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Author: Ronit Molko

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How Can We Be Happier?

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Americans today are emotionally distressed. Many are nervous about the economy, struggling to afford rent or buy a home, frustrated about the direction of the nation, feeling culturally and politically divided, socially isolated and most concerning of all, uncharacteristically unhappy.

We know Americans are feeling blue because they tell us so. According to a survey by the University of Chicago, the percentage of Americans saying they are “very happy” has nosedived since 2000 from 34% to 19% while the percentage who report they are not happy has more than doubled to 24%. That probably understates the issue because admitting this in a survey requires an individual first to admit it to themselves.

Before we bemoan our emotional state we need to determine what happiness is. Many efforts have been made to define it and they seem to coalesce around the idea that happiness isn’t so much an ephemeral state as a durable way of being. Happy humans are preternaturally happy or find ways to be; things and events don’t make us happy.

Indeed, a massive, longitudinal Harvard happiness study begun in 1938 and, still ongoing, has reached some counter-intuitive conclusions. Regardless of participants’ sex, age and other demographic attributes, even irrespective of their life experiences, the study found, genetics determine about half of happiness; some people are hard-wired to find the good or bad in everything. As for the rest, the markers of success in our country – money, health and possessions, for example – contribute little to happiness.

Poverty can inhibit happiness, but the link between income and joy frays once basic needs are met. A 2010 study by the Nobel Prize-winning psychologist Daniel Kahneman, the author of the bestseller Thinking Fast and Slow, found that income’s impact on our emotions flattens out around $75,000. Above that, an increase in income barely ripples on the happiness meter.

It is the relationships in our lives, it turns out, that have the greatest impact on our physical and emotional health, our lifespan and our happiness. “Taking care of your body is important, but tending to your relationships is a form of self-care too. That, I think, is the revelation,” said Robert Waldinger, a psychiatrist at Massachusetts General Hospital and a professor of psychiatry at Harvard Medical School, and director of the study.

As explained in this article by Gregg Vanourek, this all hints at the ultimate aim of happiness: we want to feel like we are living a meaningful life, one filled with daily pleasures, opportunities to do what we do best, and using our strengths to serve a higher purpose, like raising children, working for a cause that you’re passionate about, or simply doing good for others.

Consider this: marital satisfaction, a dynamic social life with a web of friends and family, and a strong sense of a greater purpose is the most powerful drug cocktail for achieving health and happiness. Loneliness, which affects a quarter of adults aged 65-plus, is as dangerous to health as smoking and alcoholism.

“When we gathered together everything we knew about (the participants in the Harvard study) at age 50, it wasn’t their middle-age cholesterol levels that predicted how they were going to grow old,” said Dr. Waldinger “It was how satisfied they were in their relationships. The people who were the most satisfied in their relationships at age 50 were the healthiest at age 80.”

The implications for all of us are simple but startling, and they offer a roadmap to happiness. Spend less time pursuing material advantages and more time nurturing strong human bonds with those around you. Reconnect with friends and family, curate nascent friendships, and intentionally develop or maintain a rich web of social connections.

By: Ronit Molko
Forbes Books Author
Forbes Books

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Addressing Student Mental Health Is Complex … And Critical

An image of a teen looking worried while sitting against a wall, with her right hand arm on her knee, supporting her head

Forbes Books Author
Ronit Molko
Sep 13, 2022,03:59pm EDT

In a previous blog on my website written for Radicle Health, I discussed the broad mental health issues facing students today in our schools and on-campuses across the country. The focus was primarily on current response procedures, and what certain schools and states are doing to implement more nuanced support systems for student mental health crises. As we dig a bit deeper, we find that our ongoing mental health epidemic is not evenly distributed among students.

While mental health issues in young people have spiked since the pandemic, the current landscape is truly a minefield for young women, Black and Latinx youth, and those with sexual identity issues. Marginalized groups are suffering now like never before with their emotional and behavioral health.

An Alarming Increase in Suicide Risk

The numbers suggest a new tsunami of pain and suffering across the country. Three quarters of college students reported enduring moderate or severe psychological distress, according to the American College Health Association’s fall 2021 National College Health Assessment. Rates of depression, anxiety and suicidal ideation are even higher for students with sexual identity issues. A staggering 42% reported seriously considering suicide in 2020.

When nearly three of seven young people of any kind are thinking about suicide, that is a crisis. In one sense, it’s a shocking development, considering that our society has never been more accepting of teens and young adults with sexual identity issues. At the same time, it’s no surprise at all given the social isolation Covid imposed, combined with the health scare, recent racial and political tensions, the social pressures caused by online media and growing effects of climate change. It appears to be the greatest time in history to be young – and the worst.

Institutions that engage the mind must be alert to the emotional stressors that reduce cognitive ability. That puts schools on the front line of confronting this new crisis, especially as communities beyond the campus are so ill-equipped to do so.

Thoughtful Responses and Programs are Necessary

School districts and college campuses are working to address these emotional impacts as they provide education to parents’ most precious priority. They are employing several strategies to lower the temperature of psychological distress. Many school districts are leveraging social and emotional learning (SEL), which teaches managing emotions, developing healthy identities, feeling and showing empathy, and more. Research clearly demonstrates SEL “leads to beneficial outcomes related to social and emotional skills; attitudes about self, school, and civic engagement; social behaviors; conduct problems; emotional distress; and academic performance,” according to the Collaborative to Advance Social and Emotional Learning.

Also on the prevention side, districts are establishing positive behavior intervention and supports, a combination proactive and reactive system of individualized prevention and interventions for at-risk students. Districts are also moving away from the punitive reaction model for wayward behavior to restorative discipline practices, which focuses on accountability over punishment. Districts are creating formal partnerships with community agencies and other organizations that can provide behavioral crisis support and establishing crisis-response teams inside the schools to address mental health issues. Federal funding that was part of the Covid-inspired CARES Act is fueling many of the new programs to support primary school students’ mental health.

On college campuses, mental health is on the administrative radar like never before. Campus counselors are having to update their skills to provide for gender non-conforming students and change some of their practices to account for a whole new category of patients. This includes significant changes, like building more single dorm rooms for non-binary students, and small ones, like asking for gender rather than sex on forms.

Minority Students are More Deeply Impacted

For minority students, the challenges are analogous, but different. Black and Latinx families were more likely to work on the front lines during the pandemic, unable to work from home and avoid contamination. As a result, they endured higher infection, hospitalization, and death rates from Covid, exacerbated by “racial battle fatigue” following the George Floyd killing that exposed old wounds about police brutality against Black Americans. It is perhaps not surprising that 67% of Black adults reported in a July 2020 survey by the American Psychological Association that their experiences with racism are a significant source of stress in their lives.

For schools, this may also require a new sensitivity to the special needs of minority students, says Dr. Zainab Okolo, a family therapist. “For students to feel like they’re a part of campus, they have to be willing in some ways to divorce themselves from their [home] culture,” she tells DiverseEducation.com. “For some students, the campus culture and their home culture are so alike, maybe both parents went to the school, and they were born there, that there’s no divorcing. But for some students — students of color, first-generation students — they almost have to betray themselves to fit in.”

Educational institutions that aim to serve diverse student populations are having to pivot with the times and accommodate the mental health issues facing many minority student groups who have suffered because of, and since, Covid. Even if Covid recedes into the background, it is unlikely the emotional wellness of student populations will. The critical concern now is whether the efforts being made by institutions to address emotional wellness among students will persist as well.

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Providers Working with Communities to Address Student Mental Health

an image depicting children in a classroom, with a child raising his left arm to ask the teacher a question

Emotional wellness has become the elephant in the room in our schools today, as young people struggle like never before with their mental health.

A student at Long Beach State University in California called a friend in an emotional crisis, desperate for help and threatening to harm herself. The friend knew she had to act and in the absence of any on-campus crisis response strategy, she called campus security. To her shock, she discovered she had made the problem worse.

So goes the story told to Ashley Smith, a reporter for EdSource, an online publication highlighting strategies for student success.

After the call, armed police showed up at the student’s dorm room and dragged her off to a hospital psychiatric unit. At the time, the university lacked a comprehensive mental health response plan. 

On-Campus Response Strategies Are Necessary

Following this incident, campus leaders recognized that mental health crises require a much more nuanced and humane response. Campus leaders devised a whole new strategy for student mental health. Implementation of this first-in-the-nation mental health strategic plan began last spring and will phase in its 60 action items over the next three years. Chief among them is a mobile crisis unit that responds to mental health emergencies with mental health professionals, not police.

Mental health has been a growing concern on campuses since 2013, according to a 2021 survey by the Association for University and College Counseling Center Directors. Ninety-five percent of the college counseling center directors said the number of students with significant psychological problems was increasing. First appointment visits at The University of Florida’s mental health clinic more than doubled between 2019 and 2020, and then increased again in 2021.

A Growing Crisis in Children’s Mental Health

The situation is similar for younger children. The Children’s Hospital Association reports that their member institutions recorded a nearly 38% increase in emergency department visits for mental health cases in the third quarter of 2021. They also reported nearly 54% more suicide and self-injury cases compared to 2020.

Though shocking, these numbers are not all that surprising. A pandemic that upended life for two years, mass shootings, racial tension, and angry political divisions have exacerbated the usual pressures that young people face. This is especially true for young people that are most susceptible to depression, eating disorders and other mental health issues. The rising mental health crisis among students has led to a bill presented to the California State Assembly, mandating that all public colleges in the state print a 24-hour hotline number on student identification cards for local mental health services.

There are many ways clinicians are responding to what many are calling a crisis. The Child Mind Institute this spring responded by embarking on a public awareness campaign anchored by the musician Pink, in which celebrities and ordinary people recount their stories of emotional struggle. 

How Can Schools Work With Mental Health Providers?

Because students spend more time during the week in school than with their parents, school psychologists, counselors and social workers are crucial to maintaining students’ emotional health. School staff are often the first to identify changes in student affect or behavior. School psychologists and other behavioral health professionals in the schools can hone the screening process by developing strong relationships with teachers, staff and parents. Identifying children with issues early can prevent mental health crises.It is important for schools to have a plan in place to connect students to support services, whether in-school or in the community. 

The Colorado Department of Education advises school districts to bring mental health professionals into the schools. “Utilizing mental health crisis teams can provide targeted and intensive mental health supports to students who require significant levels of support. These teams should include professionals, caregivers, community partners and stakeholders who understand robust approaches to mental health crisis management,” the department says on its website. 

Mental healthcare providers have an unprecedented opportunity to connect with in-school and out-of-school communities to address student mental health, now that schools and their surrounding communities are more amenable to that service than ever. There is so much these providers can offer. 

The Power of Telehealth to Expand Access

First, COVID has taught us the power of remote health services. Clinicians of all kinds can utilize telehealth to increase patient access to mental health services and minimize the stigma involved in seeking help by eliminating the public waiting room. Further, telehealth allows patients to receive care in the comforting surroundings and convenience of their own homes. Dropping the barriers to attending sessions boosts the likelihood of patient compliance and perseverance.

Patients have demonstrated a preference for telehealth services. The utilization of virtual appointments for mental health has hardly dropped off since COVID isolation, even as primary and secondary care patients are largely back in their doctors’ offices. 

Behavioral health providers can also expand patient access to mental health by co-locating with primary care providers to offer more comprehensive services in one place. Improved access has been shown to correlate with better outcomes.

Emotional wellness has become the elephant in the room in our schools today, as young people struggle like never before with their mental health. It is incumbent upon professionals in the field, school districts, and higher education institutions to make mental health services as accessible, available, convenient and comfortable to use as possible. 

By:
Ronit Molko
Radicle Health Advisory Board, Ph.D., BCBA-D
Aug 1, 2022

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MYTH: Nonverbal or Nonspeaking People with Autism are Intellectually Disabled

Graphic that reads MYTH: Nonverbal or Nonspeaking People with Autism are Intellectually Disabled

RONIT MOLKO, PH.D., BCBA-D
STRATEGIC ADVISOR, LEARN BEHAVIORAL

Just because someone is nonspeaking, does not mean they’re non-thinking. Around 25 to 30 percent of children with autism spectrum disorder are minimally verbal or do not speak at all. These individuals are referred to as nonverbal or nonspeaking, but even the term nonverbal is a bit of a misnomer. While nonspeaking individuals with autism may not speak words to communicate, many still understand words and even use written words to communicate.  

Nonspeaking individuals with autism utilize a variety of augmentative and alternative communication (AAC) methods. These range from no-tech and low-tech options such as gestures, writing, drawing, spelling words, and pointing to photos or written words, to high-tech options like iPads or speech-generating devices. 

There are several reasons that an individual with autism may have difficulty talking or holding conversation that are not related to intellectual disability. The disorder may have prevented the normal development of verbal communication skills. They may also have conditions such as apraxia of speech, which affects specific brain pathways, making it difficult for a person to actually formulate and speak the words they’re intending to say. Some may also have echolalia, which causes a person to repeat words over and over again.

While these conditions prevent many individuals from speaking, it does not mean they cannot learn, understand, or even communicate. There is a pervasive misunderstanding about this among the general population due to a lack of education. It is often wrongly assumed that anyone who has difficulty speaking is intellectually disabled.

This misconception can be particularly harmful when held by medical professionals. In the 1980s, as many as 69 percent of people with an autism diagnosis had a dual diagnosis of mental retardation, which would now be labeled intellectual disability. By 2014, that number had declined to just 30 percent, as researchers improved the diagnostic criteria for autism and a fuller picture of the disorder emerged.

Researchers are still working to try and improve diagnostics and better distinguish nonspeaking autism from intellectual disabilities. As Audrey Thurm, a child clinical psychologist at the National Institute of Mental Health in Bethesda, Maryland says: “We have to figure out who has only autism, who has only intellectual disability and, importantly, who has both intellectual disability and autism. That’s millions of people who could be better served by having an accurate distinction that would put them in the right group and get them the right services.”

It’s important to challenge the perception that those who do not speak cannot think. Not only do we risk failing to give them the proper supports and services, but we also undermine their individuality, ingenuity, creativity, and humanity by failing to see them as they truly are. Just because they are not talking does not mean they do not have much to tell us.

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Neurodiversity: What It Means, Why It Matters

Swedish climate activist Greta Thunberg attending Fridays For Future (School Strike for Climate) protest in front of a huge crowd near the Colosseum
BY RONIT MOLKO, PH.D., BCBA-D
STRATEGIC ADVISOR, LEARN BEHAVIORAL

If there is one enduring hallmark of the American experience, it’s the immense diversity found within our expansive borders. Most of the time, we perceive diversity via differences in skin color, language, clothing, places of worship, or even the foods people eat when gathered around the table with their families. There is, however, one major aspect of diversity that is often overlooked—one that comes as no surprise, considering it cannot be detected solely through visual means. I am, of course, referring to neurodiversity.

Coined in the late 1990s by sociologist Judy Singer—who is on the autism spectrum—neurodiversity is a viewpoint that characterizes brain differences among individuals as normal, rather than as a disability. This viewpoint reduces stigmas around learning and thinking differences, while calling attention to the ability of neurodivergent communities to benefit from multiple perspectives and make greater contributions to society. Central to the movement is a rejection of the idea that these unique individuals need to be cured or fixed. Instead, it’s held that people possessing different types of brains need to be embraced and provided support systems that allow them to participate and contribute as members of the community to the best of their ability.

Grounded in Science

Unsurprisingly, the foundations of this not so new movement are grounded firmly in science and empirical study. By leveraging MRI results from hundreds of individuals, researchers have been able to compare the brains of people diagnosed with learning differences to their counterparts. So far, studies have shown that the brains of neurodivergent individuals are, in fact, unique. For example, the part of the brain that maintains language processing works differently for people diagnosed with dyslexia. Additionally, the prefrontal cortex, which manages executive functioning and attention, develops much slower in children diagnosed with ADHD. In other words, these individuals are not necessarily operating with a learning deficit but rather possess brains that are literally wired differently.

A Neurodiverse Population

Whether a group of kids recently diagnosed with autism or adults still grappling with ADHD or dyslexia, the American neurodiverse population is quite substantial. According to a 2021 report from the Center for Disease Control and Prevention, one in every 44 children in the United States is diagnosed with some sort of autism spectrum disorder, and an estimated 5.4 million adults—or roughly 2.2 percent of the entire population—fall somewhere along the spectrum. Many people on the spectrum have contributed (or still do) to their communities every day, such as Albert Einstein, Anthony Hopkins, Henry Cavendish, Greta Thunberg, Jerry Seinfeld, and Elon Musk. They have been among the world’s highest achievers, impacting the arts, sciences, technological innovation, and activism.

In much the same way as the neurotypical population, the neurodivergent population is broad, diverse, and multidimensional. It’s crucial, then, for the public not only to embrace their different brethren but also to actively promote opportunities for them both in society and in the workplace at all abilities and levels.

Fortunately for society writ-large, corporate America is starting to take notice. A recent article published in the Harvard Business Review named neurodiversity as a bona fide “competitive advantage,” noting the unique and, often, incomparable output provided by atypical members of their workforce. Numerous companies, including Hewlett-Packard, Enterprise, Microsoft, SAP, and Ford, have recently begun to reform their HR practices in an effort to expand neurodiversity in their ranks by identifying, hiring, and empowering these unique individuals. The results, so far, have been outstanding, with managers noting legitimate “productivity gains, quality improvements, boosts in innovative capabilities, and broad increases in employee engagement.”

Diversity of all kinds, including neurodiversity, strengthens our daily institutions. Just as we are seeing a focus on diversity, equity, and inclusion (DEI) in employment and other areas of life and commerce, we must also remember that recognizing and celebrating differences, promoting justice and fairness, and ensuring true support and inclusion applies not only to people with observable differences but also to our neurodiverse populations. Not all cognitive differences are visible, and it’s crucial to keep in mind that there’s more than meets the eye when it comes to true diversity.

In another blog post, Dr. Molko explains the history and evolution of applied behavior analysis (ABA) therapy. Read the story.

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Let’s Stop Fixing Disabilities And Start Appreciating Differences

man in a wheelchair rolling through a pedestrian crossing surrounded by people walking in all directions

Able-bodied people comprise the dominant culture in America; thus, our cultural understanding of “normal” is contextualized around the contours of able-bodied activities. We consider, for example, an autistic mind or a visual deficiency that enhances other senses to be a detriment. In truth, these traits are often different ways of perceiving, understanding, and interacting with the world.

For many of the 60+ million Americans who have some kind of disability, this is frustrating. Their experience is not centered, and so their needs are not understood by a society built around how the able-bodied navigate the world. Instead, they are left to puzzle out their days with pieces that don’t always fit together. This despite the fact that even minor accommodations like a well-placed ramp or a thoughtful, private breakout space might make all the difference in helping these people lead “normal” lives. 

Website Accessibility for Everyone

Let’s take one example: In the hyper-competitive online world, one would think websites would be designed to be accessible to as many people as possible. Yet, the disabled too often find themselves unable to properly navigate many sites. Common sense, good business practice, and the Americans with Disabilities Act all demand inclusive access and a similar shopping and navigation experience, yet many organizations fail to provide it.

Daryn Harpaz, a website content accessibility guidelines compliance specialist and founder and CEO of Zenyth Group, LLC, believes it is good business to consider the needs of 15%-20% of the population, and also just plain decent. “We should be enabling our community from a social aspect to be integrated, inclusive,” he opined. “And I think that says a lot about where we need to move in the direction of disabilities in general.”

Ableism and Ableist Misconceptions

The persistent inability of the able-bodied to recognize that not everyone has the same physical or psychological experience of the world that they do is today known as ableism. Living in a world meticulously designed to accommodate your needs—and even your most indulgent wants—is privilege. And while the emergence of privilege in any system is, to a degree, inevitable, refusing to grapple with privilege and its implications is a choice. We must be attentive to eliminating assumptions that reflect an able-bodied view of the world that does not create space for everyone and their diverse needs.

People with disabilities tell me that ableist thinking includes a variety of knee-jerk assumptions and misconceptions, including this one: that people with disabilities have no autonomy and constantly need help, even if they don’t ask for it. It’s not true, but it does precede another issue: people with disabilities must constantly explain themselves, for example by detailing how they became disabled. While these things seem well-intentioned—”I just want to help” or “I’m just trying to understand your experience”—they often only serve to make the able-bodied more comfortable with people who by simply existing challenge their privilege. 

It is also an ableist misconception that all disabilities are visible. This perpetuates stigmatization and mistreatment of people with mental illness or autism, which is, after all, no different from physical impairment except that it affects the brain. Taken together, these false ableist impressions accrue and become barriers to inclusion and equity for disabled people. 

Hearing a Product of Ableism?

Deaf people view themselves as a culture, with its own cultural signs and signifiers, not as a group that needs to be fixed. Many deaf individuals have chosen not to undergo cochlear implant surgery, even with the prospect of being able to hear for the first time. 

Their rationale has been based on a fear of losing the community that has nurtured them, combined with the attendant fear of not being fully part of the hearing world. (To be fair, many deaf individuals do choose to get cochlear implants and are thrilled to enjoy the miracle of birdsong, loved ones’ voices, and the rest of the world of sound.)

Many of those who make the decision not to have the surgery report backlash from relatives and friends who can hear, but not understand their perspective. That in and of itself helps explain their decision, they say. Individuals with disabilities often want, more than anything, to be recognized as complete humans, irrespective of their disability. In other words, to be considered “normal” just the way they are. 

Oliver Sachs, the world famous neurologist and best-selling author, recounted the story in his book The Man Who Mistook His Wife for a Hat, of a man who led a full life as a blind person until doctors discovered that they could cure his blindness. His transition to sight was arduous and traumatic, and turned him into a miserable sighted person. While  his doctor and sighted wife persisted in their effort to complete his transition to a sighted person, he eventually took back his cane and returned to his contented life without vision. 

Similarly, Shona Davison, writing on the Autistic UK website, put it this way, “Often the kindest, most caring people believe the way to help us, is to help us become more ‘normal’. This is what happens when one takes a medical model approach to autism – when one considers autistic people to be broken, disordered, or ill.” 

While the challenges and needs of disabled people are as varied as the individuals, those of us who benefit most from society’s current structure have a duty to expand the scope of those benefits and create a more inclusive world for all. Our perception of “normal”  needs to shift from a binary consideration to one that is mindful of the diverse ways individuals can—and do—perceive and navigate the world. Issues of accessibility, both in physical spaces and online, need a critical examination and modern update to accommodate millions of disabled individuals who are currently marginalized by streets, buildings, and websites designed for the able-bodied and able-minded. We need to be ever-aware and ever-curious about the insidious nature of ableism, recognize it when we see it, and correct it however we can. And ultimately, the abled need to set aside their own misconceptions and personal hang-ups in order to appreciate that disabled individuals have the agency to define their own cultures and conceptions of normal. 

Trying to solve these problems is a huge undertaking that might seem impossible. However, we must try. Even though no one can transform our ingrained societal norms overnight, change is possible if the able-bodied take the time to listen, empathize, and regard every disabled individual as a complex person trying like everyone else to fit in and build a life of their own. If we are going to start somewhere, let’s start by making that mindset “normal”.

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Healthcare Services Present and Future

Healthcare Services Present and Future

Covid-19 is understandably viewed as a crisis in the U.S., with a death toll topping 100,000 amid an economic shutdown that catapulted the nation into an instant recession. Nearly every sector of the economy has been broadsided by its effects. Rippling beneath the surface have been pockets of technological advance and investment opportunities, perhaps nowhere more than in the healthcare sector.

We are witnessing a wave of unexpected innovations in healthcare caused by the pandemic. With staff furloughed to reduce costs and in-person service curtailed, healthcare organizations are discovering new, more efficient delivery models. These include deploying robots for remote patient monitoring, third-party telemetry tools, vastly expanded use of telemedicine and an array of streamlined check-in venues and methods.

Many of these advances will outlive the pandemic, as healthcare providers recognize the time and costs saved by diving deeper into technology. For example, although telemedicine has been around for decades, its sudden and nearly universal adoption during the COVID-19 crisis has revealed more vividly to healthcare executives its benefits. Doctors report that up to 80% of their visits are currently being conducted virtually and that this experience has led them to recognize that a significant percentage of medical issues can be addressed in this way.

“Telemedicine has suddenly transformed from being a long-term ‘nice-to-have’ for increasing efficiency and expanding access to an essential requirement for patient triage, diagnostics, and engagement,” say Jonathan Bluth and Adam Abramowitz of Intrepid Investment Bankers.

As volume-based care has suffered under the new paradigm, the long-awaited shift towards value-based care may finally come to fruition. Experts and advisors expect significantly increased attention to be placed on capitation, Medicare Advantage plans, and accountable care organizations going forward, all sparked by the pandemic.

Indeed, if providers can work with payors to secure long-term reimbursement and deploy sustainable clinical model improvements, COVID-19 might redefine the healthcare experience for the better. In general, many payers have loosened restrictions and changed regulations affecting billing during the pandemic to provide for wider coverage of telehealth services.

How will this alter the investment landscape in healthcare? The pause in mergers and acquisitions in the second quarter of 2020 may linger, say Bluth and Abramowitz. “The speed of change and lack of visibility of the scope of the damage and the timing and velocity of the rebound make it difficult to price risk and value assets,” they write.

Let’s consider the impact Covid-19 is having on the prospects of three healthcare sub-sectors: home health, long-term care and autism services.

Home health has been buffeted by the response to the virus, with providers scrambling to maintain distancing in a hands-on care delivery model. Home health agencies have responded with increased telecare visits and more phone and video calls. Phone apps are helping enlist the aid of neighbors by connecting homebound patients to their community for help with grocery shopping, pharmacy pickups and health monitoring. Taken together, these innovations are creating efficiencies in the home health model that can convey benefits to patients and investors after the crisis has ebbed.

The future is bleaker for nursing homes, where 30,000 of the Covid-related deaths have occurred. Costs have exploded as facilities work to meet CDC guidelines, patient loads have plummeted as patients pass away and leave unreplaced by admissions, staff have deserted for health fears and reimbursements have fallen as states rope-in Medicaid expenditures. Occupancy in many homes has dropped below the 80% break-even level and are unlikely to rebound while the coronavirus persists.

For autistic individuals, the crisis has been a decidedly mixed bag. On the one hand, those with autism may by nature practice social distancing and these new social norms may provide relief and ease anxiety for some of these individuals. On the other hand, disrupted routines particularly affect those with autism, especially kids who may rely on daily support from professionals in their homes and schools. A lack of in-home services and the widespread shut down of clinics leaves children and families without the stabilizing support systems upon which they once relied. In addition, many with autism are least prepared to cope with the social isolation and economic strain. More potent tools delivering care remotely can reshape the delivery of services and benefit those enterprises that act fastest.

Nonetheless, a changing landscape does not mean the industry is doomed. Despite difficulties brought on by shutdowns, in-home and school-based providers are surviving by providing enhanced remote services. While smaller providers are bound to feel a greater strain throughout the pandemic, lean times create more opportunities for add-on acquisitions by larger providers that are more equipped financially to manage the present disruption. In fact, we are already beginning to see this kind of activity, with larger companies buying smaller ones using creative deal structures and existing financial relationships, hopeful to avoid reticent lenders and complicated debt financing. We don’t know how much longer the industry will experience this drastic reshape, but the companies thriving in this current environment are the ones whose buyers and investors have raised their level of scrutiny when it comes to discerning whether these consolidation behaviors are sustainable or provide long-term benefit.

As we monitor the state of the industry in the weeks and months ahead, some questions will help us qualify the changes to come:

  • What telehealth solutions are viable on a long-term basis?
  • How do outcomes from telehealth compare to direct services? Who benefits from telehealth?
  • How has the use of telehealth during COVID changed the service provider model for autism services and to what degree will the model change permanently?
  • Which service providers will blend in-person services with telehealth better?
  • Will this cause the mid-sized providers to start consolidating? (so they can get more scale and take advantage of cost efficiencies.)

In the end, a spirit of innovation is what continues to propel healthcare services forward through this exceptional epoch. While the headlines may portend a stormy future, reasons for optimism remain. The expansion of telehealth to near ubiquity is increasing patient access at a time we need it most. A shift towards value-based care rather than volume-based care is underway, and consolidation activity is gradually starting to stabilize the market for service providers. With the right guidance, healthcare services could emerge from the pandemic stronger and more patient-centric.

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Home Healthcare & COVID-19

Latin American Doctor Checking Patient Infected Of Covid-19 At H

Covid-19 has upended life globally, but perhaps no more than for the elderly, children and disabled individuals receiving health care services in their homes, and for the caregivers themselves. Ten million Americans rely on home health services for such disparate health needs as speech therapy, autism services, wound care and personal hygiene.

For those over age 65, who comprise the overwhelming majority of Covid fatalities, the severe consequences of a deadly virus are exacerbated by the isolation it is imposing upon them. While families are sheltering at home together, homebound elderly are most often alone. Sheltering and distancing guidelines may be keeping friends and even family members from visiting.

Social activities, such as attending lectures, going to movies and playing Mah-Jongg with friends, have been curtailed. The result of this is social isolation that leads to an increase in mental health conditions such as anxiety, depression, and suicidal ideations. For those with conditions such as Dementia or Alzheimer’s, there is increased confusion and sadness due to the lack of comprehension and recall about the current situation.

The requirement to isolate and avoid going out makes medical care of the elderly and more fragile populations problematic. For example, while individuals managing health conditions such as diabetes or high blood pressure may be able to live relatively independently, going grocery shopping, obtaining medications and maintaining the activities that sustain health such as walking and exercise are much more challenging, if not impossible.

For those in residential facilities such as nursing homes and assisted living facilities, social distancing may mean being isolated in their rooms alone almost 24/7, with brief interactions from staff to receive food and medicine. The lack of mental stimulation, physical activity and social interaction are harbingers of mental health breakdown, to which the elderly are already more prone. It is sobering to consider that this is the punishment imposed upon prison inmates whose actions suggest they are a danger to others.

With recent changes to the Medicare program addressing the Covid crisis, many hospitals and doctors have pivoted to using telehealth and virtual appointments to see patients, which can address many issues and keep medical care current. Technical challenges are prevalent with many elderly patients struggling to use face-to-face telehealth platforms. Medicare is allowing individuals to receive services via phone, without the visual component, but this certainly has its limitations. Additionally, Medicare has revised the requirements for some coverage decisions, no longer demanding face-to-face visits and allowing patients to receive longer supplies of prescriptions.

Home health care agencies are deploying skilled care to homes for some services, but not others. For example, they are taking samples of body fluids for testing; however, the necessary physical examinations are lacking, assessments for memory loss and functioning are impacted by phone-only options and routine medical exams such as colonoscopies and scans are not being performed. This may result in increased health issues and illnesses down the road.

Meanwhile, health care providers are facing their own challenges. The Centers for Disease Control has issued guidelines for care that include daily temperature checks and personal protective equipment like N95 respirators and latex gloves. Many home health workers fear for their safety and the safety of their families should they bring the virus home with them.

While children appear to be less at risk from the virus itself – they comprise just 2% of confirmed cases in the U.S. and incur mild-to-moderate symptoms 90% of the time – children with significant healthcare needs face daunting challenges. Cloistered at home and without the support structure of school, they are now entirely reliant on their parents and those home care providers who continue to visit. Limited home care may mean health regression or the onset of new health challenges.

Home health care strategies have been forced to shift radically because of Covid-19 and new long-term approaches will be required as the ramifications of the virus linger beyond 2020 into the foreseeable future. For now, its effect on home care patients and caregivers has been profound – and the full extent of it has yet to be revealed.

By: Ronit Molko, Ph.D., BCBA-D
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Coping with Stress in Unprecedented Times Part 2

Coping-with-Stress-in-Unprecedented-Times-Part-2

In my previous post, I explored the tumult of unusual activity flowing into and out of our brains as a result of the novel Coronavirus and the worldwide response to it. The threat to lives and livelihoods, the near-total curtailment of social interaction and the departure from normalcy – all of these taken together are wreaking havoc with how we think and feel.

Worse yet might be the increased uncertainty that accompanies all this. 9/11 happened over the course of a morning. Pearl Harbor was a rallying point for action. While the devastating emotional and psychological trauma of these events can be lifelong, the events themselves were flashpoints—over in a matter of hours. We were able to begin picking up the pieces and take corrective action more immediately. With Covid-19, we’re stuck inside our homes living this new distanced reality, with serious economic impact for many, for who-knows-how-long.

As I noted in Part 1 (Blog Part 1), experts in the field of psychology and brain science  empathize with the challenges our brains are facing but also remind us that we can use our brains in an intentional way to manage our thoughts and emotions to some degree and create productive habits. We can accept that this is the new normal until it isn’t, remain positive, focus on the good things in our lives, and divert ourselves with creative and meaningful activities.

For individuals with autism individuals, the calculation is somewhat different. Most autistics thrive on predictability and structure, and struggle with change, even changes many would consider small and inconsequential. Having their lives turned upside down, as they are now, falls somewhere between extremely distressing and catastrophic.

For caregivers of children and adults with autism, the need to perform “social distancing” is incongruous. Their services are, by definition, one-on-one and in person. As Leann McQueen, a residential coordinator for the Young Adult Institute in Brooklyn, told ABC News about her organization’s services to young people with disabilities, “People need assistance with personal hygiene. Even being asked to wash your hands can be more challenging.”

Christine Motokane is an articulate self-advocate to whom I spoke when conducting research for my book, Autism Matters. In her blog, Redefining Normal: A Young Woman’s Journey with Autism, she outlines some of the challenges she faces in this extraordinary time. Everything that is familiar to her has closed – her workplace, her favorite restaurants, other non-essential business – even the weekly outings with her support person have suddenly ended.

“I had to spend and celebrate my 28th birthday at home. All of these sudden changes coupled with the fluidity and ever-changing nature of this situation, has caused my anxiety to skyrocket,” she writes.

This is particularly worrisome because anxiety is often a constant state of being for autistic individuals who are hyper-sensitive to stimuli like light and touch. While “social distancing” has relieved many of those with autism of the anxiety about shaking hands or otherwise engaging in unwanted physical contact with others, and may be comforted by the six foot barrier others are maintaining, they must also confront a degree of exacerbated uncertainty that we all find discomfiting but those with autism may be traumatized by.

Autistica, the UK’s leading autism research charity, notes that autistic individuals react to uncertainty by avoiding such situations, by over-preparing for them or by gathering information that might reduce the uncertainty. None of these strategies is well-suited to this crisis because it can’t be avoided, over-preparing can lead to hoarding and gathering information about an unknown can just result in heightened anxiety.

The strategies that I enunciated in the previous post to manage anxiety about COVID-19 probably apply to everyone, inadequate though they may seem. Keeping as much of the normalcy in our lives as possible, creating a routine and some structure to our days and engaging in activities that enable some type of social contact can ward off some of the avalanche of change in our lives.

This reminds me of a story I came across in my research about maintaining the positive therapy momentum for children with autism during COVID-19. One mother, in an effort to keep life as normal as possible for her son, wakes him up at the usual time, has him dress in school clothes, maintains the entire morning routine, ushers him into the car and drives him around the neighborhood for 20 minutes before returning home for “school”.

Unfortunately, many parents have neither the time nor the bandwidth for such an effective regimen, innovative though it is. They are struggling to keep it together themselves, juggling work at home with the intrusions of family and a lack of respite from 24-hour-a-day demands of caring for children and keeping them constructively busy.

For situations like that, it’s important not to let perfection be the enemy of good. There is no playbook for a circumstance none of us has ever encountered before. Any steps families take, even small ones, like maintaining wake-up and bedtime routines, creating regular family fun time (playing games, reading books, etc.), exercising and dedicating time to learning daily, will all help to maintain a sense of routine and normalcy which will accrue to the benefit of all of us, adults and children alike.

Published By:
Ronit Molko, Ph.D., BCBA-D
Advisor to Investors in Behavioral Health

Posted on

Coping with Stress in Unprecedented Times- Part 1

Hypochondriac Concept Disease Panic Of Outbreak Anxiety And Hypo
By Ronit Molko, Ph.D., BCBA-D

Pity your brain. This unprecedented epoch we are experiencing is playing havoc with our most vital organ, the one that is designed to act as the air traffic controller of our bodies during the impenetrable fog of a lockdown.

Our brain through our nervous system is constantly evaluating and detecting risk with the ultimate goal being safety. This occurs at a primitive level within our brain without our conscious awareness. The primary element that challenges safety and stability is uncertainty. The brain is wired to detect fear and we have an overwhelming amount of fear-generating information right now.

COVID-19 has brought the world to its knees. First, there is the physical threat of a virus that is undetectable and about which we are learning as it unfolds. Second, is the constant mental anguish caused by the uncertainty about the future, even about tomorrow.

As a result, we are seeing extreme levels of stress, anxiety, and incremental  increases in depression and addiction. The tidal wave of negative information and emotion creates a continuous brain hijack (as the brain works to manage this threat) and overwhelms our cognitive processing. This stress keeps us in a fight or flight state, affecting core brain capacities such as thinking and decision making. Hoarding of supplies and increased aggression in people are some observable results of these affected capacities.

So if you are feeling stressed, anxious, and exhausted, it’s completely normal under these circumstances.

Jump To Acceptance

In fact, Dr. David Kessler, who collaborated with Elisabeth Kübler-Ross on her treatise, On Grief and Grieving, says that what many Americans are feeling is grief. He says we have lost our normalcy, our future plans and our connection to others, ironically in a collective grief experience.

Worse yet is the uncertainty that imperils not just our health but our financial stability. We don’t know when this catastrophe will end – could this go on for six months, a year? – and that is flooding many of us with anxiety. Dr. Kessler calls this “anticipatory grief.”

Dr. Kessler recommends that we consider the six stages of grief that his co-author famously enumerated and jump as quickly as we can to acceptance. “We find control in acceptance: I can wash my hands. I can keep a safe distance. I can work virtually,” he told the Harvard Business Review.

Four Strategies to Tame Stress

Dr. David Whitehouse, the psychiatric medical director for Able To, a leading provider of virtual behavioral health care, told the Total Brain podcast of four keys to confronting the anxiety sparked by the COVID-19 crisis.

He recommends we identify what we are feeling; avoid catastrophizing, i.e., steer clear of talking ourselves into depression; focus on the positive; and engage our creative right brain.

We have about 50,000 thoughts a day, that’s 2,100 thoughts an hour.

Positive thinking has long been known to improve our overall outlook and boost our performance. Barbara Frederickson, a psychology professor and researcher at the University of North Carolina, has demonstrated that positive thinking opens us to more options than does negative or neutral thoughts. Rather than wallowing in negative thoughts and emotions, simply reminding ourselves that this situation is temporary can have significant salutary effects physiologically and emotionally.

“You can, in fact, drive that negative analytic off the table,” Dr. Whitehouse says.

Physical exercise is an elixir for stress as well. Pushing ourselves physically focuses our attention on the moment and boosts our depression-fighting endorphins. In fact, exercise is often prescribed for patients with mild to moderate clinical depression.

Deep breathing has a similar impact on us physically. It stimulates the vagus nerve, which acts as a crossing guard at the corner of flight and flight. By calming the fight or flight response, the vagus nerve allows our body to relax and our vital signs to settle back to normal. Research shows that our heart can synchronize with our breathing, so that reduced respirations produces a slower heart rate and lower blood pressure.

People who struggle with anxiety often feel that their lives are out of control. In fact, many who struggle with anxiety attempt to control every facet of their lives; when their plans fail, anxiety often comes back with a vengeance.

A relatively simple way to overcome this problem is to establish a routine. Setting a schedule and applying some self-discipline to stick with it allows us to control our daily activities to the extent possible. Adding this structure to daily living can also unlock additional free time to enjoy other things.

There is also one common sense measure we can all take to avoid driving ourselves crazy: limit our exposure to the news. At this point, there isn’t much new to learn about COVID-19 other than that we must isolate ourselves, wash our hands and practice social distancing. All the speculation about how much worse it will get or how long we must wait for normal life to resume, or for the new normal to unfold, produces anxiety without insight. So in this time, limiting exposure to news and information is self-preservation, and while I wouldn’t ordinarily recommend this, less information means more peace of mind.

What these prescriptions have in common is that they are under our control. If we commit to accepting the current circumstances, thinking positively, challenging our bodies and minds, avoiding the news and simply taking a deep breath, we can calm our brains and reduce our psychic pain.