Month: October 2022

Want your child to grow up healthy, happy, smart, capable, and resilient? Play with them. Infants and toddlers thrive on playful games that change as they grow.

Why does play matter during the first few years of life?

More than a million new nerve connections are made in the brain in the first few years of life. And pruning of these neural connections makes them more efficient. These processes literally build the brain and help guide how it functions for the rest of that child’s life. While biology — particularly genetics — affects this, so does a child’s environment and experiences.

Babies and children thrive with responsive caregiving. Serve and return, a term used by the Harvard Center on the Developing Child, describes this well: back-and-forth interactions, in which the child and caregiver react to and interact with each other in a loving, nurturing way, are the building blocks of a healthy brain and a happy child, who will have a better chance of growing into a healthy, happy, competent, and successful adult.

Play is one of the best ways to do responsive caregiving. To maximize the benefits of play:

• Bring your full attention. Put the phone down, don’t multitask.
• Be reciprocal. That’s the “serve and return” part. Even little babies can interact with their caregivers, and that’s what you want to encourage. It doesn’t have to be reciprocal in an equal way — you might be talking in sentences while your baby is just smiling or cooing — but the idea is to build responsiveness into the play.
• Be attuned to developmental stages. That way your child can fully engage — and you can encourage their development as well.

Great games to play with infants: 6 to 9 months

The Center for the Developing Child has some great ideas and handouts for parents about specific games to play with their children at different ages.

6-month-olds and 9-month-olds are learning imitation and other building blocks of language. They are also starting to learn movement and explore the world around them.

Here are some play ideas for this age group:

• Play peek-a-boo or patty-cake.
• Play games of hiding toys under a blanket or another toy, and then “find” them, or let the baby find them.
• Have back-and-forth conversations. The baby’s contribution might just be a “ma” or “ba” sound. You can make the same sound back, or pretend that your baby is saying something (“You don’t say! Really? Tell me more!”).
• Play imitation games: if your baby sticks out their tongue, you do it too, for example. Older babies will start to be able to imitate things like clapping or banging, and love when grownups do that with them.
• Sing songs that involve movement, like “Itsy Bitsy Spider” or “Trot, Trot to Boston” with words and motions.
• Play simple games with objects, like putting toys into a bucket and taking them out, or dropping them and saying “boom!”

Great games to play with toddlers

Between 12 months and 18 months, young toddlers are gaining more language and movement skills, and love to imitate. You can:

• Play with blocks, building simple things and knocking them down together.
• Do imaginative play with dolls or stuffed animals, or pretend phone calls.
• Use pillows and blankets to build little forts and places to climb and play.
• Play some rudimentary hide-and-seek, like hiding yourself under a blanket next to the baby.
• Continue singing songs that involve movement and interaction, like “If You’re Happy And You Know It.”
• Go on outings and explore the world together. Even just going to the grocery store can be an adventure for a baby. Narrate everything. Don’t worry about using words your baby doesn’t understand; eventually they will, and hearing lots of different words is good for them.

Older toddlers, who are 2 or 3 years old, are able to do more complicated versions of these games. They can do matching, sorting, and counting games, as well as imitation and movement games like “follow the leader” (you can get quite creative and silly with that one).

As much as you can, give yourself over to play and have fun. Work and chores can wait, or you can actually involve young children in chores, making that more fun for both of you. Checking social media can definitely wait.

Playing with your child is an investment in your child’s future — and a great way to build your relationship and make both of you happy.

About the Author

Claire McCarthy, MD, Senior Faculty Editor, Harvard Health Publishing

Claire McCarthy, MD, is a primary care pediatrician at Boston Children’s Hospital, and an assistant professor of pediatrics at Harvard Medical School. In addition to being a senior faculty editor for Harvard Health Publishing, Dr. McCarthy … See Full Bio View all posts by Claire McCarthy, MD

Many people and their families associate the term palliative care with the end of life. Some may think that palliative care and hospice care are one and the same. So it’s worth explaining that palliative care is a medical specialty able to help people during many different stages of health, not just during a terminal illness. Importantly, the services offered could help you or someone you love enjoy a better quality of life, ease uncomfortable symptoms, and avoid unnecessary hospitalizations.

Asmedical oncologists (cancer doctors), we’ve witnessed how helpful this care can be when people experience cancer or another serious illness. Yet we find that not enough people who could benefit from this care receive it. By addressing misconceptions about what palliative care is and who it can help, we hope more people will ask for the full range of care they deserve, and inquire about whether a referral to palliative care is right for them.

What is palliative care?

Palliative care looks holistically at ways to improve quality of life for people and caregivers by

• helping people manage pain, nausea, fatigue, and other troubling symptoms associated with illness or treatment, to optimize their comfort and ability to function
• providing support for depression, anxiety, or stressors such as finances or relationships that may be affected by a serious illness
• improving care coordination by communicating with other health care providers to make sure everyone is on the same page regarding needs and preferences
• if appropriate, explaining and providing options for end-of-life care (this form of palliative care is part of hospice care).

In many health care settings, palliative care is handled by one or a few health care providers, such as a physician, physician assistant, or nurse practitioner. In others, palliative care may be provided by a team of clinicians and social workers, spiritual counselors, and case managers.

People sometimes think of palliative care as a last resort; you might have heard this, or even thought this way yourself. It may help to know that the type of care we’re describing is now recognized as essential to treatment, even during the early stages of serious illnesses like cancer, emphysema, heart failure, and kidney disease. People can and should receive palliative care while also receiving curative or life-prolonging treatments.

Who can palliative care help?

Palliative care can help any person experiencing a serious medical problem causing physical or emotional distress.

Typically, this refers to people with life-threatening or chronic illnesses such as cancer, heart disease, lung disease, neurologic impairment, or kidney failure. It can also refer to people who have experienced an injury resulting in physical ailments, emotional distress, or both. So in a sense, these services can be offered to anyone based on their symptoms rather than their specific diagnosis. Palliative care services are also available to support families and caregivers.

Why is my doctor talking to me about palliative care?

You might feel alarmed if your doctor recommends palliative care. However, it’s important to understand that the benefits of palliative care are greatest when introduced early after a new diagnosis of a serious illness, pain syndrome, or physical trauma. In our practice, we tend to explain the concept of palliative care soon after a cancer diagnosis for people who may benefit from additional support.

Our goal is to offer information on the resources available to support well-being, not to take away hope or scare people. The better you feel, the better you’ll do. Experiencing less pain, nausea, fatigue, or depression makes medical treatments and surgeries easier to tolerate, which may expand both quality and quantity of life.

We’ve answered frequently asked questions below.

Why is my doctor talking about palliative care?

To enhance support for people experiencing tough times and serious illnesses, not when “there’s nothing left to do.”

Am I dying?

A referral to palliative care does not mean that you are dying — it just means that you and your family may need more support to help you live as long and as well as possible.

Are you still my doctor?

Yes! Palliative care providers are consultants who team up with your doctors, including your primary care doctor and other specialists involved in your care.

If I have a question, who do I call?

If your question is related to a symptom or medicine managed by your palliative care team, then it is appropriate to reach out to them. However, you can never go wrong by calling the primary doctor directing your care, such as your oncologist if you have cancer. They can field your question and send you to the right person.

What medicines will be available to me?

Any medicines to help you feel better or live longer, including cancer treatments, are available if deemed helpful by you and your doctors.

Do I have to continue seeing my palliative care provider or team?

Just like any other doctor, they are available if you find you benefit from their services. If you no longer feel that you have needs that they can address, then you do not have to continue receiving their care.

Will my family benefit from palliative care?

Yes, definitely! One of the main goals of palliative care is to improve quality of life for people and their families or caregivers through counseling, information, and helping to coordinate doctor visits and medical tests.

About the Authors

Emily Stern Gatof, MD, Guest Contributor

Dr. Emily Stern Gatof is a hematology/oncology fellow at Beth Israel Deaconess Medical Center (BIDMC). She is pursuing a career as a breast oncologist and has a special interest in hereditary cancer syndromes. After attending the … See Full Bio View all posts by Emily Stern Gatof, MD

David J. Einstein, MD, Contributor

Dr. David J. Einstein is a genitourinary medical oncologist at Beth Israel Deaconess Medical Center, and an assistant professor of medicine at Harvard Medical School. In addition to patient care, he leads clinical/translational research in immunotherapy … See Full Bio View all posts by David J. Einstein, MD

Everyone has moments when their brain suddenly goes haywire. They repeatedly fixate on the same thought, like being stuck on a hamster wheel. Or their thoughts aimlessly bounce from one random topic to the next like a pinball.

People often refer to these thought patterns as racing thoughts, and the most common cause is anxiety, says Fairlee Fabrett, PhD, a psychologist at Harvard-affiliated McLean Hospital.

“People who struggle with racing thoughts are constantly worried about what needs to be done, what hasn’t been done, and what is next,” says Fabrett. “Or they obsess about past, present, or future situations.” For example, you replay a conversation with different versions of dialogue, ruminate about an upcoming meeting with your boss or medical appointment, or worry about an unlikely doomsday scenario.

“When racing thoughts take over your mind you can’t stay focused, and you feel trapped, which makes you even more anxious and stressed, and the cycle continues,” says Fabrett.

Breaking the cycle of anxiety and racing thoughts

How can you break this cycle and keep racing thoughts from controlling you? Here are five strategies to try.

Give yourself permission. Racing thoughts are often made worse by the anxiety over having racing thoughts. To escape this, give yourself permission to experience them. “Acknowledge that racing thoughts are just noise, it is what our minds sometimes do, and that’s okay,” says Fabrett. “This gives you a sense of control so you don’t feel helpless. When you put racing thoughts in their proper context, they feel less threatening and easier to manage.”

Get mindful. Practicing mindfulness can help change your thought patterns. For instance, try counting your breaths. Close your eyes and count to yourself as you take slow, steady breaths: count one on the inhale, two on the exhale, etc. When you reach 10, start over and repeat the process until you calm down. “This is also a great remedy before sleep when most people’s minds begin to ruminate,” says Fabrett. Also, practice this breath work at times when your thoughts are not racing, so you will have the skill when you need it.

Distract yourself. You can sometimes break the cycle by distracting your mind. “As soon as you notice yourself worrying again or thinking about things over and over, make an internal comment to yourself, like ‘here I go again, with my list of thoughts that never ends,” says Fabrett. Then make a conscious decision to do something else, like reading, listening to music, or calling a friend.

Get moving. It sounds like token health advice — exercise more — but movement is helpful for defusing anxiety. For instance, when an episode of racing thoughts strikes, do a set of push-ups, 10 jumping jacks, take a five-minute walk, or do household chores. “These not only help break the cycle of racing thoughts but give your mind something else to focus on,” says Fabrett. Also, try to build regular exercise into your life as well as these short bursts of activity. That can help relieve anxiety and stress.

Schedule worry time. Sometimes it’s best to let racing thoughts run their course; otherwise, they may linger indefinitely. To do this, schedule worry time. When anxious racing thoughts occur, recognize them, but tell yourself that now is not worry time and you will deal with them later. Then at a fixed time of your choosing, do nothing but explore those thoughts and work through them. For example, write down the thoughts that come to mind without editing, including all the worst-case scenarios you can think of.

“You can also talk about them aloud and ask what makes you nervous and why,” says Fabrett. “This allows you to confront your anxiety head-on, but on your schedule without taking away from other activities,” says Fabrett. Set a limit to worry time, like 10 to 20 minutes. When the time is up, you move on.

If racing thoughts regularly affect your life or interfere with sleep, talk to your doctor or a mental health professional. “Frequent racing thoughts may be related to anxiety disorders, attention deficit hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD), trauma, or other mental health issues that need exploring,” says Fabrett.

About the Author

Matthew Solan, Executive Editor, Harvard Men's Health Watch

Matthew Solan is the executive editor of Harvard Men’s Health Watch. He previously served as executive editor for UCLA Health’s Healthy Years and as a contributor to Duke Medicine’s Health News and Weill Cornell Medical College’s … See Full Bio View all posts by Matthew Solan

About the Reviewer

Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing

Howard LeWine, M.D., is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD

Ketamine is an unusual type of psychedelic drug — called a dissociative — that is undergoing a resurgence in popularity. Originally derived from PCP, or “angel dust,” ketamine has been used in hospitals and veterinary clinics as an anesthetic for decades, and has been cited as a drug of misuse under the moniker “special K.”

It is the effects that ketamine reliably produces that underlie both its medical and recreational uses: pain control, forgetfulness, intoxication, disassociation, and euphoria. Recently, it has been used more widely due to its approval for treatment-resistant depression (TRD) — that is, severe depression that has not improved via other therapies, including people who are experiencing suicidal thoughts.

Evidence of the benefit of ketamine

A prescription version of ketamine called esketamine (Spravato), given through a nasal spray, was approved in 2019 by the FDA for TRD; however, according to the guidelines, it is only to be used “under the supervision of a health care provider in a certified doctor’s office or clinic.” That means medical professionals need to watch you use it, and then follow you after you’ve taken your dose, checking your vital signs and how you are doing clinically.

The effectiveness of ketamine for TRD was first demonstrated for short-term treatment in research that resulted in clinically and statistically significant decreases in depression scores for ketamine versus placebo (In both groups in this study, the patients continued with their regular antidepressants because of concern of not treating TRD in the placebo arm.) Nasal ketamine was shown to have longer-term efficacy, in a study where ketamine (plus the regular antidepressant) helped people stay in stable remission 16 weeks into treatment.

Relief from TRD with ketamine happens rapidly. Instead of waiting for an SSRI to hopefully provide some relief over the course of weeks, people who are suffering under the crushing weight of depression can start to feel the benefits of ketamine within about 40 minutes.

Is ketamine the right treatment for you?

This is a discussion that should include your primary care doctor, your mental health provider, and any other health care professionals who care for you. It’s important to remember that ketamine isn’t a first-option treatment for depression, and it is generally used only when other, more longstanding treatments haven’t been effective. It is not thought to be curative; rather, it improves symptoms for a certain amount of time. It is easier to say who isn’t appropriate for ketamine treatment, based on the side effects.

Should you go to a ketamine clinic for treatment?

Independent, outpatient ketamine clinics are popping up all over the place. It is estimated that there are currently hundreds to thousands of these clinics — almost all of which were established in 2019 when ketamine was approved for TRD. Typically, these clinics are for-profit enterprises that are staffed by some combination of either a psychiatrist or an anesthesiologist (who can administer the infusion), a nurse, a social worker, and (of course) the businesspeople who make it all work.

In writing this piece, I called several ketamine clinics, posing as a patient, to investigate what would be involved in receiving ketamine therapy. Most of them seemed as if they would provide ketamine for me without any major hurdles, after an introductory medical interview by a nurse or a social worker. A few clinics required communication or a diagnosis from my psychiatrist — and this seemed quite sensible.

The clinics operate on a fee-for-service arrangement, so you would pay out of pocket, as insurance rarely covers this treatment. In the Boston area where I live, the ketamine infusions cost about $600 each, and a course of six infusions and a clinical re-evaluation are typically recommended. (I should note that the ketamine clinics affiliated with medical academic institutions seem to have more safeguards in place, and they may also be enrolling people in clinical trials.)

Are ketamine clinics safe?

These ketamine clinics raise many questions — namely, what does one look for in a reputable and safe ketamine clinic? Currently, we don’t yet have definitive answers to that question. One wonders if a ketamine infusion, which can cause a profound dissociation from reality, would be better controlled in a hospital setting, where there are protocols for safety in case anything goes wrong. It was unclear (in part because I didn’t actually go through with the therapy) how much communication, if any, there would be between the ketamine clinic staff and your health care providers, and typically the treatments you receive would not be included in your primary electronic medical record.

What are the side effects?

Ketamine is generally considered safe, including for those who are experiencing suicidal ideation (thoughts or plans for suicide). The main side effects are dissociation, intoxication, sedation, high blood pressure, dizziness, headache, blurred vision, anxiety, nausea, and vomiting. Ketamine is avoided or used with extreme caution in the following groups:

• people with a history of psychosis or schizophrenia, as there is concern that the dissociation ketamine produces can make psychotic disorders worse
• people with a history of substance use disorder, because ketamine can cause euphoria (likely by triggering the opioid receptors) and some people can become addicted to it (which is called ketamine use disorder)
• teenagers, as there are some concerns about the long-term effects of ketamine on the still-developing adolescent brain
• people who are pregnant or breastfeeding
• older adults who have symptoms of dementia.

More detailed research needs to be done on the longer-term benefits and side effects of ketamine treatment, and on its safety and effectiveness for teens and older adults, as well as for the emerging indications of ketamine therapy for PTSD, OCD, alcohol use disorder, and other mental health conditions.

Finally, there is some concern that, with repeated dosing, ketamine can start to lose its effectiveness and require larger doses to produce the same effect, which is not sustainable.

Ketamine could provide hope for people with serious depression

Serious, treatment-resistant depression can rob people of hope for the future and hope that they will ever feel better. Ketamine can provide help and hope to patients who have not found relief with any other treatments. Given its efficacy in people considering suicide, it is plausible that ketamine may be lifesaving.

As we learn more from research on ketamine and from people’s experiences in newer clinics, we will be better able to answer the questions of ketamine’s longer-term effectiveness and what safeguards are needed for treatment. We may also learn who is most likely to safely benefit from ketamine therapies, and the best method of administration: intravenous infusion, a nasal spray, or a pill.

About the Author

Peter Grinspoon, MD, Contributor

Dr. Peter Grinspoon is a primary care physician, educator, and cannabis specialist at Massachusetts General Hospital; an instructor at Harvard Medical School; and a certified health and wellness coach. He is the author of the forthcoming book Seeing … See Full Bio View all posts by Peter Grinspoon, MD

Parents like to think that they know what is going on with their children — and that they would know if their teen was suicidal. However, research shows that this is not always the case.

Teens may consider suicide more often than parents realize

In a study published a few years ago in the journal Pediatrics, researchers interviewed more than 5,000 adolescents ages 11 to 17. In those interviews, they asked them if they had ever thought about killing themselves — or if they had ever thought a lot about death or dying. The teens' parents were asked if they believed that their teens had ever thought about killing themselves, or had thought a lot about death or dying.

There wasn’t a whole lot of match-up. Half of the parents of the adolescents who thought of killing themselves were unaware — as were three-quarters of the parents of adolescents who thought often about death.

This disconnect looms larger as research shows mental health problems are on the rise in youth. According to the 2021 Youth Risk Behavioral Survey, 42% of high school students reported persistent feelings of sadness and hopelessness; 22% seriously considered suicide, and 10% attempted it.

The numbers were higher for girls and youth who identify as LGBTQ+:

• Almost 60% of girls experienced persistent sadness and hopelessness; 30% seriously considered attempting suicide, and 13% attempted it.
• Among LGBTQ+ youth, 70% experienced persistent sadness and hopelessness; 45% seriously considered attempting suicide, and 22% attempted it.

Many factors contribute to this. Stress and isolation caused by the pandemic clearly played a role. While teens are back in school, re-entry has been difficult for many. Social media clearly plays a role, inviting unrealistic comparisons, reinforcing negative thoughts and ideas, and encouraging doomscrolling. It is also a source of bullying: in the report, 16% of high school students reported being bullied electronically, including 20% of girls and 27% of those who identify as LGBTQ+.

Why the disconnect between teens and parents?

It’s not that surprising that parents don’t always know that their teens are considering suicide. Teens may not always realize how bad they are feeling, and may not want to tell their parents when they do — both for fear of worrying them, and also because of uncertainty about how their parents might react.

Parents may miss signs of depression in their teens, or quite genuinely misinterpret them or attribute them to something innocent; after all, it’s natural to want to believe that your child is fine, rather than thinking that they might be suicidal. And given how much drama can be intrinsic to the life of a teen, it’s understandable that parents could misinterpret statements about death or dying as, well, just teen drama.

What can parents do?

• Be aware of signs of depression in teens, and never ignore them. Acting sad is one of them, but there are many others:
  • dropping grades
  • being irritable or angry often
  • acting bored all the time, and/or dropping out of activities
  • difficulty with relationships, including changing peer groups or becoming more isolated
  • dangerous or risky behavior
  • persistent physical complaints such as headaches or stomachaches
  • fatigue.
• Listen to your teen, and never assume that statements like “nobody cares if I live or die” are just drama. Instead of saying, “You don’t mean that,” ask them if they do mean it. Often parents worry that asking about suicide might “give them ideas,” but asking may be the only way to know — and the best way to show your teen that you are taking them seriously.
• Learn how to have tough conversations about mental health and suicide. The American Academy of Pediatrics has many tips and resources for parents.
• Get help. Call your doctor, call a mental health professional, call the new nationwide number 988 that can link you to local help like a suicide hotline, or take your child to a local emergency room. This is crucial. If counseling is recommended, do your best to schedule it, letting your doctor know if you are having trouble finding a provider. Make sure your teen sticks with it.
• If you suspect your teen may be depressed or suicidal, take precautions. If you have a gun in your house, make sure it is locked up with the ammunition locked separately. Take stock of prescription medications and alcohol in your house that could be used for self-harm, and either get rid of them or be sure they are stored safely.

Sometimes it is just drama — or short-term blues after a breakup or another one of life’s inevitable disappointments. And in the study, half of the teens whose parents thought they were suicidal, and two-thirds of those whose parents believed their teens thought about death, said they were fine. But when it comes to suicide, it’s always better to be safe than sorry. So ask the questions — and ask for help.

About the Author

Claire McCarthy, MD, Senior Faculty Editor, Harvard Health Publishing

Claire McCarthy, MD, is a primary care pediatrician at Boston Children’s Hospital, and an assistant professor of pediatrics at Harvard Medical School. In addition to being a senior faculty editor for Harvard Health Publishing, Dr. McCarthy … See Full Bio View all posts by Claire McCarthy, MD