recommended for working on concept formation and abstract reasoning. The objective is to get the rest of the players to guess an animal by pointing out the icons that appear on the board. One of its main advantages is that it does not require the use of verbal language or the learning of reading. Therefore, it is ideal for children from 4 years old.
  • ANIMAL ON ANIMAL: A version of the classic Jenga adapted for children, which will test their concentration and visuospatial skills. It is one of those basics that never goes out of fashion, getting the whole family. (From 4 years old).
Board games are a wonderful way to spend quality time with our children, because what they will remember when they grow up is not that fascinating toy Santa brought them, but all those special moments we spent as a family.
Written by Alba Ferrero.


What can we do if we are told that a family member has cancer?

What can we do if we are told that a family member has cancer?

Receiving news as serious as the illness of a family member is often an event with enormous destabilizing potential. This fact becomes even worse if we talk about cancer, since this disease carries with it an enormous stigma as it is socially considered a fatal condition, although in practice it is not always the case.
Many people, once the initial shock of the news has passed, then to ask themselves if there is something they can do for their family member, but many times the question arises of how a person can be helped in this situation at all.

As we discussed earlier in posts on this topic, talking about cancer in general is misleading, since this disease, depending on the location, size and health status of the patient can be as harmless as to have practically no complications (in cases of rapid detection and intervention), or as terminal as being inoperable and deadly.

In any case, many of the things we can do for people who suffer from this disease are the same regardless of the degree of severity of their condition, so we are going to make certain points and then mention special cases.

1) Understand what kind of help our family member needs: We all have a way in which we like to be comforted, some people need physical contact, it calms them and makes them feel better, but other don’t stand it and may feel uncomfortable with it. In the same way, there are people who appreciate regular interaction and being checked on to see how they are doing, and there are those who prefer to have their own space and time alone to manage the wave of emotions that comes with this type of news. Since we cannot read the minds of the people we live with, there is a little trick that almost always works: Ask!
Giving space to our familiar, and asking questions like: “is there anything I can do to help you?”, “Would you rather we talk about this often, or do you think it would be better for you to deal with this on your own?” “Would it make you feel better if we made plans more often?” are great ways to empower the person we speak to. We allow them to manage the interactions they have in the way that is easiest for them, and we also have the certainty that we are helping.

2) Be attentive to intense emotional reactions: It is very normal that after receiving news of this caliber, emotions can overtake the person who listens to them. The emotions that someone may feel can be really varied; sadness, shame, guilt for not having acted before, anxiety, fear, anger and many more. Sharing the burden of these emotions (always at the pace the affected person sets, as mentioned before) always makes them easier to manage. In addition, normalizing these types of emotional reactions and accompanying the person who suffers them is never a bad option.

3) Pay attention to distorted thoughts: When we suffer waves of intense negative emotions, they often bias our way of thinking and we can end up having thoughts that are somewhat dramatic, illogical and somewhat extreme. It is not uncommon to meet people who think that what happens to them is a punishment for something they did wrong, that their life no longer has meaning, or that others cannot help them at all. Helping patients eliminate these thoughts is the job of a psychologist, but sometimes simply being aware that they exist and are negatively affecting us helps reduce the effect they have on us.

In some cases, unfortunately, cancer is terminal, and although the previously mentioned shows of support are just as important, these cases have a particularities to them.

It is worth mentioning that in the face of death many times people re-evaluate their life and consider how it has gone, what they could have done differently, etc. This is a natural and desirable process, in which the accompaniment of a professional will always help.

Even so, there is an element that usually gives meaning to the last moments of the life of a person in the terminal phase, and it is the opportunity to say goodbye to their loved ones. Many people who die naturally do not have the opportunity to say goodbye to family and friends, and sometimes this is something that takes its toll to the point of complicating the grief of those close to them. However, expressing emotions, desires and affections while still can help both the sick and their families to move on and face the end in a less painful way.
There are always last wishes and actions to take, and it is at these times that patients have the option to do so.

Cancer is an increasingly studied and understood disease, and there are already many professionals in both oncology and mental health (psycho-oncology) who dedicate their lives to helping people who suffer from it. Accompaniment in these moments by qualified personnel can always be a relief that allows to lighten the burden of such a difficult moment for those who need it.

Sinews, Hacemos Fácil lo Difícil
Sinews MTI
Multilingual Therapy Institute
Psychology, Psychiatry and Speech Therapy
Clinic Appointment

el maltrato en la pareja

Intimate partner violence

Intimate partner violence (IPV) consists in any act of physical, sexual, emotional or financial violence exerted by one member of the couple in order to achieve total control over their partner.

It is considered one of the most widespread forms of violence against women, and according to Spain’s government, a 14.2% of the female population has suffered physical and/or sexual violence by an intimate partner. It is difficult to ascertain the real percentage of IPV cases, since the fear of retaliation, lack of support and stigma, hope that their partner would change, or lack of knowledge on how to get help, prevent people from reporting it. This is particularly frequent in cases of emotional abuse, where the violence is harder to see or prove.

What are the types of abuse committed during IPV?

We can organize violent behavior in four different categories, depending on the type of abusive act that is used to corner the person into submission.

  • Physical abuse: This type of violent behavior is aimed at inflicting pain, fear and humiliation through the use of punches, kicks, burns, hair pulling, strangulation, shoves, or any other form of physical abuse. Other methods used by the abuser are threatening to kill or hurt with a weapon, destroying household items (punching walls or doors, hurling objects…), forcing to consume substances or alcohol, driving recklessly, abandoning the person in dangerous places to “teach them a lesson”, preventing the person from getting medical assistance, or not allowing the person to leave the house.
  • Sexual violence: Any act consisting on forced sexual interactions, either through the use of direct physical force, threats or manipulation; or any non-consensual degrading sexual act performed during intercourse. Other forms of sexual abuse can be using demeaning sexual remarks in private or public settings; insisting on having sex even when the other person feels tired/sick; including a third party in a sexual interaction without consent; filming or photographing the person in sexual situations without their knowledge, or using the material to threaten and manipulate; or not considering the person’s feelings during sex.
  • Emotional abuse: The use of verbal violence, shame, guilt, disdain, isolation and intimidation to undermine the person’s self-esteem and instil feelings of fear, insecurity and helplessness. This type of violence is the most difficult to prove and detect, but also the most widespread and insidious. The use of insults; the constant criticism or devaluation of the other person’s personality, physical appearance, hobbies, actions or abilities; spying the person’s physical movements or communication with other people; ridiculing the person in public or private settings; using the silent treatment or giving the cold shoulder to punish the person; gaslighting in order to disorient and confuse, make the other person believe they are crazy or minimize the abuse; isolating the person from their family/friends/loved ones by sabotaging relationships or the use of jealousy and distrust; threatening to hurt or kill loved ones, pets or oneself are other examples of psychological violence.
  • Financial abuse: The use of income, savings or money to control and manipulate the person. The abuser will try to create a sense of total financial dependence in their partner through the control of the couple’s monetary resources; stealing from the other person, or using their money without their permission; impeding access to their salary or savings; or impairing the person from getting a job or education.

How can i tell if I am suffering from IPV?

Most of the time, abusive situations are hard to identify or detect; particularly if emotional abuse is playing a main role in the relationship, as it is usually subtle and hard to pinpoint. Another reason why we might not be fully aware it is happening to us, is the abuse always occurs gradually. Small painful acts that are easy to disregard are slowly normalized within the relationship, which eventually allows for more blatant forms of violence to occur unnoticed. Lastly, human beings tend to protect themselves from harmful or harsh realities. The person might minimize or deny the abuse is occurring in order to avoid the pain and shock of being aware the person they might love the most is knowingly tormenting them with the direct intention of subjugating and controling them.

In order to ascertain if we are being victims of any form of abuse or intimate partner violence, we can observe common behaviors of people who have been through this type of violence and compare them to our own. Victims often hide things from their partners in order to avoid an explosive fit of rage; they might avoid expressing a difference in opinion to their partner for fear of being ridiculed; be wary to contradict the other person to avoid a negative or violent reaction; they might have lost the confidence in their decision making, or the sense of control in their own actions and lives; they avoid to talk to or spend time with friends or family members for fear of their partner’s reaction of disapproval, jealousy or anger; accept to have sexual intercourse without wanting to in order to avoid conflict or tension; tolerate invasions of their privacy, such as the access to their devices and communications with other people; find themselves asking their partner’s permission (not opinion) to do things; be in constant fear of making any mistake that might spark their partner’s anger; suffer from feelings of worthlessness; feel unable to make decisions over their own life, the people they see, how they dress, or how they spend time.

Another way to identify if we are being subjected to IPV is identifying the psychological damage that it generates. The impact of sustained abusive behavior by a partner includes the destruction of one’s self-esteem, chronic stress, sleep and eating disturbances, substance or alcohol abuse, social isolation, apathy or depression, abrupt changes in mood, suicidal ideation and hopelessness, headaches or gastrointestinal problems, constant feelings of shame, guilt or insecurity, and the loss of trust in one’s ability to function as an adult.

How can I cope with the psychological impact of abuse?

One of the ways we can recover from the damage suffered in the context of intimate partner violence (after we have ensured our physical and emotional safety) is to receive counseling or support through psychotherapy. The main goal of treatment will processing the emotional trauma in order to understand, accept and leave it behind. However the restoration and bolstering of our self-esteem and self-confidence will also be a cornerstone of treatment; in addition to working on the symptoms derived from the abuse such as anxiety, depression or substance use.

Inés Zulueta Iturralde
Division of Psychology, Psychotherapy and Coaching
Inés Zulueta Iturralde
Psychologist
Adults and adolescents
Languages: English and Spanish
See Resumé

How to identify eating disorders in teenagers: 12 red flags!

How to identify eating disorders in teenagers: 12 red flags!

Eating disorders are complicated illnesses that affect adolescents with increasing frequency. They are ranked as the 3rd most common chronic illness in adolescent female, with a dramatic increasing rate over the past three decades. The causes of eating disorders are broadly accepted to be a combination of several factors: genetic, psychological, and sociocultural.
Eating disorders are extensive patterns of behavior driven by tremendous fear, anxiety and guilt from the person suffering it.

The three main eating disorders are: Anorexia nervosa, Bulimia nervosa and Binge eating disorder

  • Anorexia nervosa is an eating disorder in which people maintain a weight that is below average for their age and height. People with anorexia nervosa have an intense fear of gaining weight, therefore, always worried with food, and having a distorted body image. To stay underweight, they may starve themselves, eat sparsely and infrequently, purge food by vomiting or using laxatives, or exercise extremely.
  • Bulimia nervosa is manifested by series of extreme overeating and feelings of loss of control about eating, followed by purging or other behaviors to compensate for the overeating like vomiting, exercise or use of laxatives. Binge eating is often done in private because most people with bulimia nervosa are of average weight or even slightly overweight, it might not be readily apparent to others that something is wrong.
  • Binge eating disorder is characterized by recurrent episodes of extreme overeating and in secret but do not attempt to get rid of calories once the food is consumed. People with binge eating disorder may be embarrassed or feel guilty about binge eating, but they feel such a compulsion that they cannot stop. These people can have average weight, overweight or obese.

Unique features of adolescents and the developmental process of adolescence are often crucial considerations in determining the diagnosis, the treatment or outcome of the eating disorder.

Therefore, each adolescent has to be considered separately and differentiated from adults patients with eating disorders. It is important to realize that the list of red flags given below serve as a guidance, however, it can diverge for each adolescent.

12 Red Flags

1. Body insecurity
Having negative or obsessive thoughts about body size or shape. Persistent worries or complaints about being fat or the need to loose weight. Comparisons to other individuals and their shape/weight. (However, eating disorders are possible without body insecurity).

2. Intense and extreme exercise
Obsessive about doing exercise, sometimes even daily. Also, obsessive about exercise even when injured, tired or sick.

3. Fear of eating in front of others
Avoids situations that include eating in front of other or in public. Becoming more avoidant, secretive, irritable or anxious in the content of food (ex: difficulty at the family meal or going out for meals) Makes excuses about not being able to eat with friends or family.

4. Pleasure in others’ eating
Prepares elaborate meals for others, especially foods with high caloric intake that he/she will not eat.

5.Changes in appearance and clothing
Significant weight loss or again. Major hair loss, dry hair or skin or excessive facial or body hair. Also, change of clothing style (ex: baggies and bigger clothes).

6. Physiological changes
Develops unusual sleep patterns (ex: insomnia) and high sensitivy to low temperatures, feels tired most of the time, menstruation changes or there is an absence of it (amenorrhea). Also, constipation, stomach pain and dental cavities might be signs of having an ED.

7. Excessively restricting foods
Considers certain foods or groups of food completely off limits. Denying to eat or making excuses not to eat even to the point of skipping meals. There exists a incessant worry about dieting and calories.

8. Disproportionate fear
Avoids certain foods because of fear of choking or fear of purging after its intake.

9. Purging
May compensate for the food eaten through vomits, use of laxatives or diuretic abuse. As soon as the meal is over, leave the table immediately to purge.

10. Secretive eating
Large amounts of food disappear over short periods of time. Also, hoarding food can become part of the disease. A person may stockpile large amounts of food in various places where are binge may typically occur for them: car, home, break room, etc. Finding wrappers or containers that might indicate secret consumption of large quantities of food.

11. Eating rituals
When it comes time to eat in public, there exists a fixation to cut food into very small pieces or arrange food in a certain way to make it seem like they’re eating, while little or no food is consumed.

12. Isolation
There exists withdraws from usual friends, family and activities that used to be enjoyed before. Tends to isolate themselves in the room and get moody especially after eating. There is constant irritability and persistent low mood.

If your son/daughter or close friend you care about has changed their relationship with food, is skipping meals, making excuses for not eating, following a very limiting diet or focuses compulsively on eating, they could be suffering from an eating disorder. If left untreated, eating disorders can lead to serious illness and even death. Those girls with lower body weight can lose their menstrual periods, which could possibly lead to osteopenia, early bone loss that can lead to painful fractures. Also, eating disorders are highly related to other serious health troubles such as kidney disease and heart disease. Therefore, it is important to express your concerns in a caring and loving manner. If it’s your kid, speak with a professional, since teens are especially at risk and early intervention is key.

Rita Lara
Division of Psychology, Psychotherapy and Coaching
Rita Lara
Psychologist
Adults and adolescents
Languages: English and Spanish
See Resumé

Neurology in children. The Role of Child Neuropsychiatry (PART II)

Neurology in children. The Role of Child Neuropsychiatry (PART II)

In the second part of the article, we will provide some insights into four of the most prevalent neuropsychiatric conditions as follows:
1.-Epileptic syndromes: Temporal Lobe Epilepsy (TLE)
2.-Neurodevelopmental disorders:
2.a-Guilles Tourette Syndrome (GTS).
2.b-Autism Spectrum Disorders (ASD).
2.c-Attention Deficit and Hyperactivity Disorder (ADHD).

1.-TEMPORAL LOBE EPILEPSY

Temporal lobe epilepsy (TLE) is the most common of the anatomically defined syndromes accounting for around 60% of all patients with localisation-related epilepsy. Temporal lobe seizures produce varied and complex symptoms. It can become challenging for psychiatrists to distinguish these symptoms from similar presentations in other psychiatric conditions.

The most frequent cause of TLE is mesial temporal sclerosis (50-70% of cases), which is the slimming of the cortical hippocampal region of the brain. Mesial sclerosis is strongly associated with a history of childhood febrile convulsions, although in most cases aetiology remains unclear, that is, primary.

Temporal lobe seizures may take the form of simple (level of consciousness is preserved) or complex (reduced level of consciousness) and can be displayed as partial (movements of one part of the body) or generalized seizures (movements of the whole body).

A variety of autonomic features and visceral sensations have been described in so-called temporal lobe auras, being epigastric auras the most common of such presentations, that is, ill-defined sensations rising from epigastrium towards the throat. Other autonomic symptoms include changes in skin color, blood pressure or heart rate.

From a mental health perspective, it is worth noting that affective experiences have been commonly observed prior to temporal lobe seizures. Specifically, patients tend to complain about anxiety-related symptoms and subjective feelings of depression, guilt and/or anger, which are, of course, unpleasant. In addition, deja vú phenomena, that is, the patient erroneously reports having experienced the same reality before, have been frequently observed in those suffering from TLE. On the other hand, pleasurable effects of joy, elation or ecstasy can occur, although less frequently. In this regard, it has been speculated that Santa Teresa de Jesus may have suffered from TLE.

Of note, patient’s family members should be aware of the impact of aura on emotions, which can be associated with hallucinatory experiences and/or disturbed behaviour. More specifically, temporal lobe epilepsy sufferers can present with auditory, olfactive and/or visual hallucinations, which can be, of course, very stressful.

Not only patients with temporal lobe epilepsy can present hallucinations, but also visual and olfactive hallucinations can be displayed by people with dementia. Although auditory hallucinations can be considered as cardinal symptoms of schizophrenia, auditory hallucinations in TLE are an intrinsic part of the seizure, usually stereotyped, brief, evolving and lack an emotional response, that is, distress.

2.- NEURODEVELOPMENTAL DISORDERS

2.A Guilles de la Tourette Syndrome (GTS):
Guilles Tourette Syndrome (GTS) has been currently categorised as a neurodevelopmental disorder in the DSM 5, which is the most up-to-date classification of mental disorders by the American Psychiatric Association. GTS onset usually occurs at age 6 and there is a higher predominance in males than in females (3:1).
The aetiology (i.e., causes) of GTS remains poorly understood, although a combination of genetic, epigenetic and environmental factors have been postulated to underlie this syndrome. Truly, most patients with GTS have first-degree relatives with symptoms, which would provide support for a genetic component.
Regarding GTS presentations, the core characteristic is the presence of multiple tics which tend to go with forced involuntary vocalisations, which usually takes the form of obscene words or phrases (which is known as coprolalia). Specifically, GTS symptoms can be summarised as follows:
1.-INVOLUNTARY MOVEMENTS AND TICS:
Multiple motor tics (simple or complex) and at least one vocal tic is required for making a GTS diagnosis. Tics occur very frequently throughout the day almost every day for more than a year.
Tics are simple non-purposeful movements of functionally related muscle groups, which can be divided into simple tics which affect specific muscle group (for instance, eye-blinking) and complex tics, which involve several muscle groups, such as touching parts of the body. Phonatory muscles have been linked with vocal tics, such as sounds or grunt.
2.-BEAHAVIOURAL ALTERATIONS:
Psychiatric symptoms and behavioural disturbances in GTS patients can mirror features of obsessive-compulsive disorder (OCD), which may raise issues about the differential diagnosis between the two. More specifically, up to 28-65% of patients with GTS have been reported to have intrusive thoughts, which tend to focus on order and symmetry.
3.- COGNITIVE ISSUES:
To make matters more complicated, GTS patients can present with comorbid ADHD, which occurs in 31-91% of cases. Occurrence of ADHD is not associated with severity of the tic disorder, however. Other cognitive issues, such as executive dysfunction, have been commonly associated with GTS, which can have a very negative impact on their academic performance.

2.B. Autism spectrum disorders (ASD):
Today’s psychiatry has expanded autism boundaries to include a more heterogeneous group of patients that can present with a wide variety of symptoms and relevant differences in functional outcomes. Accordingly, the term spectrum has been adopted. In other words, ASDs include from patients with mild deficits to severely affected children and adolescents.
ASD core symptoms affect three domains:
1.- RECIPROCAL SOCIAL COMMUNICATION ISSUES:
ASD patients usually suffer reciprocal social communication issues, that is, problems in setting up bidirectional language. More specifically, verbal and non-verbal communication deficits have been described, such as catching doble senses and jokes, being able to create stories or the ability to flexibilise the language, poor eye contact, abnormalities in tone, intonation and rhythm of the conversation and/or limited range of gestures.
2.-STEREOTYPED AND REPETITIVE BEHAVIOURS:
ASD children tend to struggle to regulate their own behaviours, that is, changing routines and activities. As a result, ASD patients show restrictive and stereotyped behaviours, and an inappropriate lack of cognitive flexibility which affects their quality of life, including interests, habits and play. Patients with ASD usually lack creativity and imagination which turns in repetitive play more focused on objects and sequences.
Additionally, abnormal specific sensory interests have been reported in children with ASD. For example these patients tend to struggle with new colours, textures, smells and/or sounds, which can even trigger an outburst at home. Although the neurobiological mechanisms underlying these sensory issues remain unknown, the role of hyperreactivity in specific brain regions has been widely accepted.
Also, parents and caregivers should be aware of repetitive non purposeful movements, such as balancing or flapping, as major symptoms of classic ASD.
3.-SOCIAL INTERACTION DEFICITS
Most importantly, ASD has a significant impact on social day-to-day life. These children tend to become socially isolated as a result of difficulties in making and maintaining social relationships, which is a core symptom of the disorder. To make matters worse, lack of understanding of conventional social rules (for example grief, parties or celebrations) may result in inappropriate behaviours. Therefore, all the stakeholders involved in the care of ASD children have a role in mitigating their social isolation. This noted, early detection leading to early intervention has been demonstrated to be the most successful strategy to improve short- and long-term outcomes in ASD patients, thus improving their quality of life as well as reducing the burden of their family members and careers.

2.C. Attention deficit and hyperactivity disorder (ADHD):
Diagnosis of ADHD tends to be confirmed at around 6-7 years old, although earlier symptoms have been observed, which may be linked with worse prognosis. Up to 5% of children may suffer from ADHD and approximately half of them will continue to display ADHD symptoms in adulthood, particularly if untreated.
ADHD core symptoms can be categorised in three main domains, which are detailed below. Although most ADHD patients present with abnormalities in the three domains, more rare types of ADHD with deficits in a single domain have been described. Also, it is worth noting that many day-to-day behaviours displayed by ADHD children actually involve several domains, which therefore overlap each other.
As alluded to above, currently available pharmacological and non-pharmacological interventions can alleviate these symptoms and reduce their impact on functioning. Moreover, if (early) treated, ADHD can get ‘cured’. Hence, no ADHD patient should be prevented from receiving such a successful treatment, which, otherwise may have long-term implications.
1.- ATTENTION:
ADHD patients have significant difficulties in staying focused on cognitive processes, such as following multiple-step instructions and/or picking up specific details during a conversation. This inattention is not related to motivation. Thus, not only inattention can be observed when carrying out school tasks, but also during leisure time.
In addition, these children seem to get easily distracted by stimuli so they may not listen to others when directly questioned. Moreover, poor compliance with instructions in ADHD patients have been linked with poorer academic performance. Consistent with this, parents complain of their tendency to losing personal belongings and avoidance of those tasks requiring high levels attention/concentration.
2.- HYPERACTIVITY:
Hyperactivity observed in most of these children led to the conceptualization of ADHD decades ago. In particular, ADHD children are unable to keep still without moving different parts of the body, e.g. restless legs. Fidgetiness can be easily picked up by non-professionals, e.g. restless legs, rolling or rubbing their hands and/or having tics. Sometimes these features can be observed during sleep time.
Parents of children with ADHD have also reported that their children tend to choose games which do not involve cognitive processes. Rather, they prefer to play with more physical-based games and they appear to be unable to wait turn, e.g. queuing, travelling by plane or going to the cinema. These behaviours are frequently picked up by teachers who observed their inability to keep seated and to follow lessons at school. Moreover, ADHD children are usually described as talkative people who can become disruptive by interrupting others in conversations, which may contribute further to worsening their academic performance.
3.- IMPULSIVITY:
Impulsivity in ADHD refers to a tendency towards a decision-making style characterised by not reflection on consequences. As a result, they tend to take much risk, e.g. crossing the road without checking the traffic, climbing high places or walking around closed areas. These decisions can result in accidents (for instance, while cycling) and fractures.
ADHD-related impulsivity also involves emotional regulation and communication issues. Examples of these behaviours include interrupting others in conversations, prompting inadequate responses, lending others’ belongings and/or jumping queues.
Similarly, impulsivity is observed in terms of emotional regulation and understanding their own emotions, which they can express inadequately.

Summary and conclusions

Through this article we have intended to provide an overview of the role of Neuropsychiatry, which as a branch of psychiatry remains unknown to many people, in the management of children suffering from neuropsychaitric conditions. 

In particular, four highly prevalent neuropsychiatric conditions, which have been detailed above and have a relevant impact on child neurodevelopment, highlight the importance of better understanding neuropsychiatry. On reflection, professional staff should undertake specific training in neuropsychiatry, which should result in high-quality multidisciplinary teams delivering care to these complex children in need.

To sum up, highly qualified neuropsychiaty professionals should be prioritised in order to better manage children and adolescents suffering from neuropsychiatric conditions. In particular, the aforementioned complex needs of these patients and the high prevalence of neuropsychiatric disorders such as ASD and ADHD require integrative treatments delivered by multidisciplinary teams working collaboratively from a multiagency approach.

Sinews, Hacemos Fácil lo Difícil
Sinews MTI
Multilingual Therapy Institute
Psychology, Psychiatry and Speech Therapy
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