Amanda Rose, in an study published in the July issue of Development Psychology has found that girls who talk very extensively about their problems with friends are likely to become more anxious and depressed (Prospective Associations of Co-Rumination With Friendship and Emotional Adjustment: Considering the Socioemotional Trade-Offs of Co-rumination)
The six-month study, which included boys and girls, examined the effects of co-rumination - excessively talking with friends about problems and concerns. Rose discovered that girls co-ruminate more than boys, especially in adolescence, and that girls who co-ruminated the most in the fall of the school year were most likely to be more depressed and anxious by the spring.
When girls co-ruminate, they're spending such a high percentage of their time dwelling on problems and concerns that it probably makes them feel sad and more hopeless about the problems because those problems are in the forefront of their minds. Those are symptoms of depression. In terms of anxiety, co-ruminating likely makes them feel more worried about the problems, including about their consequences. Co-rumination also may lead to depression and anxiety because it takes so much time - time that could be used to engage in other, more positive activities that could help distract youth from their problems. This is especially true for problems that girls can't control, such as whether a particular boy likes them, or whether they get invited to a party that all of the popular kids are attending.
The study involved 813 third, fifth, seventh and ninth grade students. The participants answered questionnaires that assessed co-rumination, depression, anxiety and the quality of their best friendship in the fall and spring of the school year.
Ironically, although co-rumination was related to increased depression and anxiety, Rose also found that co-rumination was associated with positive friendship quality, including feelings of closeness between friends. Boys who co-ruminated also developed closer friendships across the school year but did not develop greater depressive and anxiety symptoms over time.
What's intriguing about theses findings is that co-rumination likely represents too much of a good thing. Some kids, especially girls, are taking talking about problems to an extreme. When that happens, the balance tips, and talking about problems with friends can become emotionally unhealthy. Rose recommended adolescents should be encouraged to talk about their problems, but only in moderation and without co-ruminating.
This is an interesting study for several reasons. The most important is that it calls into question the utility of individual therapy for children (especially girls). If it can lead to further depression and anxiety, is it an ethical thing to do? Talking about the problem may be useful up to a degree and then it may become too dangerous.
Therapy effectiveness and efficacy studies point to activities that will engage the body as well as active solution focused therapy as better methods of dealing with these issues.
Showing posts with label child depression. Show all posts
Showing posts with label child depression. Show all posts
Wednesday, July 18, 2007
Friday, July 13, 2007
Overweight Children Face Stigma
The July issue of Psych Bulletin has an article which indicates that overweight children are teased by their peers as early as age 3. They face bias from their parents and teachers, giving them a quality of life comparable to people with cancer, a new analysis concludes. Children who report teasing, rejection, bullying and other types of abuse because of their weight are two to three times more likely to report suicidal thoughts as well as to suffer from other health issues such as high blood pressure and eating disorders, researchers said.
Even with a growing percentage of overweight people, the stigma shows no signs of subsiding, due to the fact that television and other media continue to reinforce negative stereotypes.
Children as young as 3 are more likely to consider overweight peers to be mean, stupid, ugly and sloppy. A growing body of research shows that parents and educators are also biased against heavy children. In a 1999 study of 115 middle and high school teachers, 20 percent said they believed obese people are untidy, less likely to succeed and more emotional.
Tuesday, March 20, 2007
Bereaved Children Of 9/11 Victims Suffered High Rates Of Psychiatric Illness
The rate of psychiatric illness among children who lost a parent in the Sept. 11, 2001, World Trade Center attack doubled -- from about 32 to nearly 73 percent -- in the years following the event, according to a new study in the journal Biological Psychiatry. The study was conducted by researchers at NewYork-Presbyterian Hospital/Weill Cornell Medical Center.
More than half (56.8 percent) of the young children studied suffered from some sort of anxiety disorder, including post-traumatic stress disorder (PTSD), which affected nearly three in 10 bereaved children.
Some highlights:
- More than half (56.8 percent) of the young children studied suffered from some sort of anxiety disorder
- 3 out of 10 children in this bereaved groups were positive for a diagnosis of post-traumatic stress disorder (PTSD)
- heightened activity of the brain's "stress-response system" in many children who lost a parent on 9/11
- Continued activation of this system can lead to long-term hypersensitivity to stress as adults and even impact on bone health, since the stress hormone cortisol can harm bone.
- PTSD rates were 10 times that seen in non-bereaved children
- 27.3 percent of bereaved youngsters suffered from separation anxiety, double the rate seen in non-bereaved youngsters
- 25 percent experienced generalized anxiety, double the rate seen in non-bereaved youngsters
- rates of simple phobias in bereaved children was also double that of non-bereaved children (13.6 percent vs. 5.9 percent).
- rates of major depressive disorder in bereaved children was twice that of non-bereaved children -- 13.6 percent compared to 5.9 percent, respectively
- the researchers conducted saliva analysis and idenitfied elevated cortisol levels in many bereaved children throughout the two-year study. That suggests that the HPA axis remained switched on at a relatively high level
- chronic HPA activation in childhood may make individuals hypersensitive to stressors throughout their lifespan. Chronically elevated cortisol levels can also negatively impact bone health and boost risks for insulin-related dysfunction.
Monday, March 05, 2007
Severe stress harmful to children's brain
A study conducted by researchers at the Standford School of Medicine and Lucile Packard Hospital found that severe stress can affect children's brain development, according to U.S. researchers. Although this finding had been replicated previously with animals, this was the first study of its kind conducted with children.
Children with PTSD and high levels of cortisol (a stress hormone released by the adrenal glands) were likely to experience a decrease in the size of the hippocampus, a brain structure important in memory processing and emotion.
The children in the study were suffering from post-traumatic stress disorder, or PTSD, as a result of undergoing physical, emotional or sexual abuse, witnessing violence or experiencing lasting separation and loss. This type of developmental trauma often impairs the child's ability to reach social, emotional and academic milestones.
The researchers studied 15 children from age 7 to 13 suffering from PTSD. They measured the volume of the hippocampus at the beginning and end of the 12- to 18-month study period.
After correcting for gender and for physiological maturity, they found that kids with more severe PTSD symptoms and higher bedtime cortisol levels (another marker of stress) at the start of the study were more likely to have reductions in their hippocampal volumes at the end of the study than their less-affected, but still traumatized peers.
The researchers speculated that cognitive deficits arising from stress hormones interfere with psychiatric therapy and prolong symptoms.
Children predisposed by genetics or environment to be more anxious than their peers are also more likely to develop PTSD in response to emotional trauma, perhaps because their responses to other life experiences simply left them closer to that threshold than less-anxious children, according to the study to be published in the March issue of Pediatrics.
Children with PTSD and high levels of cortisol (a stress hormone released by the adrenal glands) were likely to experience a decrease in the size of the hippocampus, a brain structure important in memory processing and emotion.
The children in the study were suffering from post-traumatic stress disorder, or PTSD, as a result of undergoing physical, emotional or sexual abuse, witnessing violence or experiencing lasting separation and loss. This type of developmental trauma often impairs the child's ability to reach social, emotional and academic milestones.
The researchers studied 15 children from age 7 to 13 suffering from PTSD. They measured the volume of the hippocampus at the beginning and end of the 12- to 18-month study period.
After correcting for gender and for physiological maturity, they found that kids with more severe PTSD symptoms and higher bedtime cortisol levels (another marker of stress) at the start of the study were more likely to have reductions in their hippocampal volumes at the end of the study than their less-affected, but still traumatized peers.
The researchers speculated that cognitive deficits arising from stress hormones interfere with psychiatric therapy and prolong symptoms.
Children predisposed by genetics or environment to be more anxious than their peers are also more likely to develop PTSD in response to emotional trauma, perhaps because their responses to other life experiences simply left them closer to that threshold than less-anxious children, according to the study to be published in the March issue of Pediatrics.
Monday, February 26, 2007
Brain Pacemakers aricle in Wired magazine
Wired magazine this month has an article written by Steven Gulie, a programmer for Apple. Gulie wrote a first hand account of his brain pacemaker operation and subsequent "tunings" in order to help alleviate his Parkinson's Disorder.
A common purpose of modern brain implants and the focus of much current research is establishing a biomedical prosthesis circumventing areas in the brain, which became dysfunctional (in Gulie's case, the area which was targeted was the subthalamic nucleus, which normally produces dopamine). What was described was a process of inserting two filaments (deep brain stimulator lead wires) which were connected (with some peripheral wires) to a pacemaker surgically implanted into the person's collar.
The pacemaker then releases low volatge shocks which stimulate specific parts of the brain to bring upon the desired effect. Gulie described the pacemaker as being about the size of an Ipod.
Although this article is of interest, what is much more interesting is that recent research has focused on implanting pacemakers into the brains of individuals with Tourrette's Syndrome and depression.
Specifically for depression, the pacemaker is set to affect the vagus nerve; these electrical stimulations affect blood flow to different parts of the brain, and affect neurotransmitters including serotonin and norepinephrine.
Gulie wrote about some side effects after the operation, which were related to the identification of the appropriate voltage and rate of shocks that the pacemaker was to deliver. Very interesting stuff indeed.
As he identified, this operation was part of a very Web 2.0 procedure; previous brain pacemakers were much more crude and more difficult to work with.
A common purpose of modern brain implants and the focus of much current research is establishing a biomedical prosthesis circumventing areas in the brain, which became dysfunctional (in Gulie's case, the area which was targeted was the subthalamic nucleus, which normally produces dopamine). What was described was a process of inserting two filaments (deep brain stimulator lead wires) which were connected (with some peripheral wires) to a pacemaker surgically implanted into the person's collar.
The pacemaker then releases low volatge shocks which stimulate specific parts of the brain to bring upon the desired effect. Gulie described the pacemaker as being about the size of an Ipod.
Although this article is of interest, what is much more interesting is that recent research has focused on implanting pacemakers into the brains of individuals with Tourrette's Syndrome and depression.
Specifically for depression, the pacemaker is set to affect the vagus nerve; these electrical stimulations affect blood flow to different parts of the brain, and affect neurotransmitters including serotonin and norepinephrine.
Gulie wrote about some side effects after the operation, which were related to the identification of the appropriate voltage and rate of shocks that the pacemaker was to deliver. Very interesting stuff indeed.
As he identified, this operation was part of a very Web 2.0 procedure; previous brain pacemakers were much more crude and more difficult to work with.
Saturday, February 10, 2007
School Psychologists and Suicide
One of my students contacted me this morning and was quite upset about a problem she was facing.
She had dealt with a child who was evidencing suicidal ideation, and she told her principal and AP about it (her supervisor was out sick). Her administration told her to ignore it. She didn't. She spoke to her supervisor and they agreed that they needed to report this.
She called the parents of the child and arranged for a hospital visit. Her administration was not amused. They apparently threatened to "get them in trouble".
I told her that this was a common reaction of administrators when school psychologists do things that are not in their control. According to the NASP Ethics Code: "School psychologists are committed to the application of their professional expertise for the purpose of promoting improvement in the quality of life for children, their families, and the school community." This child obviously did not have a good quality of life, and, her actions were an attempt to make that better.
Good job, I say. For further information, check out the NASP reprint of an article in the communique discussing what can be done for children who are suicidal.
http://www.nasponline.org/publications/cq/cq354suicide.aspx
She had dealt with a child who was evidencing suicidal ideation, and she told her principal and AP about it (her supervisor was out sick). Her administration told her to ignore it. She didn't. She spoke to her supervisor and they agreed that they needed to report this.
She called the parents of the child and arranged for a hospital visit. Her administration was not amused. They apparently threatened to "get them in trouble".
I told her that this was a common reaction of administrators when school psychologists do things that are not in their control. According to the NASP Ethics Code: "School psychologists are committed to the application of their professional expertise for the purpose of promoting improvement in the quality of life for children, their families, and the school community." This child obviously did not have a good quality of life, and, her actions were an attempt to make that better.
Good job, I say. For further information, check out the NASP reprint of an article in the communique discussing what can be done for children who are suicidal.
http://www.nasponline.org/publications/cq/cq354suicide.aspx
Friday, February 09, 2007
Can young children accurately be diagnosed?
Well, yes, I actually do think that you can and should diagnosed young children if they require it - diagnosis oftentimes means that young children get the help that they need.
However, John Grohol brings up a good point - oftentimes medical professionals see a psychiatric diagnosis as a reason and excuse to prescribe medication. That is a practice that would require a great deal more of research before it becomes common.
http://psychcentral.com/blog/archives/2007/02/09/can-a-3-year-old-be-accurately-diagnosed/
However, John Grohol brings up a good point - oftentimes medical professionals see a psychiatric diagnosis as a reason and excuse to prescribe medication. That is a practice that would require a great deal more of research before it becomes common.
http://psychcentral.com/blog/archives/2007/02/09/can-a-3-year-old-be-accurately-diagnosed/
Wednesday, February 07, 2007
Kids' Suicides Rise, CDC Report Finds
Something isn't going well - and I'm not sure why
Kids' Suicides Rise, CDC Report Finds
Associated Press - February 05, 2007
CHICAGO - New government figures show a surprising increase in youth suicides after a decade of decline, and some mental health experts think a drop in use of antidepressant drugs may be to blame.
Suicides climbed 18 percent from 2003 to 2004 for Americans under age 20, from 1,737 to 1,985 deaths. Most suicides occurred in older teens, according to the data - the most current to date from the federal Centers for Disease Control and Prevention.
By contrast, the suicide rate among 15- to 19-year-olds fell in previous years, from about 11 per 100,000 in 1990 to 7.3 per 100,000 in 2003.
Suicides were the only cause of death that increased for children through age 19 from 2003-04, according to a CDC report released Monday.
"This is very disturbing news," said Dr. David Fassler, a University of Vermont psychiatry professor.
He noted that the increase coincided with regulatory action by the U.S. Food and Drug Administration that led to a black box warning on prescription packages cautioning that antidepressants could cause suicidal behavior in children.
Fassler testified at FDA hearings on antidepressants during 2003 and 2004 and urged caution about implementing black box warnings. The agency ordered the warnings in October 2004 and they began to appear on drug labels about six months later.
Psychologist David Shern, president of Mental Health America, called the new data "a disturbing reversal of progress."
Other research has linked certain antidepressants with decreasing suicide rates, Shern said, adding, "We must therefore wonder if the FDA's actions and the subsequent decrease in access to these antidepressants in fact have caused an increase in youth suicide."
The advocacy group receives funding from makers of antidepressants, government agencies and private donations.
The suicide data are in a report on vital statistics published in February's Pediatrics.
Antidepressant use among children decreased during the same time period. Data from Verispan show 3 million antidepressant prescriptions were written for kids through age 12 in 2004, down 6.8 percent from 2003. Among 13- to 19-year-olds, the number dropped less than 1 percent to 8.11 million in 2004. Steeper declines in both age groups occurred in 2005, according to the prescription tracking firm.
The suicide data are preliminary and don't show whether suicides might have been concentrated in one region or among one gender or ethnic group, said the CDC's Dr. Alexander Crosby.
"It's something that we want to look a little bit closer into," Crosby said. "It's probably too early to say" if declining use of antidepressants had anything to do with it, he said,
The CDC is expected to issue a more thorough report on the data in a month or two.
The data are concerning, but it's too soon to know if they're anything more than a statistical blip, said Dr. John March, a Duke University psychiatry professor. He led landmark National Institute of Mental Health research linking antidepressant use with an increased risk for suicidal behavior, but also showing that getting psychotherapy at the same time canceled out that risk.
Some mental health experts believe suicide prevention programs and effective use of treatment including drugs and therapy contributed to the decline in suicides that occurred in the 1990s.
Funding cuts for school-based suicide prevention programs might have contributed to the apparent rise noted in the new CDC report, said Emory University psychologist Nadine Kaslow. But the rise might not indicate a nationwide trend and needs to be investigated, she said.
"It's definitely concerning" but will need to be followed to see whether increases occurred in subsequent years, Kaslow said.
Kids' Suicides Rise, CDC Report Finds
Associated Press - February 05, 2007
CHICAGO - New government figures show a surprising increase in youth suicides after a decade of decline, and some mental health experts think a drop in use of antidepressant drugs may be to blame.
Suicides climbed 18 percent from 2003 to 2004 for Americans under age 20, from 1,737 to 1,985 deaths. Most suicides occurred in older teens, according to the data - the most current to date from the federal Centers for Disease Control and Prevention.
By contrast, the suicide rate among 15- to 19-year-olds fell in previous years, from about 11 per 100,000 in 1990 to 7.3 per 100,000 in 2003.
Suicides were the only cause of death that increased for children through age 19 from 2003-04, according to a CDC report released Monday.
"This is very disturbing news," said Dr. David Fassler, a University of Vermont psychiatry professor.
He noted that the increase coincided with regulatory action by the U.S. Food and Drug Administration that led to a black box warning on prescription packages cautioning that antidepressants could cause suicidal behavior in children.
Fassler testified at FDA hearings on antidepressants during 2003 and 2004 and urged caution about implementing black box warnings. The agency ordered the warnings in October 2004 and they began to appear on drug labels about six months later.
Psychologist David Shern, president of Mental Health America, called the new data "a disturbing reversal of progress."
Other research has linked certain antidepressants with decreasing suicide rates, Shern said, adding, "We must therefore wonder if the FDA's actions and the subsequent decrease in access to these antidepressants in fact have caused an increase in youth suicide."
The advocacy group receives funding from makers of antidepressants, government agencies and private donations.
The suicide data are in a report on vital statistics published in February's Pediatrics.
Antidepressant use among children decreased during the same time period. Data from Verispan show 3 million antidepressant prescriptions were written for kids through age 12 in 2004, down 6.8 percent from 2003. Among 13- to 19-year-olds, the number dropped less than 1 percent to 8.11 million in 2004. Steeper declines in both age groups occurred in 2005, according to the prescription tracking firm.
The suicide data are preliminary and don't show whether suicides might have been concentrated in one region or among one gender or ethnic group, said the CDC's Dr. Alexander Crosby.
"It's something that we want to look a little bit closer into," Crosby said. "It's probably too early to say" if declining use of antidepressants had anything to do with it, he said,
The CDC is expected to issue a more thorough report on the data in a month or two.
The data are concerning, but it's too soon to know if they're anything more than a statistical blip, said Dr. John March, a Duke University psychiatry professor. He led landmark National Institute of Mental Health research linking antidepressant use with an increased risk for suicidal behavior, but also showing that getting psychotherapy at the same time canceled out that risk.
Some mental health experts believe suicide prevention programs and effective use of treatment including drugs and therapy contributed to the decline in suicides that occurred in the 1990s.
Funding cuts for school-based suicide prevention programs might have contributed to the apparent rise noted in the new CDC report, said Emory University psychologist Nadine Kaslow. But the rise might not indicate a nationwide trend and needs to be investigated, she said.
"It's definitely concerning" but will need to be followed to see whether increases occurred in subsequent years, Kaslow said.
Monday, December 19, 2005
Adolescent suicide and antidepressants
Although this article does nor get to the bottom of the issue, it is an interesting intro into the nature of adolescent anti-depressant usage and suicide. In general, what I have seen is that the nature of most medications is not well-researched in children (except with Ritalin), and more studies are needed in this area. So the area is ripe for armchair discussion. I would be curious to hear what any or all of you have to say on the issue....
What happens outside a tightly-controlled study is harder to know. Indeed, any chance that a teen may take his or her life is reason for concern. Suicides accounted for nearly 32,000 American deaths in 2002, with most of them occurring in teens between 18 and 19 years of age. Dr. David Shaffer, the director of child and adolescent psychology at Columbia University and a leading expert on suicidal behavior, discusses these risks and puts the recent controversy over antidepressants into perspective.
How common is it for adolescents to have suicidal thoughts? They are very, very common. Suicidal thoughts occur in around 20 percent of all high school-aged kids. One in five high school kids have thought about suicide within the last year.
Have the thoughts or attempts of suicide gone down in recent years? The rate of attempts doesn't appear to have gone down. The rate of ideation [suicidal thoughts] that's being tracked has gone down from about 25 percent two years ago to about 19 percent today
These lower rates have happened while more and more teens are taking antidepressants. Is it possible that the antidepressants are decreasing the risk of suicide? I think it's highly likely. There have only been two previous periods in the last 105 years when suicide rates have gone down and both were during World War I and World War II. They were probably related to alcohol, because alcohol tends to drive the suicide rate. If you look at the 1990-2004 alcohol use rates, there has been no decline in alcohol use at all. So there are other possible explanations and I think we've all looked at them, and nothing strikes one as very convincing.
What about the possibility that antidepressants may increase the risk of suicide? The really big argument that antidepressants are not causing a lot of suicides comes from autopsy studies. There are two places, one in New York and one in Salt Lake City, where they've been doing toxicology on youth suicides, and they're just not finding any trace of SSRIs [antidepressants, like Prozac] there. So my best guess is that non-treatment is more likely to lead to suicide than the reverse. However, that's not to say that antidepressants don't influence your behavior in a way that might make you talk much more about suicide, and it may also make you more aggressive and hostile.
Why has there been such a concern about antidepressants? Most suicidal thoughts are kept inside, with even more attempts never revealed to anyone. When you're on an SSRI, you become less inhibited, and kids who have been totally silent and really uncommunicative within a few doses may be over-talkative and disclosing a lot. You are more likely to disclose your thoughts after taking an antidepressant. That doesn't necessarily mean to say the antidepressant is working; it's just one of the nonspecific effects.
Is there no risk of suicide from taking these drugs? There are some kids who become quite hostile and aggressive when they take antidepressants. If you become aggressive and hostile, it's possible that you will get into trouble.
Do the benefits outweigh the risk? I think the risk of not treating depression is much, much greater than the possible effects of treatment. But I think because you can get side effects, you can't just hand out a starter pack and say, "Try these and come back in a month."
How do you prevent this kind of reaction in teens who take antidepressants? You tell the parents about the risk, and you start the patients on a very low dose. If you're not going to see the patient for a week or for two weeks, then you make sure that there are telephone contacts. And so you telephone the parent to ask what changes they've noticed, if any. And you give them a list of some of the things to look out for, like losing your temper, having difficulty sleeping or talking about suicide.
What happens outside a tightly-controlled study is harder to know. Indeed, any chance that a teen may take his or her life is reason for concern. Suicides accounted for nearly 32,000 American deaths in 2002, with most of them occurring in teens between 18 and 19 years of age. Dr. David Shaffer, the director of child and adolescent psychology at Columbia University and a leading expert on suicidal behavior, discusses these risks and puts the recent controversy over antidepressants into perspective.
How common is it for adolescents to have suicidal thoughts? They are very, very common. Suicidal thoughts occur in around 20 percent of all high school-aged kids. One in five high school kids have thought about suicide within the last year.
Have the thoughts or attempts of suicide gone down in recent years? The rate of attempts doesn't appear to have gone down. The rate of ideation [suicidal thoughts] that's being tracked has gone down from about 25 percent two years ago to about 19 percent today
These lower rates have happened while more and more teens are taking antidepressants. Is it possible that the antidepressants are decreasing the risk of suicide? I think it's highly likely. There have only been two previous periods in the last 105 years when suicide rates have gone down and both were during World War I and World War II. They were probably related to alcohol, because alcohol tends to drive the suicide rate. If you look at the 1990-2004 alcohol use rates, there has been no decline in alcohol use at all. So there are other possible explanations and I think we've all looked at them, and nothing strikes one as very convincing.
What about the possibility that antidepressants may increase the risk of suicide? The really big argument that antidepressants are not causing a lot of suicides comes from autopsy studies. There are two places, one in New York and one in Salt Lake City, where they've been doing toxicology on youth suicides, and they're just not finding any trace of SSRIs [antidepressants, like Prozac] there. So my best guess is that non-treatment is more likely to lead to suicide than the reverse. However, that's not to say that antidepressants don't influence your behavior in a way that might make you talk much more about suicide, and it may also make you more aggressive and hostile.
Why has there been such a concern about antidepressants? Most suicidal thoughts are kept inside, with even more attempts never revealed to anyone. When you're on an SSRI, you become less inhibited, and kids who have been totally silent and really uncommunicative within a few doses may be over-talkative and disclosing a lot. You are more likely to disclose your thoughts after taking an antidepressant. That doesn't necessarily mean to say the antidepressant is working; it's just one of the nonspecific effects.
Is there no risk of suicide from taking these drugs? There are some kids who become quite hostile and aggressive when they take antidepressants. If you become aggressive and hostile, it's possible that you will get into trouble.
Do the benefits outweigh the risk? I think the risk of not treating depression is much, much greater than the possible effects of treatment. But I think because you can get side effects, you can't just hand out a starter pack and say, "Try these and come back in a month."
How do you prevent this kind of reaction in teens who take antidepressants? You tell the parents about the risk, and you start the patients on a very low dose. If you're not going to see the patient for a week or for two weeks, then you make sure that there are telephone contacts. And so you telephone the parent to ask what changes they've noticed, if any. And you give them a list of some of the things to look out for, like losing your temper, having difficulty sleeping or talking about suicide.
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