Ido in Autismland : Book Review

 

Ido in Autismland by Ido KedarIdo_in_Autismland_Cover_for_Kindle

Although I am not an expert in this area, I believe that this will be a landmark book for families, educators and any professionals who work with young people with autism. It is a book of short essays written by a 15 year old about his experience with his condition starting with some pieces written when he was 12 years old.

What is unusual, unique and very important about this author is that he cannot speak and only when he was about 11 years old did he begin to communicate by pointing to letters on a letter board. Up to that point no one had any idea that he was an above average intelligent kid who began to read when he was about three years old. He was terribly frustrated by being treated by well meaning experts in autism and education by drilling him on simple exercises meant for a three year old child who was having trouble learning. He was asked to point to his nose which he often could not do and was judged accordingly.  Even when he began to point to letters and make intelligent sentences, just about everyone thought that his mother was guiding his hand since she had to steady it for him to point. It took his father, who is a scientist, two more years before he was convinced that his son was truly communicating fully formed intelligent sentences. The problem would seem to be that he could not control his body. He often would have great difficulty even signaling that he could make even  simple calculations or understood basic concepts.  This was further complicated by his arm flapping which would occur when he was anxious which he referred to as “stims” . Other times he would do unexplainable pieces of behavior such as pulling his Mom’s hair or that of beloved aide when he was frustrated or embarrassed. This pattern of behavior is common in many children who fall under the rubric of autism except they are usually not recognized to understand things and mainly have trouble in controlling their bodies to communicate. Instead they are often deemed “retarded” and/or  “developmentally handicapped.”

Ido believes that he is not “one in a million” and that he has had indication that many of his friends with non verbal autism are as frustrated as he used to be. Once Ido proved he could communicate with a letter board and then on the keys of a computer, a new world opened up to him. He was put in mainstream classes which he would attend with an aide and has entered high school with the aspiration to go to college. It is a constant uphill battle, as while the administrators of his middle school were very supportive, he found that was not the case of the first high school which he entered. Obviously, it did takes a great deal of resources and some special accommodation to allow him to function in a regular high school environment. After transferring to a second high school he seemed to be quite adjusted as he continues forth.

This book traces his progress as well as clarifying many of his characteristics and experiences. For example he sees people in different colors such as red blue, yellow etc. which are related to their emotional state perhaps in relationship to himself. He is also very sensitive to sound and appears to have very keen hearing . He therefore at times gets overwhelmed by loud noises, certain music. being in the presence of multiple people talking . These and other situations can cause him to have what would appear to be overwhelming panic attacks. This is not only experienced as severe anxiety but it intensifies uncontrolled movements of his body. Over the years he has found that various types of physical training and exercise actually improved his self control, something that was not initially recognized as it was neglected in any attempts to assist him.

I found it interesting, as a psychiatrist,  that he did not mention whether or not he was given a trial on any anti-anxiety and anti-panic medications which are believed to directly  effect various pathways in the brain which are involved when people have such overwhelming emotions. I would imagine that the medical experts in this field have evaluated the  effect of such drugs as an adjunct to his treatment program but if they have not, it certainly should be done.

Ido frequently mentions that he knows that he has an illness that places many limitations on him but he prefers to focus on what he can do and what he hopes to be able to do in the future. He also is dedicated to teaching the public as well as families of children with autism and experts about the potential of people like himself.   Ido would probably say “so called experts” since he has a sense of humor and he is keenly aware of how so many experts have misinterpreted his abilities). Not only is he becoming an advocate but he must be also considered to be a hero for so many people who are locked in the land of autism. 

For a view of brief video clip of Ido at a meeting as one of his speeches is read go to:  http://www.youtube.com/watch?v=V4VR1KYRX8s

 (This book can be purchased through AMAZON by clicking the AMAZON link in the right hand column)

Psychological Implications of the Connecticut School Shooting

A lone gunman killed 20 children and 6 adults including himself at a Connecticut) School He used guns registered to his mother. The emergence of ASD and PTSD Acute Stress Disorder and/ Post Traumatic Stress Disorder) were identified as happening after a major incident such as this one. The symptoms that can be present in this situation were reviewed as well as some possible long term effects. The grieving process was also discussed. In the aftermath of such situations, attention is often focused on people with mental illness who might have the potential do do violence and/or commit a copycat crime even though in retrospect this is very small proportion of the population.The gun control issue and related psychological factors were also discussed.

I am writing this blog one day after the horrific massacre at a school in Newtown, Connecticut. Thus far it is known that a 24 year old man shot and killed his mother and then took three weapons including automatic assault rifle, dressed in combat gear and  appeared at the school where his mother taught. He was recognized as the son of a teacher and was buzzed in. He then killed 4 adults including the principle who had recently  instigated stricter security measures at the school and 20 students between the ages of 6 and 10 as well as himself. There was one report that he had some kind of argument at the school the day before the shooting. There are also descriptions that he was a troubled kid in school who had no friends and was very shy. He was said to be very bright in math. It was suggested that  he may have had Asperger’s Syndrome and was on the Autism Spectrum. Another report said that he spoke of demons and therefore suggesting he may have been paranoid with schizophrenia. His parents were divorced after 17 years of marriage and his mother was reported as very protective. He has a brother at college.

I have no idea of his diagnosis and would not make any attempt to speculate on on the nature of his mental condition.

Psychological Trauma 

Common wisdom and research in this area tell us  that the closer a person is to the traumatic event,  the more likely and the more severe the psychological trauma will be. This however is a complicated issue. Certainly the adults and children who witnessed the shooting (including of course anyone wounded ) would be directly effected.  This would include anyone in the school  who heard sounds and participated in the terror of hiding and escaping from danger.

The two conditions that will emerge from such an incident  are  Acute Stress Disorder (ASD) and Post Traumatic Stress Disorder(PTSD) . According to the Diagnostic Manual of the American Psychiatric Association (DSM IV), the necessary requirement for both of these conditions must include the following :

The person has been exposed to a traumatic event in which both of the following were present.

1-The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others.

2- The person’s response involved intense fear, helplessness, or horror (in children, this may be expressed instead by disorganized or agitated behavior.)

In addition for us to make a diagnosis of ASD there needs to be three or more  symptoms such as  numbing, detachment, absence of emotional responsiveness or reduction in awareness of his or her surroundings (being in a daze) or derealization ( things don’t seem real) or depersonalization ( you don’t feel like yourself) , a tendency to re-experience the event by flashbacks, an avoidance phenomena related to recollection of the traumatic event, impairment of social and other areas of functioning, increased  anxiety and arousal with sleep and concentration problems and a duration of these symptoms  2 to 4 weeks.

In order for us to make diagnosis of PTSD  there needs to be similar symptoms as ASD with one or more symptoms of recurrent and intrusive recollections (manifested in young children by repetitive play), recurrent dreams, re-experiencing the traumatic event with illusions , hallucinations and flashbacks , physiological reactions, , persistent avoidance of stimuli associated with the trauma, numbing , efforts to avoid thoughts and feelings related to trauma, decreased interest or estrangement, inability to have loving feelings, insomnia, outbursts of anger , exaggerated startle response  impairment in social functions, with a t least one of these symptoms lasting more than one month.

For more detailed and exact definitions see the DSM IV (or the new DSM V which may be somewhat revised )

Trauma Not Limited to Immediate Geographic  Area

The development of these symptoms is not limited to people in the immediate vicinity.

Classmates who didn’t attend school that day can have symptoms as can people all over the world who are traumatized by accounts in the media which vividly reconstruct the events and allow others to identify with the victims. There will be very few school age children in the U.S. who will not have heard about the details of this event

I recall at the time of the Challenger disaster, we saw school children all over the country effected by seeing this spacecraft carrying the astronauts and some teachers disintegrate before their eyes on television . Similar situations have happened in other tragedies, which are covered, on TV.

Long Term Effects

It should be recognized that the acute and  long term psychological  effects of this trauma  goes beyond the two disorders described above The experience also  becomes woven in the psychological makeup of people who are impacted by it whether near or far where it happened . For some, the innocence of childhood is taken away . The sense of security is changed forever. Long after the acute symptoms are gone, the effects of this event will have changed the individuals who experienced it. In some cases it will be a determining factor in how they will mold their future lives. Perhaps they will always be a cautious person, looking for unexpected danger. In other ways, the trauma can motivate persons to become doctors, nurses, police, researchers or influence the way they view their own lives for better or worse.

The Need for Immediate Psychological Intervention;

There has immediately been an outpouring of offers of psychological help.

I am sure the school system ,local and state agencies  will bring in counselors and therapists. Local mental health professionals  will ofter their help. I know the Committee on Disasters of the American Psychiatric Association ( of which I have been a member ) has offered the local Psychiatric Society materials and information that can be useful . There has been offers from International Groups that have experience  with these situations as well as from the Red Cross and from the nearby Yale Child Study Group. There will be individual and group meeting with the teachers and counselors as well with parents and of course with the children. The teachers will be trained how to be sensitive to the reactions of the children. It is important that all involved be aware of the various symptoms that can develop after events like this (some of which were described above) Danger signals need to be picked up. I am sure a wide variety of techniques will be used for one to one therapy  as well as in groups. Talking in groups can be useful for many but for others individual sessions can be very helpful  or a combination can  be used. For some of the children, the comfort of discussions and interactions with their parents will be  most important. Some parents will know how to handle this, other parents will benefit by discussion or counseling. I don’t believe there is one method which needs to be applied. The techniques used in individual and group treatment can cover a wide range from catharsis which involves expressing  one’s experience and feelings, Cognitive Behaviors Therapy ( CBT) which uses correcting misconceptions  and directly dealing with ideas and behavior and  psychodynamic therapy  where underlying meaning is explored and interpreted. In some acute situations medication (anti-anxiety or other stronger tranquilizers  can be used and when conditions  such as major depression is identified, antidepressants may be prescribed.  Other techniques and combinations of approaches will be used especially the human support and caring offered by people near and far and by such groups as the Red Cross which will be quite useful and meaningful.

Grieving the Loss of Life.

As most of us know grieving is a very intense process. Kubler-Ross described five stages of grief ; denial,, bargaining , anger , depression and acceptance. However, when there is unexpected death, traumatic death especially by murder and death of children, the grief takes on a different pattern which has been labeled Complicated Grief. We can expect the anger and depression to be greatly intensified and the duration of the intense emotions to be much more prolonged especially when there is the loss of a young child. Ultimately various types of memorials to the lost child which can give significances to the lost out life can be helpful

Concern About Other Disturbed Individuals Including Copycat Incidents

It is only natural that there will be concern on all levels that disturbed individuals who might do anything like this incident should be identified , receive help and be safely  in a place where they can not harm anyone. This problem is accentuated at the time of such an incident and in the immediate aftermath since we know that sometimes in the mind of a severely mentally disturbed person, media reports of this event have  the possibility of precipitating a copycat pattern of behavior in another disturbed person. The presence of mental illness is usually identified by family , friends and teachers at an relative early point in life. While there has been great progress in providing mental health care in the United States since the 1960s , there are still people who do not get the care that they need because of finances and the unavailability of services. Quality health care should be available to everyone and this includes those with mental illness.

The Overwhelming Majority of People with Mental Illness are Not Dangerous

Only a very small percentage of people with mental illness are a serious danger to other people. An incident such as this school shooting invariably unfairly intensifies the stigma towards people with mental illness. This can hinder recovery and adaptation to this condition. We need continued research in identifying people who could be dangerous and we also need to understand and educate the public about mental illness.

The Gun Control Issue and The Psychological Implications.

We don’t yet know the history and the story why the Connecticut shooter’s mother   had registered guns in the house. I would guess that most probably if there were not these guns in the house ( which included automatic weapons ) that untold psychological trauma would not have occurred. The young man may have done something terrible but if guns were not available to him, the   chances are,  not as many people would have been killed.

I also wonder about the psychological effect of his growing up in a household where such guns were owned , kept and valued. I understand the argument that most gun owners may teach their children about gun safety. However when there are guns present, there may very well be the underlying message to a disturbed child, that when you are angry this is the way that you can act.

 

One in Five American Suffer From Mental Disorders

Everyone has occasional feelings of anger, frustration sadness, fear of inadequacy and worries about the future. Often just talking about such feelings with friends or loved ones is enough to get you through a difficult period. But sometimes the problems don’t go away, resulting in sleep problems and added difficulty in working or socializing.  Anyone can develop an emotional problem. At any given time between 30 million and 45 million Americans-nearly one in five- have a mental disorder that can involve a degree of incapacity, interfering with employment, attendance at school or daily activities. There is a very strong likelihood that  mental problems  have touched  you or your love one in a very personal way.  Consider the following:

8-14 million Americans suffer from depression each year. As many as two out of ten Americans will have at least one episode of major depression during their life times.

20% of ailments for which Americans seek a doctor’s care are related to anxiety disorders such as panic attack, that interfere with their ability to live normal lives.

About 12-15  million children under the age of 18 suffer from mental disorders such as autism, depression and hyperactivity.

In all 1.5 million Americans suffer from schizophrenia disorders and 300,000 new cases occur each year

13 million Americans suffer from alcohol abuse or dependency and another 12.6 million suffer form drug abuse or dependence.

It is substantially worse when a person is suffering a drug addiction combined with a mental disorder, a medical condition described as a dual diagnosis.

Nearly 1/4 of the elderly who are labeled senile actually suffer some form of mental illness that can be effectively  treated.

The cost of work related mental health problems to businesses is very high. Almost 3  billion dollars and an estimated 50 million working days are lost each year.

What are implications of these and other similar statistics to your life? What are implications to our health care system? What is the meaning to the mental health professions?

 

Recent Research About Autism

The following are three recent research developments concerning the Autism Spectrum Disorders

Dr. Ricardo Dolmetsch

Stem Cell Possiblities in Autism Research

Dr. Thomas R. Insel

Dr. Ricardo Dolmetsch from Stanford University  and his colleagues have generated stem cells from children with autism allowing them to study how the brain develops in children with Autism Spectrum Disorder (ASD). The motivations for this research occurred when a child with autism spectrum was born to Dr. Dolmetsch and his wife . In a video  interview with With Dr. Thomas Insel, director of the National Institute of Mental Health, he described how this event led to change in the direction of the  research that he had previously been doing.

Stem cells can be made from skin cells or blood cells. The stem cell has the capacity to make any cell in the body including brain cells. Dr. Dometsch explained how he has been able to take skin cells from his own child with autistm and make little pieces of brain which can be analyzed as to their development and function. One of preliminary findings is that some autistic children are making too many cells that produce dopamine, a chemical that transmits signals to various cells in the brain and nervous system. This provides a potential target for future therapeutic research. To see a video clip of this interview please go to:   http://www.nimh.nih.gov/media/video/dolmetsch.shtml

Increased Incidence of Autism Spectrum in Children

In an earlier interview, Dr. Insel interviewed Dr. Peter Bearman, Professor of Sociology at Columbia University, on his research into the prevalence of autism. It is s quite remarkable that in the past several years the prevalence has increased from 1 in 1500 births to 1 in 150 births.  If one just looks at Autism Spectrum, the prevalence may be 1 in 100 births. Some of these statistics may be due to the fact that there has been a change in the diagnostic critieria which would include more children to fit into this diagnosis. This may account for ¼ of this

Dr. Peter Bearman

increase. Another important discovery which may influence these statistics is the discovery that there are certain relatively small geographic areas called  “spatial clustering” where there is an apparent very high incidence of the diagnosis of ASD. This raises the possibility of some toxic agent in this area. There also is the consideration that such an increase incidence is due person to person education and awareness which allows for cases of ASD not to be missed and therefore a higher reported rate. One other factor which may account for the increased incidence in the diagnosis of autism and ASD is the fact that people are having children at a later age. It has been postulated that increased parental age leads to mutations which are associated with this condition. To see a video clip of this interview please go to : http://www.nimh.nih.gov/media/video/bearman.shtml

Repetitive Behaviors in Adults with Autism Spectrum Disorders Significantly Lessen With Antidepressant Treatment

In News release from the American Psychiatric Assoication dated 12/2/11 it was reported that a .12-week study showed that the antidepressant fluoxetine produced a greater decrease in repetitive behaviors and more overall improvement than placebo in adults with autism spectrum disorders. The study by Eric Hollander, M.D., of the Albert Einstein College of Medicine and Montefiore Medical Center and colleagues from Mt. Sinai School of Medicine represents the first large-scale, double-blind, placebo-controlled trial of fluoxetine in adults that targeted changes in the core domain

Dr. Eric Hollander

of repetitive behaviors as well as overall functioning. Overall improvement in autistic symptoms occurred in 35% of individuals receiving fluoxetine and none of those receiving placebo. Half of the individuals in the fluoxetine group experienced substantial improvement in their repetitive behaviors (versus 8% of those receiving placebo). Previous trials of treatments for these disorders have mostly tested interventions for children. An earlier high-profile trial of another antidepressant, citalopram, did not reduce repetitive behaviors in children with autism spectrum disorders.

Although treatments for common characteristics have been studied, Dr. Hollander notes, “Research on medications for the core features of autism spectrum disorders is still in the early stages, and successful treatments could greatly improve the daily lives of patients and their families. The full study will be published in a future edition of the American Journal of Psychiatry

First Anniversary of PsychiatryTalk.com

This blog is written to mark the first year of PsychiatryTalk.com being on the Internet. The readership has expanded from 25 hits/week to over 300 hits/day and it is still growing. A followup on the topics of several of the blogs written in the past year was reported.

I started PsychiatryTalk  a little more than one year ago and it has been an interesting experience for me. I have met people from around the world via this blog  and it is very gratifying to see the number of hits on it to continue to grow. Initially, there would be an average of 25 pages /day that were read. Now it is well over 300/day and growing. I originally thought that the blog would generate online discussion.  I was surprised to find that readers are reluctant to put comments on the blog itself, although many people will write to me or people whom I know will speak with me in person about various subjects about which I have written. I still encourage any readers to put comments directly on the blog in the comments section and they will be posted usually within a day or two. It is easier for me to write the blog every other week rather than weekly so I have recently switched to biweekly postings.

I thought that this might be a good time to report some follow-up on various blogs which I have written .

The first blog that I wrote on October 12, 2009 was Review of Fox TV Show Mental. It was a critique of a new television show  which was about a psychiatrist. In my opinion, the program lacked authenticity and missed the opportunity to depict psychiatry and mental illness in a realistic manner.The show was not renewed. There is an excellent program about a psychotherapist on  HBO titled In Treatment which  just began it’s third season. It stars Gabriel Byrne as Dr. Paul Weston who has weekly sessions with patients , including one with his own therapist. This is a scripted show and although the writing is quite good, it is fiction based on a similar Israeli TV show.  I believe that it  would be possible to develop a high quality reality tv show of an actual ongoing therapy which could not only show real therapy sessions but also allow for interesting discussion by experts. There would be some ethical considerations in doing it which but I believe could be overcome and it  could be done in a thoughtful manner.

The second blog on October 19th was titled When a Mother Kills Her Children. It was about post partum psychosis with a discussion of the Proposed bill before the US Congress tiltled the Melanie Stokes Mothers Act . I am pleased to say that in March of 2010 it was passed and signed by the President. This  legislation will establish a comprehensive federal commitment to combating postpartum depression through new research, education initiatives and voluntary support service programs.

In December 2009 I first wrote a blog Condolence for Soldier Suicide where I made the case that it was wrong for the President of the United States not to write a letter of condolence to the families of American soldiers who have died by suicide. Another blog was written on this subject in August  2010 titled We Can’t Avoid PTSD and Suicides . While the President has still not changed his policy, the Secretary of the Army has recently written to some of the families and expressed his regret on the death of the soldiers. Perhaps this may be a sign of things to come. I authored an Action Paper with Dr. Roger Peele of Washington D.C. requesting the Assembly of the American Psychiatric Association to ask the President to reconsider his policy on this issue. It was passed by the APA Assembly and also endorsed by the Board of Trustees of the APA . This makes it the policy of our 38,000 psychiatrists organization. In addition Mental Health America and the American Foundation for the  Prevention of Suicide has passed similar resolutions and also are in the process of gathering signature for a petition to  President Obama. I believe we are getting closer to this long over due recognition to the families of these soldiers .

Another important military issue  and human rights issue was discussed in the February 2010 blog titled Abolishing Don’t Ask Don’t Tell (DADT).  Polls have consistently shown a majority of the public supports letting gays serve, and Defense Secretary Robert Gates and top military commanders such as Admiral Mike Mullen have recently endorsed it. In September 56 Democratic senators voted for the defense authorization bill, which included DADT repeal, but the measure failed to achieve the 60 votes needed to overcome a Republican filibuster.  A recent study conducted by the Pentagon concluded that ” …while a repeal of DADT will likely in the short term bring out some limited and isolated disruption to unit cohesion and retention, we do not believe this disruption will be widespread or long-lasting, and can be adequately addressed. The report, based on responses from 115,000 service members and 44,266 spouses, includes interviews with former gay or lesbian service members, some of whom were discharged from the military under the “don’t ask, don’t tell” policy. Of those surveyed, 69 percent said they had served with a gay service member and 92 percent of those respondents said they were able to work together.Fifty to 55 percent of those surveyed said the repeal won’t have any effect, 15 to 20 percent said it would have a positive effect and 30 percent said the effect would be negative.The report went on to say that  “The reality is that there are gay men and lesbians already serving in today’s U.S. military and most service members recognize this,” the report states. “Much of the concern about open service is driven by misperceptions and stereotypes about what it would mean.”I still like the words of Barry Goldwater on this issue who said, ” It is not important if your are straight , just that you can shoot straight.”

When there was a proposal for a 39% hike in healthcare rates purposed in California by private insurance companies, I raised the question in a March 2010 blog titled  Stockholders Must Vote CEO Pay whether  there should be  law where stockholders,not Board of Directors of Compensation Committees, should be required to approve any compensation packages more than 200 times the minimum wage in the US. That controversy seems to have been revived just this past month when compensation at Wall Street firms was reported to be  expected to hit $144 million . A column in the Wall ll Street Journal raised the question I brought up that since the 2008 financial crisis profits remain 20% below the 2006 level while the pay at these firms rose an astonishing 23 % over that time frame,  shouldn’t the owners of these firms be the ones to decide if they want to spend their money raising the compensation of their executives. ?

The May 12th 2010  blog titled Autism & FragileX- New Treatment has become the most looked at blog of PsychiatryTalk of the year so far. In it,  two new research projects concerning Autism Spectrum Disorder and Fragile X Syndrome are briefly reviewed. In the first, a random controlled study of children with Autism Spectrum showed that the Early Start Denver Model showed statistically improvement over a control group in regard to intellectual development and adaptive behavior. In the second study, preliminary research showed that a new medication improved behavior associated with Fragile X Syndrome compared to the control group. There is also some belief that such medication would be effective with children with Autism Spectrum.  As a followup I don’t find any announcements of new breakthrough research. However, there is  a $211 million HHS-wide initiative that would invest an additional $1 billion over the next eight years in autism related activities, the NIH budget includes $141 million in FY 2010 for research into the causes of and treatments for autism spectrum disorders (ASD). The funded research will  include identifying biomarkers; improving ASD screening; establishing ASD registries; understanding genetic and environmental risk factors, as well as interactions between the immune and central nervous systems; and enhancing services that can help people with ASD across the lifespan.


Also in May I wrote two blogs addressing financial issues in the  American Psychiatric Association and they were Impact of APA Budget Cuts and  Increase APA Budget $1.5 Miilion. In the the former I discussed the expected impact of the cuts on the APA Assembly and APA Components particularly the Communications Committee and the Disaster Committee. In the second blog I outlined several specific suggestions how I felt that the APA could gain this large increase in it’s budget. Certainly the APA continues as a very vigorous organization representing 38,000 psychiatrist and speaking out on important issues concerning mental health. It is still too early to determine if the cutbacks will seriously hinder it in it’s effectiveness. I understand that some of my suggestions are being considered by some of the leadership but as far as I know no steps have been taken to implement any of them

In a July 14th blog titled I would Like to Thank My Psychiatrist It was stated that Los Angeles Laker Ron Artest after his team won the NBA Championship thanked his psychiatrist on national television. This is was noted to be  example how an increasing number celebrities are comfortable publicly discussing their psychiatric history. Television programs, movies, the Internet and the new media have all contributed to the reduction of stigma about mental health problems and treatment. My colleague Bill Arroyo informed me that Artest was mistaken in that his therapist was not a psychiatrist but another mental health professional. While I appreciate the correction, the changing attitudes towards discussing therapy still  holds and is a good trend.

Last month I wrote my first blog on Miners in Chile anticipating any psychological issues that people who have gone through  a traumatic event may experience. As the miners began to emerge from the successful rescue efforts asecond blog was written in conjunction with a blog that I wrote for  CNN.com which I suggest that in this situation I believe that resiliency will be the default and most if not all of these miners will not have any long lasting psychological effects. In fact this brush with death may end up being a positive experience for them . It is obviously too early to tell  but it is very gratifying to see the good feeling around the world for these miners. However, just recently  29 miners  died in an explosion in New Zealand and we are reminded how such tragedies occur all the time and so cause great mental anguish for so many people. In this regard still another report of a recent tragedy caught my eye and that was the traumatic event in Cambodia where more  more than 378 people died and hundreds more were injured in a stampede at the end of the annual Water Festival late Monday in Phnom Penh. So many of these victims  were young people , many in their teens. I hope that there are mental health professionals and others available to help the survivors, families and friends deal with their grief.

Needless to say, I am still enthused about continuing this blog. I do appreciate the growing readership and I would want to encourage each of you to feel free to comment directly on the blog with your own views are particular topics. Whenever I have had occasion to give a talk whether it has been at a national meeting, a Grand Rounds or even a local group, I am always very pleased if there are 25 people in the audience, as it is privilege to share my interest with others. So it becomes a special opportunity to use the Internet to reach much larger numbers throughout the world through this wonderful medium. Thank you all for your continued interest.