In a recent Morbidity and Mortality Weekly Report the Centers for Disease Control Published information regarding Adverse childhood experiences (ACEs) data from all 50 states and the District of Columbia by surveying adults from 2011-2020. Surveys found that ACEs, which are associated with negative health outcomes, are highest among women, persons aged 25–34 years, non-Hispanic American Indian or Alaska Native adults, non-Hispanic multiracial adults, adults with less than a high school education, and adults who were unemployed or unable to work. Prevalence of individual and total number of ACEs varied across jurisdictions. Adverse childhood experiences (ACEs) are defined as preventable, potentially traumatic events that occur among persons aged <18 years and are associated with numerous negative outcomes; data from 25 states indicate that ACEs are common among U.S. adults (1). Disparities in ACEs are often attributable to social and economic environments in which some families live (2,3). Understanding the prevalence of ACEs, stratified by sociodemographic characteristics, is essential to addressing and preventing ACEs and eliminating disparities, but population-level ACEs data collection has been sporadic (1). Using 2011–2020 Behavioral Risk Factor Surveillance System (BRFSS) data, CDC provides estimates of ACEs prevalence among U.S. adults in all 50 states and the District of Columbia, and by key sociodemographic characteristics. Overall, 63.9% of U.S. adults reported at least one ACE; 17.3% reported four or more ACEs. Experiencing four or more ACEs was most common among females (19.2%), adults aged 25–34 years (25.2%), non-Hispanic American Indian or Alaska Native (AI/AN) adults (32.4%), non-Hispanic multiracial adults (31.5%), adults with less than a high school education (20.5%), and those who were unemployed (25.8%) or unable to work (28.8%). Prevalence of experiencing four or more ACEs varied substantially across jurisdictions, from 11.9% (New Jersey) to 22.7% (Oregon). Patterns in prevalence of individual and total number of ACEs varied by jurisdiction and sociodemographic characteristics, reinforcing the importance of jurisdiction and local collection of ACEs data to guide targeted prevention and decrease inequities. CDC has released prevention resources, including Preventing Adverse Childhood Experiences: Leveraging the Best Available Evidence, to help provide jurisdictions and communities with the best available strategies to prevent violence and other ACEs, including guidance on how to implement those strategies for maximum impact (4–6). BRFSS is an annual survey of health-related risk behaviors and chronic health conditions representative of noninstitutionalized adults collected from all 50 states, the District of Columbia, and three U.S. territories (7). In addition to core questions administered annually to all participants, jurisdictions and territories can include jurisdiction-approved optional modules, as well as jurisdiction-added questions.* From 2011 to 2020, ACEs questions were included in the BRFSS questionnaire at least once by all 50 states and the District of Columbia as either an optional module (2011–2012 and 2019–2020) or jurisdiction-added questions (2013–2018). For jurisdictions that included ACEs questions in more than 1 year, the most recent year was included. The optional ACEs module includes 11 questions to determine exposure to eight types of ACEs: physical abuse, emotional abuse, sexual abuse, witnessing intimate partner violence, household substance abuse, household mental illness, parental separation or divorce, and incarcerated household member† (1). The Arkansas and New Hampshire questionnaires differed from the optional ACEs module. Arkansas collapsed three sexual abuse questions into a single question, and New Hampshire omitted two of the three sexual abuse questions.§ The Arkansas questionnaire also combined household drug abuse and alcohol abuse questions into a single household substance abuse question. Responses to all ACE types were dichotomized**; ACE scores were calculated for participants by summing affirmative responses to all eight ACE types and then categorized into zero, one, two to three, or four or more ACEs. Four or more ACEs were selected as the upper cut-off given the volume of research linking exposure to four or more ACEs with negative health and life outcomes (1,2,8,9). The New Hampshire questionnaire did not include divorce or emotional abuse questions; therefore, the maximum ACE score in New Hampshire was six. Participants with missing data for any type of ACE were excluded (79,797), leaving 264,882 participants (72.5% of total). Weighted prevalence estimates and 95% CIs were calculated for individual ACEs and total ACE score, by jurisdiction and by sociodemographic characteristics (sex, age group, race and ethnicity, annual household income, educational attainment, and employment status). Age-stratified jurisdictional prevalence estimates for four or more ACEs were also calculated. All analyses accounted for survey design by using recommended weights and complex survey procedures in SAS software (version 9.4; SAS Institute). This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.†† Survey response rate ranged by jurisdiction from 30.6% (Illinois, 2017) to 67.2% (Mississippi, 2020) (Table 1). Nearly two thirds of U.S. adults (63.9%) experienced one or more ACE: 23.1% reported one; 23.5% reported two to three; and 17.3% reported four or more ACEs (Table 2). The prevalence of four or more ACEs was highest among females (19.2%), persons aged 25–34 years (25.2%), AI/AN adults (32.4%), and multiracial adults (31.5%). The prevalence of four or more ACEs was also higher among adults with household incomes <$15,000 (24.1%), those with less than a high school education (20.5%), and those who were unable to work (28.8%). Prevalence of four or more ACEs was lowest among persons aged ≥65 years (7.7%). Emotional abuse was the most reported type of ACE (34.0%), followed by parental separation or divorce (28.4%), and household substance abuse (26.5%) (Table 3). Patterns in prevalence of individual types of ACEs differed by sociodemographic characteristics. Prevalence of individual ACEs (Table 3), total number of ACEs (Table 1), and four or more ACEs varied by jurisdiction (figure 1-suppliments table 1) For example, Alaska had one of the highest prevalences of reported emotional abuse (42.2%) but one of the lower prevalences of physical abuse (19.4%). Among jurisdictions that asked all eight types of ACE questions, the prevalence of adults reporting four or more ACEs ranged from 11.9% (New Jersey) to 22.7% (Oregon). Geographic patterns of reporting four or more ACEs also differed by age group (Supplementary Figure 2), with some consistent regional differences observed across age groups (e.g., increased prevalence of reporting 4 or more ACEs among jurisdictions in the Pacific Northwest). https://www.cdc.gov/mmwr/volumes/72/wr/mm7226a2.htm?s_cid=mm7226a2_w#T1_down Discussion This study provides the first estimates of ACEs among U.S. adults for all 50 states and the District of Columbia using BRFSS data. During 2011–2020, nearly two thirds of U.S. adults reported at least one ACE, and approximately one in six U.S. adults reported four or more ACEs. Among certain sociodemographic groups, for example, AI/AN or multiracial adults, these numbers are even higher, reflecting inequities in socioeconomic conditions that increase risk for ACEs. These numbers also highlight the potential intergenerational impact of ACEs through lost opportunities and lasting impacts on behavior and health (8). The prevalence of ACEs is strikingly lower among adults aged ≥65 years than among younger age groups; although this might be due to recall bias or differing trends over time, it might also reflect the risk of premature mortality accompanying exposure to a high number of ACEs (9). Patterns in individual and total number of ACEs varied widely by jurisdiction and among sociodemographic groups, reinforcing the importance of population-level and local collection of ACE data to inform targeted prevention and intervention strategies. Variations in ACEs can result from several factors: differing demographic patterns, jurisdiction-level policies related to domestic violence, economic supports for families, historical and ongoing trauma because of discrimination, and social conditions (4). Better understanding of the relative contributions of these factors to ACEs in individual jurisdictions can help policymakers identify the most promising areas for intervention and the populations with the greatest need for services (4). Jurisdictions could consider further contextualizing their ACEs data with other BRFSS questions, such as those examining social determinants of health. CDC has released prevention resources to help provide jurisdictions and communities with the best available strategies to prevent violence and other ACEs, including guidance on how to implement those strategies for maximum impact (4–6). Clinicians and others who work directly with families play an important role in mitigating and preventing ACEs, from primary prevention opportunities (e.g., home visitation programs), to secondary and tertiary prevention strategies that reduce harms associated with ACEs (e.g., trauma-informed care, ensuring required linkage to services, and supports for identified issues) (10). The findings in this report are subject to at least four limitations. First, data were collected over a 10-year period; prevalence might have changed in jurisdictions without recent data. In addition, jurisdiction-specific prevalences reflect the experiences of adults living in that jurisdiction, but do not necessarily represent the jurisdiction in which the ACE occurred. Second, although most jurisdictions used identical measures, two states (Arkansas and New Hampshire) collapsed or omitted sexual abuse questions, and one state (New Hampshire) omitted two types of ACEs. As a result, estimates for emotional abuse and parental separation or divorce are unavailable for New Hampshire. The reported prevalences of ACEs might be underestimated because respondents with missing ACEs data (79,797) were excluded from the analysis; these respondents reported higher prevalence of individual ACEs on the questions they did answer than those who answered all of the ACEs questions. Third, recall and social desirability biases might reduce the accuracy of self-reported ACEs, leading to underestimation, because participants might no longer remember or be willing to disclose potentially traumatic events from their childhood. Finally, BRFSS questions measure a limited set of ACEs and do not reflect the full range, severity, or frequency of ACEs. It is possible that ACEs included in BRFSS are experienced differently by certain groups, thereby shaping some of the demographic and geographic differences observed. In addition, certain limitations need to be considered when interpreting jurisdiction-specific estimates. First, BRFSS records a small subset of potential ACEs; there might be ACEs that are particularly relevant in certain parts of the country that are not included on BRFSS (e.g., experiences of racism or discrimination and community violence) and are thereby not reflected in estimates. Second, adults with six or more ACEs die approximately 20 years earlier on average than do those without ACEs (9); survivorship bias might undercount ACE prevalence in regions affected by premature mortality related to ACEs. Despite these limitations, the findings from this study update the baseline for ACEs measurement from previous estimates from 25 states (1), providing actionable data for all 50 states and the District of Columbia. ACEs are common, but not equally distributed within the population. Differing patterns by jurisdiction and sociodemographic characteristics demonstrate the importance of collecting ACEs data at the jurisdiction level to understand the scope of the problem, identify populations more affected by ACEs, and ACEs-related outcomes; to help guide prevention and mitigation interventions and policies (6). CDC has released prevention resources to help provide jurisdictions and communities with the best available strategies to prevent violence and other ACEs, and with guidance on how to implement those strategies for maximum impact (4–6). Clinicians and others who work directly with families play an important role in mitigating and preventing ACEs, from primary prevention opportunities (e.g., home visitation programs) to secondary and tertiary prevention strategies that reduce harms associated with ACEs (e.g., trauma-informed care, ensuring appropriate linkage to services, and supports for identified issues) (10). Source: Morbidity and Mortality Weekly Report

"Dietary supplements", aka herbal remedies are not stringently regulated as medicines. Despite the regulation by the FDA, various medications have strong side effect profile so it is always important to advocate for yourself when seeing a physician (such as primary care or psychiatrist) about how your body is reacting to the medication, as various mood stabilizers and anti-psychotic medications have horrible side effects. It was very surprising that the FDA approved Abilify and Risperdal for the treatment of irritability for children with Autism Spectrum Disorder. Both of these medications having side effects such as weight gain, blunting the dopamine receptor (the happy neurotransmittor) - one potential cause of overeating as you receive dopamine responses with food. Risperdal was originally developed to treat patients with schizophrenia, which is odd how it would reduce the irritability of patients with ASD. Personally, I think there are many agents that can help control the symptoms of irritability if you understand the root cause of where it is coming from. Sorry that was a tangent, as I tend to be very cautious about use of mood stabilizers/anti-psychotics, as it seems that everyone is on it these days. I have added a link below so you can read and identify that you are not having severe or moderate side effects to your medications, as I could imagine it would be a frustrating experience. You are trying to get rid of one problem, while adding on one or more. Regardless, consumers are left in an unregulated industry, unprotected by watchdogs like the FDA there is very hard to predict which manufacturer, products, and forms would we good for our consumption. Also, there is a lot of misinformation and erroneous information on the internet so it is important to know the source of information. It is always important to use these supplements under the guidance of a clinician, as sometimes herbal remedies are not potent enough for the underlying condition or may need to be augment with a medication and/or therapy. Self-diagnosis is always frowned upon as we innately have our own biases and lack objectivity. Also, it is important to understand and recognize that there is no such thing as a "fully safe treatment", even herbal remedies. It is important to recognize that the source of herb is just as important, as there are many ways of mass producing products that are not high grade with fillers/preventatives/contaminants. A majority of the content that I use is from Herbs of the Mind, which I feel is a well written book that helps a person understand and integrate mental health from a holistic model, is from two experienced psychiatrist from Duke University Medical Center, Johnathan Davidson, MD and Kathryn Connor, MD. There is various studies that reflect simple herbs, which should be taken under the care of a physician, such as St. John's Wort (which can induce mania in patients) or 5-HTP can reduce symptoms of depression, Kava can alleviate stress and anxiety, valerian root can help with sleep issues, or ginkgo can help slow the rate of declining memory. Now, each response in on a case by case basis, again as mentioned is not full safe, therefore I would not recommend purchase these products without a physician's supervision. Did you know that Gingko Biloba can reverse the sexual side effects of SSRIs? St. John's Wort can long been used to help reduce the symptoms of depression (with caution based on concerns of inducing mania). Kava bars exist around the world, particularly in the Polynesia, but more recently into the US. The advantage of kava is can potential improve cognitive acuity unlike other anxiolytics that have a dulling effect. Valerian root is an alternative for people suffering with insomnia or mild anxiety (particular at night), compared to sleep aid (which cause sedation, which typically disrupt REM sleep). Most of data for herbal remedies comes from Europe, however there is limited long term data present in the US, as it is not typically studied as it is seen a non-lucrative, that is open to a lot of competition as it is hard to patient natural remedies, as they are hundreds, if not thousands of years old. One herb Ashwaganda has been used for thousands of years in India for anxiety, with minimal side effects. Source: Herbs of the Mind

Gambling disorder involves repeated, problem gambling behavior. The behavior leads to problems for the individual, families, and society. Adults and adolescents with gambling disorder have trouble controlling their gambling. They will continue even when it causes significant problems. Diagnosis A diagnosis of gambling disorder requires at least four of the following during the past year: Need to gamble with increasing amounts to achieve the desired excitement. Restless or irritable when trying to cut down or stop gambling. Repeated unsuccessful efforts to control, cut back on or stop gambling. Frequent thoughts about gambling (such as reliving past gambling or planning future gambling). Often gambling when feeling distressed. After losing money gambling, often returning to get even. (This is referred to as "chasing" one's losses.) Lying to hide gambling activity. Risking or losing a close relationship, a job, or a school or job opportunity because of gambling. Relying on others to help with money problems caused by gambling People with gambling disorder can have periods where symptoms subside. The gambling may not seem a problem in between periods of more severe symptoms. Gambling disorder tends to run in families. Factors such as trauma and social inequality, particularly in women, can be risk factors. Symptoms can begin as early as adolescence or as late as older adulthood. Men are more likely to start at a younger age. Women are more likely to start later in life. Gambling Disorder Treatment Some people can stop gambling on their own. But many people need help to address their gambling problems. Only one in ten people with gambling disorder seek treatment. Gambling affects people in different ways. Different approaches may work better for different people. Several types of therapy are used to treat gambling disorders, including cognitive behavioral therapy (CBT), psychodynamic therapy, group therapy, and family therapy. Counseling can help people understand gambling and think about how gambling affects them and their family. It can also help people consider options and solve problems. There are no FDA-approved medications to treat gambling disorders. Some medications may help treat co-occurring conditions like depression or anxiety. Support from family and friends can be critical to a person's recovery from gambling. However, only the individual can decide to stop the behaviors. Counseling can help: Gain control over your gambling. Heal family relationships. Deal with your urge to gamble. Handle stress and other problems. Find other things to do with your time. Put your finances in order. Maintain recovery and avoid triggers. Support Groups and Self-Help Support groups, such as Gamblers Anonymous and Alcoholics Anonymous, use peer support to help others stop gambling. Some research has shown physical activity can help those with gambling disorder. Many states have gambling helplines and other assistance. A National Helpline is available at 1-800-662-HELP (4357). Strategies to Deal with Cravings Reach out for support. Call a trusted friend or family member. Go to a Gamblers Anonymous meeting. Distract yourself with other activities. Postpone gambling. Giving yourself time may allow the urge to pass or weaken. Stop for a moment and consider what will happen when you gamble. Avoid isolation. "Dos" and "Don'ts" for Partners, Friends, or Family Members Do Seek the support of others with similar problems; attend a self-help group for families such as Gam-Anon. Recognize your partner's good qualities. Remain calm when speaking to the person with a gambling disorder. Let them know that you are seeking help for yourself; the gambling is affecting you (and possibly children). Explain problem gambling to children. Understand the need for treatment of problem gambling and that it may take time. Set boundaries in managing money; take control of family finances; review bank and credit card statements. Don't Preach, lecture, or allow yourself to lose control of your anger Exclude the gambler from family life and activities Expect immediate recovery, or that all problems will be resolved when the gambling stops Bailout the gambler Preventing Suicide Problem gamblers are at increased risk of suicide. It’s very important to take any thoughts or talk of suicide seriously. For immediate attention, call 988, text 988, or chat at 988lifeline.org. Source: Yale Medicine - Gambling Disorder

Body Dysphoric Disorder Individuals with body dysmorphic disorder are preoccupied with what they perceive as flaws in their physical appearance. The perceived flaws are not noticeable or appear only slight to others but are seen as ugly or abnormal to the person with body dysmorphic disorder. It is not the same as the typical concerns many people have about their appearance. Body dysmorphic disorder also involves repetitive behaviors (such as checking a mirror or seeking reassurance) or repetitive thinking (such as comparing one’s appearance with others). The preoccupations can focus on one or many body areas, most commonly the skin, hair or nose. The preoccupations and behaviors are intrusive, unwanted, and time-consuming (occurring, on average, three to eight hours per day). The individual feels driven to perform them and usually has difficulty resisting or controlling them. The preoccupation causes significant distress or problems in daily activities such as work or social interactions. This can range from avoiding some social situations to being completely isolated and housebound. Body dysmorphic disorder is associated with high levels of anxiety, social anxiety, social avoidance, depressed mood and low self-esteem. Many individuals seek and too often receive cosmetic treatment, such as skin treatments or surgery, to try to fix their perceived defects. People with body dysmorphic disorder may or may not understand that their concerns about their appearance are distorted. Many individuals with body dysmorphic disorder believe that other people take special notice of them or mock them because of how they look. It affects an estimated 2% of people. It typically begins before age 18 and affects both men and women. Body dysmorphic disorder is usually treated with a combination of cognitive behavior therapy and medication, such as selective serotonin reuptake inhibitors (SSRIs). Muscle Dysphoria - subcategory of Body Dysphoria Muscle dysmorphia, a form of body dysmorphic disorder, more common in males, consists of preoccupation with the idea that one’s body is too small or too heavy, or not muscular enough. Individuals with this form of the disorder actually have a normal-looking body or are even very muscular. A majority (but not all) diet, exercise, and/or lift weights excessively. Source: Mayo Clinic - Body Dysphoric Disorder

Obsessive-compulsive disorder (OCD) is a disorder in which people have recurring, unwanted thoughts, ideas or sensations (obsessions). To get rid of the thoughts, they feel driven to do something repetitively (compulsions). The repetitive behaviors, such as hand washing/cleaning, checking on things, and mental acts like (counting) or other activities, can significantly interfere with a person’s daily activities and social interactions. Many people without OCD have distressing thoughts or repetitive behaviors. However, these do not typically disrupt daily life. For people with OCD, thoughts are persistent and intrusive, and behaviors are rigid. Not performing the behaviors commonly causes great distress, often attached to a specific fear of dire consequences (to self or loved ones) if the behaviors are not completed. Many people with OCD know or suspect their obsessional thoughts are not realistic; others may think they could be true. Even if they know their intrusive thoughts are not realistic, people with OCD have difficulty disengaging from the obsessive thoughts or stopping the compulsive actions. A diagnosis of OCD requires the presence of obsessional thoughts and/or compulsions that are time-consuming (more than one hour a day), cause significant distress, and impair work or social functioning. OCD affects 2-3% of people in the United States, and among adults, slightly more women than men are affected. OCD often begins in childhood, adolescence, or early adulthood. Some people may have some symptoms of OCD but not meet full criteria for this disorder. Obsessive-compulsive disorder Obsessions Obsessions are recurrent and persistent thoughts, impulses, or images that cause distressing emotions such as anxiety, fear or disgust. Many people with OCD recognize that these are a product of their mind and that they are excessive or unreasonable. However, the distress caused by these intrusive thoughts cannot be resolved by logic or reasoning. Most people with OCD try to ease the distress of the obsessional thinking, or to undo the perceived threats, by using compulsions. They may also try to ignore or suppress the obsessions or distract themselves with other activities. Examples of common content of obsessional thoughts: Fear of contamination by people or the environment Disturbing sexual thoughts or images Religious, often blasphemous, thoughts or fears Fear of perpetrating aggression or being harmed (self or loved ones) Extreme worry something is not complete Extreme concern with order, symmetry, or precision Fear of losing or discarding something important Can also be seemingly meaningless thoughts, images, sounds, words or music Compulsions Compulsions are repetitive behaviors or mental acts that a person feels driven to perform in response to an obsession. The behaviors typically prevent or reduce a person's distress related to an obsession temporarily, and they are then more likely to do the same in the future. Compulsions may be excessive responses that are directly related to an obsession (such as excessive hand washing due to the fear of contamination) or actions that are completely unrelated to the obsession. In the most severe cases, a constant repetition of rituals may fill the day, making a normal routine impossible. Examples of compulsions: Excessive or ritualized hand washing, showering, brushing teeth, or toileting Repeated cleaning of household objects Ordering or arranging things in a particular way Repeatedly checking locks, switches, appliances, doors, etc. Constantly seeking approval or reassurance Rituals related to numbers, such as counting, repeating, excessively preferencing or avoiding certain numbers People with OCD may also avoid certain people, places, or situations that cause them distress and trigger obsessions and/or compulsions. Avoiding these things may further impair their ability to function in life and may be detrimental to other areas of mental or physical health. Treatment Patients with OCD who receive appropriate treatment commonly experience increased quality of life and improved functioning. Treatment may improve an individual's ability to function at school and work, develop and enjoy relationships, and pursue leisure activities. Cognitive Behavioral Therapy One effective treatment is a type of cognitive-behavioral therapy (CBT) known as exposure and response prevention (ERP). During treatment sessions, patients are exposed to feared situations or images that focus on their obsessions. Although it is standard to start with those that only lead to mild or moderate symptoms, initially the treatment often causes increased anxiety. Patients are instructed to avoid performing their usual compulsive behaviors (known as response prevention). By staying in a feared situation without anything terrible happening, patients learn that their fearful thoughts are just thoughts. People learn that they can cope with their thoughts without relying on ritualistic behaviors, and their anxiety decreases over time. Using evidence-based guidelines, therapists and patients typically collaborate to develop an exposure plan that gradually moves from lower anxiety situations to higher anxiety situations. Exposures are performed both in treatment sessions and at home. Some people with OCD may not agree to participate in CBT because of the initial anxiety it evokes, but it is the most powerful tool available for treating many types of OCD. Medication A class of medications known as selective serotonin reuptake inhibitors (SSRIs), typically used to treat depression, can also be effective in the treatment of OCD. The SSRI dosage used to treat OCD is often higher than that used to treat depression. Patients who do not respond to one SSRI medication sometimes respond to another. The maximum benefit usually takes six to twelve weeks or longer to be fully visible. Patients with mild to moderate OCD symptoms are typically treated with either CBT or medication depending on patient preference, the patient’s cognitive abilities and level of insight, the presence or absence of associated psychiatric conditions, and treatment availability. The best treatment of OCD is a combination of CBT and SSRIs, especially if OCD symptoms are severe. Neurosurgical treatment Some newer studies show that gamma ventral capsulotomy, a surgical procedure, can be very effective for patients who do not respond to typical treatments and are very impaired, but it is underused due to historical prejudice and its invasiveness. Deep brain stimulation, which involves an implanted device in the brain, has data to support efficacy and does not permanently destroy brain tissue as done in a capsulotomy. However, it is still highly invasive and complex to manage, and there are limited providers and hospital systems trained to offer this treatment and, able to provide the long-term support needed by DBS patients. How to Support a Loved One Struggling with OCD In people with OCD who live with family, friends, or caregivers, enlisting their support to help with exposure practice at home is recommended. In fact, the participation of family and friends is a predictor of treatment success. Self-care Maintaining a healthy lifestyle can help in coping with OCD. Getting enough good quality sleep, eating healthy food, exercising, and spending time with others can help with overall mental health. Also, using basic relaxation techniques (when not doing exposure exercises) such as meditation, yoga, visualization, and massage can help ease the stress and anxiety. Source: International OCD foundation

These are a group of disorders that are linked by varying difficulties in controlling aggressive behaviors, self-control, and impulses. Typically, the resulting behaviors or actions are considered a threat primarily to others’ safety and/or to societal norms. Some examples of these issues include fighting, destroying property, defiance, stealing, lying, and rule breaking. These disorders are: Oppositional defiant disorder Intermittent explosive disorder Conduct disorder Pyromania Kleptomania Other specified disruptive, impulse-control and conduct disorder Unspecified disruptive, impulse-control, and conduct disorder Problematic behaviors and issues with self-control associated with these disorders are typically first observed in childhood and can persist into adulthood. In general, disruptive, impulse-control, and conduct disorders tend to be more common in males than females, with the exception of kleptomania. Behavioral issues are a common reason for referral to psychiatrists or other mental health providers. It is important to note that it can be developmentally appropriate for kids to become disruptive or defiant at times. However, disruptive, impulse, and conduct disorders involve a pattern of much more severe and longer-lasting behaviors then what is developmentally appropriate. For instance, these behaviors are frequent, occur in various settings, and can have significant consequences (including legal repercussions). It is also important to consider that anger and defiance can be manifestations of other disorders. One difference between disruptive behavioral disorders and many other mental health conditions is that with behavioral disorders, a person's distress is focused outward and directly affects other people. With most other mental health conditions, such as depression and anxiety, a person's distress is generally directed inward toward themselves. Types of Disorders Oppositional Defiant Disorder Oppositional defiant disorder is a common disorder in children and adolescents who are referred to mental health providers for behavioral issues. Individuals with this disorder experience varying levels of dysfunction secondary to oppositionality, vindictiveness, arguments, and aggression. Symptoms of oppositional defiant disorder include a pattern of: Angry/irritable mood—often loses temper, easily annoyed, often angry and resentful. Argumentative/defiant behavior—often argues with authority figures or adults, often refuses to comply with requests or rules, deliberately annoys others, blames others for mistakes or misbehavior. Vindictiveness—spiteful or vindictive. These behaviors are distressing to the individual and alarming to others. Anger, threatening behaviors, and spitefulness cause disruption at school or work and affect relationships with others. Of note, these behaviors do not include aggression towards animals or people, destruction, or theft. In other words, there are no violations to others or societal norms. Individuals with oppositional defiant disorder, will likely experience conflict with adults and authority figures. To be diagnosed with Oppositional defiant disorder, the behaviors must occur with at least one individual who is not the person's sibling. Signs of the disorder typically develop during preschool or early elementary school but can also begin in adolescence. For children under age 5, the behaviors occur on most days for at least six months. For people 5 and older, the behaviors occur at least once per week for at least six months. The severity of this illness is based on the number of settings in which these behaviors are observed. The cause of oppositional defiant disorder is not fully understood. However, it is believed that ODD might be secondary to several biological, psychological, and social factors. There are several risks associated with the development of oppositional defiant disorder: having poor frustration tolerance, high levels of emotional reactivity, neglect during childhood, and inconsistent parenting.ODD tends to be more common in children who live in poverty and is more common in boys than girls prior to adolescence. The prevalence of oppositional defiant disorder is about 3.3%. Many, but not all, children and adolescents who have been diagnosed with oppositional defiant disorder will later be diagnosed with Conduct Disorder, which is typically considered a more severe behavioral disorder. More information on Conduct Disorder to follow. However, oppositional defiant disorder is not necessarily a chronic condition. About 70% of individuals with oppositional defiant disorder will have resolution of the symptoms by the time they turn 18 years old. Furthermore, about 67% of children diagnosed with oppositional defiant disorder will no longer meet diagnostic criteria within a 3 year follow up. Of note, adults and adolescents who have been diagnosed with oppositional defiant disorder have a 90% chance of being diagnosed with another mental illness in their lifetime3 - especially anxiety disorders, mood disorders, substance abuse, conduct disorder, antisocial personality disorder, and other personality disorders. Individuals with oppositional defiant disorder, have higher risk of dying by suicide then the general population. Oppositional defiant disorder is diagnosed by a psychiatrist or other mental health professional based on information from the individual (child, adolescent, adult) and, for children/adolescents, from parents, teachers and other caregivers. The American Academy of Child and Adolescent Psychiatry (AACAP) notes that it's important for a child to have a comprehensive evaluation to identify any other conditions which may be contributing to problems, such as ADHD, learning disabilities, depression or anxiety. Treatment of oppositional defiant disorder often involves a combination of therapy and training for the child, and training for the parents. For children and adolescents, cognitive problem-solving training can teach positive ways to respond to stressful situations. Social skills training helps children and youth learn to interact with other children and adults in a more appropriate, positive way. In some cases, medications might be necessary. Parent management training can help parents learn skills and techniques to respond to challenging behavior and help their children with positive behavior. The training focuses on providing supportive supervision and immediate, consistent discipline for problem behavior. According to ACAAP, one-time or short programs that try to scare or coerce children and adolescents into behaving, such as tough-love or boot camps, are not effective and may even be harmful.1 If you're concerned about your child's behavior, talk to your child's doctor or a mental health professional, such as a child psychiatrist or psychologist or a child behavioral specialist. Disruptive, Impulse Control and Conduct Disorders Adapted from Understanding Mental Disorders: Your Guide to DSM-5 Conduct Disorder Conduct disorder involves severe behaviors that violate the rights of others or societal norms. Behaviors may involve aggression towards others, animals, and/or destruction of property all of which could result in legal consequences.4 As stated in the oppositional defiant disorder section, many (but not all) children and adolescents with oppositional defiant disorder will eventually meet diagnostic criteria for conduct disorder. However, not all individuals who are diagnosed with Conduct Disorder were first diagnosed with ODD.5 Symptoms of conduct disorder include varying patterns of: Aggression to people and animals (bullies, intimidates others, initiates fights, use of weapons, cruelty to others, cruelty to animals, stolen while confronting a victim, raped others). Destruction of property (deliberate fire setting, vandalization). Deceitfulness or theft (broken into properties, manipulates others, stolen). Serious violations of rules (runs away from home, truant from school, stays out at night). Per the DSM-5, these behaviors can first be observed in pre-school. However, the more significant symptoms tend to appear between middle childhood and middle adolescents. It is rare for these symptoms to first appear after the age of 16. Conduct disorder is only diagnosed in children and youth up to 18 years of age. Adults with similar symptoms may be diagnosed with antisocial personality disorder. Early treatment can help prevent problems from continuing into adulthood. There are multiple risk factors for the development of conduct disorder, including: harsh parenting styles, exposure to physical or sexual abuse during childhood, unstable upbringing, maternal substance use during pregnancy, parental substance use and criminal activity, and poverty.5 These behaviors cause significant dysfunction in multiple settings such as at home, in school, in relationships, and in occupational settings. However, people with conduct disorder may deny or downplay their behaviors. Conduct disorder is generally considered more serious than ODD. It can be associated with criminal behaviors, dropping out of high school, and substance abuse. About 40% of individuals who meet diagnostic criteria for conduct disorder, will later meet diagnostic criteria for antisocial personality disorder. The prevalence of conduct disorder is between 1.5% and 3.4%. It tends to be more common in males. About 16-20% of youth with conduct disorder also have ADHD.5 Of note, youth that have both ADHD and Conduct Disorder have higher risk of substance use. Therapy can help children learn to change their thinking and control angry feelings. Treatment may include parent management training and family therapy, such as Functional Family Therapy. Functional Family Therapy helps families understand the disorder and related problems, teaches positive parenting skills and helps build family relationships. It can help families apply positive changes to other problem areas and situations. Intermittent Explosive Disorder Intermittent explosive disorder is a disorder associated with frequent impulsive anger outbursts or aggression—such as temper tantrums, verbal arguments, and fights.2 The observed behaviors result in physical assaults towards others or animals, property destruction, or verbal assaults.6 The aggressive outbursts: Are out of proportion to the event or incident that triggered them. Are impulsive. Cause much distress for the person. Cause problems at work or home. It is important to note that these aggressive behaviors are not planned, they are impulsive and anger based.7 They happen rapidly after being provoked and typically do not last longer than 30 minutes.2 These outbursts must be associated with subjective distress or social or occupational dysfunction.7 Affected individuals tend to have poor life satisfaction and lower quality of life.7 In order to meet diagnostic criteria, affected individuals must be at least 6 years old or the developmental equivalent.2 However, this disorder is usually first observed in late childhood or adolescence.2 The one-year prevalence is 2.7% and lifetime prevalence is 7%.8 Many risk factors have been identified with the development of Intermittent Explosive Disorder, such as: being male, young, unemployed, single, having lower levels of education, and being victim of physical or sexual violence.6 Intermittent explosive disorder is associated with anxiety and bipolar disorders.6 Individuals with this disorder have higher risks of developing substance use disorders than those without it.7 Treatment typically involves cognitive behavioral therapy focusing on changing thoughts related to anger and aggression and developing relaxation and coping skills. Sometimes, depending on a person's age and symptoms, medication may be helpful. Pyromania While fire setting can be a common issue among young individuals and a cause of significant destruction in the United States, it is different from pyromania which is a rare disorder that involves repeated impulses or strong desires to set intentional fires.9 Fire setting is typically motivated by curiosity and tends to occur in unsupervised children with access to lighters and matches.9 Individuals with pyromania, on the other hand, are fascinated by fire and its uses. Affected individuals engage in repeated and deliberate fire setting that is not motivated by external reasons.10 They experience strong urges to engage in dangerous fire setting. They also experience internal tension prior to setting fires that is followed by pleasure after fires are lit. These individuals set fires to release built-up inner emotional tension, not for any type of material gain or revenge. Some known risk factors for pyromania are male gender, substance use, victim of abuse, being fascinated with fires, and having mental illness.11 The prevalence of pyromania is about 1% in the United States.9 It is associated with personality disorders or traits (especially antisocial personality disorder or antisocial behaviors), conduct disorder, and substance use disorders.9 Treatment of pyromania usually involves cognitive behavioral therapy and education. The therapy can help people become more aware of the feelings of tension and find ways to cope. Every child should be taught about the dangers of playing with fire and possible consequences.9 Kleptomania Kleptomania is a rare disorder that involves involuntary, impulsive, and irresistible stealing of objects that are not needed for personal or other forms of use. This is different from shoplifting in that shoplifters steal for some form of gain and often plan out their actions.21 However, individuals with Kleptomania do not need what they have stolen. They often give away, return, hide, or hoard the stolen objects.13 People with kleptomania know what they are doing is wrong but cannot control the impulse to steal, leading to hasty and poorly thought-out stealing.12 They experience internal tension before stealing that is then relieved after the theft. While they experience pleasure or gratification from stealing, they tend to have guilt or sadness afterwards.13 Many people with this disorder may try to stop stealing but feel guilt and shame about their inability to do so.13 Unfortunately, many may be apprehended or jailed for these behaviors.13 This disorder tends to appear in adolescence. However, its onset can vary significantly between childhood and old age.13 The prevalence of this disorder is not known, but it is believed to be a generally uncommon diagnosis12 that may be more common in females and psychiatric patients.13 Many with this disorder also have substance use disorders, mood disorders, and first-degree relatives with substance use disorders and OCD.13 Symptoms tend to be more severe when patients also experience anorexia nervosa, bulimia nervosa, and obsessive-compulsive disorder.12 The disorder can be chronic if not treated.13 Treatment for this disorder varies between medications and therapy. Related Conditions Attention-deficit/hyperactivity disorder Autism spectrum disorder Disruptive mood dysregulation disorder Source: American Psychiatric Association

Intellectual disability involves problems with general mental abilities that affect functioning in two areas: Intellectual functioning (such as learning, problem solving, judgement). Adaptive functioning (activities of daily life such as communication and independent living). Additionally, the intellectual and adaptive deficit begin early in the developmental period. Intellectual disability affects about 1% of the population, and of those about 85% have mild intellectual disability. Males are more likely than females to be diagnosed with intellectual disability. Diagnosing Intellectual Disability Intellectual disability is identified by problems in both intellectual and adaptive functioning. Intellectual functioning is measured with individually administered and psychometrically valid, comprehensive, culturally appropriate, psychometrically sound tests of intelligence. While a specific full-scale IQ test score is no longer required for diagnosis, standardized testing is used as part of diagnosing the condition. A full-scale IQ score of around 70 to 75 indicates a significant limitation in intellectual functioning. However, the IQ score must be interpreted in the context of the person’s difficulties in general mental abilities. Moreover, scores on subtests can vary considerably so that the full-scale IQ score may not accurately reflect overall intellectual functioning. Therefore, clinical judgment is needed in interpreting the results of IQ tests. Three areas of adaptive functioning are considered: Conceptual – language, reading, writing, math, reasoning, knowledge, memory. Social – empathy, social judgment, communication skills, the ability to follow rules and the ability to make and keep friendships. Practical – independence in areas such as personal care, job responsibilities, managing money, recreation, and organizing school and work tasks. Adaptive functioning is assessed through standardized measures with the individual and interviews with others, such as family members, teachers and caregivers. Intellectual disability is identified as mild (most people with intellectual disability are in this category), moderate or severe. The symptoms of intellectual disability begin during childhood. Delays in language or motor skills may be seen by age two. However, mild levels of intellectual disability may not be identified until school age when a child has difficulty with academics. Causes There are many different causes of intellectual disability. It can be associated with a genetic syndrome, such as Down syndrome or Fragile X syndrome. It may develop following an illness such as meningitis, whooping cough or measles; may result from head trauma during childhood; or may result from exposure to toxins such as lead or mercury. Other factors that may contribute to intellectual disability include brain malformation, maternal disease and environmental influences (alcohol, drugs or other toxins). A variety of labor- and delivery-related events, infection during pregnancy and problems at birth, such as not getting enough oxygen, can also contribute. Treatment Intellectual disability is a life-long condition. However, early and ongoing intervention may improve functioning and enable the person to thrive throughout their lifetime. Underlying medical or genetic conditions and co-occurring conditions frequently add to the complex lives of people with intellectual disability. Once a diagnosis is made, help for individuals with intellectual disability is focused on looking at the individual’s strengths and needs, and the supports he or she needs to function at home, in school/work and in the community. Services for people with intellectual disabilities and their families can provide support to allow full inclusion in the community. Many different types of supports and services can help, such as: Early intervention (infants and toddlers). Special education. Family support (for example, respite care support groups for families). Transition services from childhood to adulthood. Vocational programs. Day programs for adults. Housing and residential options. Case management. Under federal law (Individuals with Disabilities Education Act, IDEA, 1990), early intervention services work to identify and help infants and toddlers with disabilities. Federal law also requires that special education and related services are available free to every eligible child with a disability, including intellectual disability. In addition, supports can come from family, friends, co-workers, community members, school, a physician team, or from a service system. Job coaching is one example of a support that can be provided by a service system. With proper support, people with intellectual disabilities are capable of successful, productive roles in society. A diagnosis often determines eligibility for services and protection of rights, such as special education services and home and community services. The American Association of Intellectual and Developmental Disabilities (AAIDD) stresses that the main reason for evaluating individuals with intellectual disabilities is to be able to identify and put in place the supports and services that will help them thrive in the community throughout their lives. Related and Co-occurring Conditions Some mental health, neurodevelopmental, medical and physical conditions frequently co-occur in individuals with intellectual disability, including autism spectrum disorder, cerebral palsy, epilepsy, attention-deficit hyperactivity disorder, impulse control disorder, and depression and anxiety disorders. Identifying and diagnosing co-occurring conditions can be challenging, for example recognizing depression in an individual with limited verbal ability. Family caregivers are very important in identifying subtle changes. An accurate diagnosis and treatment are important for a healthy and fulfilling life for any individual. Autism spectrum disorder Attention-deficit hyperactivity disorder Impulse control disorder Depression Anxiety disorders. Tips for Parents Ask for help, learn about your child’s disability. Connect with other parents of children with disabilities. Be patient; learning may come slower for your child. Encourage independence and responsibility. Educate yourself on the educational services your child deserves. Learn the laws that are written to help your child live their best life. Look for opportunities in your community for social, recreational and sports activities (such as Best Buddies or Special Olympics). References The term intellectual disability used in DSM-5 replaces “mental retardation” used previously. The majority of people, 68%, have IQ scores between 85 and 115. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA APA Publishing. 2013.

The term “transgender” refers to a person whose sex assigned at birth (i.e. the sex assigned at birth, usually based on external genitalia) does not align their gender identity (i.e., one’s psychological sense of their gender). Some people who are transgender will experience “gender dysphoria,” which refers to psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity. Though gender dysphoria often begins in childhood, some people may not experience it until after puberty or much later. Gender Dysphoria People who are transgender may pursue multiple domains of gender affirmation, including social affirmation (e.g., changing one’s name and pronouns), legal affirmation (e.g., changing gender markers on one’s government-issued documents), medical affirmation (e.g., pubertal suppression or gender-affirming hormones), and/or surgical affirmation (e.g., vaginoplasty, facial feminization surgery, breast augmentation, masculine chest reconstruction, etc.). Of note, not all people who are transgender will desire all domains of gender affirmation, as these are highly personal and individual decisions. It is important to note that gender identity is different from gender expression. Whereas gender identity refers to one’s psychological sense of their gender, gender expression refers to the way in which one presents to the world in a gendered way. For example, in much of the U.S., wearing a dress is considered a “feminine” gender expression, and wearing a tuxedo is considered a “masculine” gender expression. Such expectations are culturally defined and vary across time and culture. One’s gender expression does not necessarily align with their gender identity. Diverse gender expressions, much like diverse gender identities, are not indications of a mental disorder. Gender identity is also different from sexual orientation. Sexual orientation refers to the types of people towards which one is sexually attracted. As with people who are cisgender (people whose sex assigned at birth aligns with their gender identity), people who are transgender have a diverse range of sexual orientations. Diagnosis The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR)1 provides for one overarching diagnosis of gender dysphoria with separate specific criteria for children and for adolescents and adults. The DSM-5-TR defines gender dysphoria in adolescents and adults as a marked incongruence between one’s experienced/expressed gender and their assigned gender, lasting at least 6 months, as manifested by at least two of the following: A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics) A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics) A strong desire for the primary and/or secondary sex characteristics of the other gender A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender) A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender) A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender) In order to meet criteria for the diagnosis, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning. The DSM-5-TR defines gender dysphoria in children as a marked incongruence between one’s experienced/expressed gender and assigned gender, lasting at least 6 months, as manifested by at least six of the following (one of which must be the first criterion): A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender) In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing A strong preference for cross-gender roles in make-believe play or fantasy play A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender A strong preference for playmates of the other gender In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities A strong dislike of one’s sexual anatomy A strong desire for the physical sex characteristics that match one’s experienced gender As with the diagnostic criteria for adolescents and adults, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning. Treatment Support for people with gender dysphoria may include open-ended exploration of their feelings and experiences of gender identity and expression, without the therapist having any pre-defined gender identity or expression outcome defined as preferable to another.2 Psychological attempts to force a transgender person to be cisgender (sometimes referred to as gender identity conversion efforts or so-called “gender identity conversion therapy”) are considered unethical and have been linked to adverse mental health outcomes.2,3 Support may also include affirmation in various domains. Social affirmation may include an individual adopting pronouns, names, and various aspects of gender expression that match their gender identity.4,5 Legal affirmation may involve changing name and gender markers on various forms of government identification.6 Medical affirmation may include pubertal suppression for adolescents with gender dysphoria and gender-affirming hormones like estrogen and testosterone for older adolescents and adults. Medical affirmation is not recommended for prepubertal children. Some adults (and less often adolescents) may undergo various aspects of surgical affirmation. Family and societal rejection of gender identity are some of the strongest predictors of mental health difficulties among people who are transgender.14 Family and couples’ therapy can be important for creating a supportive environment that will allow a person’s mental health to thrive. Parents of children and adolescents who are transgender may benefit from support groups. Peer support groups for transgender people themselves are often helpful for validating and sharing experiences. Challenges/Complications Transgender people suffer from high levels of stigmatization, discrimination and victimization, contributing to negative self-image and increased rates of other mental health disorders.15 Transgender individuals are at higher risk of victimization and hate crimes than the general public. Suicide rates among transgender people are markedly higher than the general population.16 Transgender children and adolescents are often victims of bullying and discrimination at school, which can contribute to serious adverse mental health outcomes.17 Interventions are often needed to create safe and affirming school environments. Transgender individuals may also face challenges in accessing appropriate health care and insurance coverage of related services. Terminology Important terms related to Gender Dysphoria: Cisgender: Describes a person whose gender identity aligns in a traditional sense with the sex assigned to them at birth. Gender diverse: An umbrella term describing individuals with gender identities and/or expressions and includes people who identify as multiple genders or with no gender at all. Gender dysphoria: A concept designated in the DSM-5-TR as clinically significant distress or impairment related to gender incongruence, which may include desire to change primary and/or secondary sex characteristics. Not all transgender or gender diverse people experience gender dysphoria. Gender expression: The outward manifestation of a person’s gender, which may or may not reflect their inner gender identity based on traditional expectations. Gender expression incorporates how a person carries themselves, their dress, accessories, grooming, voice/speech patterns and conversational mannerisms, and physical characteristics. Gender identity: A person’s inner sense of being a girl/woman, boy/man, some combination of both, or something else, including having no gender at all. This may or may not correspond to one's sex assigned at birth. Nonbinary: A term used by some individuals whose gender identity is neither girl/woman nor boy/man. Sex/gender assigned at birth: Traditional designation of a person as “female,” “male,” or “intersex” based on anatomy (e.g., external genitalia and/ or internal reproductive organs) and/or other biological factors (e.g., sex chromosomes). “Sex” and “gender” are often used interchangeably, but they are distinct entities. It is best to distinguish between sex, gender identity, and gender expression and to avoid making assumptions about a person regarding one of these characteristics based on knowledge of the others. This is sometimes abbreviated as AFAB (assigned female at birth) or AMAB (assigned male at birth). Sexual orientation: Describes the types of individuals toward whom a person has emotional, physical, and/or romantic attraction. Transgender: An umbrella term describing individuals whose gender identity does not align in a traditional sense with the gender they were assigned at birth. It may also be used to refer to a person whose gender identity is binary and not traditionally associated with that assigned at birth. References Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). American Psychiatric Association. 2022 The American Academy of Child & Adolescent Psychiatry. (2018). Conversion Therapy. https://www.aacap.org/AACAP/Policy_Statements/ 2018/Conversion_Therapy.aspx. Accessed November 7, 2020. Turban, J. L., Beckwith, N., Reisner, S. L., & Keuroghlian, A. S. (2020). Association between recalled exposure to gender identity convers

More than 25 years after the first federal mental health parity protections were put in place, adequate coverage for behavioral health (BH) care – including both mental health and substance use conditions –remains elusive for many consumers with health insurance.1 Federal BH parity rules require health plans that offer BH coverage to ensure that financial requirements (such as deductibles, copayments, coinsurance, and out-of-pocket limits) and treatment limits (such as day and visit limits as well as nonquantitative limits on benefits such as prior authorization) on these benefits are no more restrictive than those on medical and surgical benefits. Mental Health Parity at a Crossroads The COVID-19 pandemic has heightened awareness and exacerbated existing challenges in BH. Strengthening BH parity protections is just one part of a larger policy discussion that includes addressing the BH workforce shortage, rising BH treatment needs among children and youth, an inadequate health care infrastructure to address those in crisis, and the need for improved coordination and integration of primary care and BH care in the health care delivery system. All of these issues contribute to the access and coverage challenges in health insurance that BH parity was supposed to address. The stakes are high for coverage protection, as nearly 90% of nonelderly individuals with a BH condition have some form of health coverage. Despite having coverage, many insured adults (36%) with moderate to severe symptoms of anxiety and depression did not receive care in 2019. There have been consistent calls for more federal guidance on the specific protections in the federal BH parity law, as well as for increased enforcement. As Congress2 debates reforms to address these concerns in BH care, and as federal agencies plan to update parity regulations, this brief explains the federal BH parity requirements – including who they apply to and how they’re enforced — and sets out key policy issues. Federal BH Parity Protections Federal protections for BH coverage sought to correct historical differences in how health insurance covered this care when compared to medical/surgical benefits. The focal point of these protections has evolved over the years from the narrow initial federal law, the Mental Health Parity Act of 1996 (MHPA), to the broader protections in the current law, the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) (Appendix Figure 1). With MHPAEA, an initial focus on ensuring that consumers were not subject to higher cost sharing and more restrictive day and visit limits for BH shifted to looking at disparities in treatments limits in coverage that are not expressed numerically. These so-called “nonquantitative treatment limits” or NQTLs include plan features that limit the scope or duration of care such as prior authorization requirements and medical necessity reviews, standards for provider admission to a network, and provider reimbursement rates. Federal regulations implementing parity for commercial plans and for Medicaid and the Children’s Health Insurance Program (CHIP) have set out substantially similar protections (See Appendix Table 1 for major differences between commercial parity and Medicaid). These are detailed and complex standards making it a challenge for consumers with coverage to know what practices violate the law. Federal agencies have issued FAQs and other guidance for both commercial and Medicaid/CHIP to explain how these standards work. The basic protections are described below. Who does the law apply to? Federal BH parity rules apply to most health coverage, public and private, but do not apply to Medicare. Table 1 summarizes the basic rules and exceptions. Parity applies to all health coverage in the individual, small and large group insurance markets, as well as to all private employer-sponsored plans (insured and self-insured) with the exception of self-insured employer plans covering groups of no more than 50 employees, “retiree only” plans, short-term limited duration coverage and coverage considered “excepted benefits.”3 It also applies to self-insured state and local governmental plans (called nonfederal governmental plans), though these plans have the ability to opt out of MHPAEA protections, as hundreds of plans across 31 states currently do. Source: Kaiser Family Foundation

It is astonishing at the rate for death for children and teenagers from firearms in the US, compared to many other countries across the world (particularly industrialized countries). The graph reflect the nature of death amongst children and teenagers, illustrating that their needs to be more stringent regulations on the right to bear arms and safety measures, as weapons can be easily found by children/teenagers. Such preventative measures may include safe, lock box, etc. Access for fatal weapons are killing the youth in the American more than motor vehicles accidents, bodily injuries. US demonstrates a widespread epidemic of mental health issues relating in substance issues and intentional suicidal completions or accidental fatality through firearms, which continues to be on a rise. Source: Kaiser Family Foundation

In 2020 and 2021, firearms contributed to the deaths of more children ages 1-17 years in the U.S. than any other type of injury or illness. The child firearm mortality rate has doubled in the U.S. from a recent low of 1.8 deaths per 100,000 in 2013 to 3.7 in 2021. The United States has by far the highest rate of child and teen firearm mortality among peer nations. In no other similarly large, wealthy country are firearms in the top four causes of death for children and teens, let alone the number one cause. U.S. states with the most gun laws have lower rates of child and teen firearm deaths than states with few gun laws. But, even states with the lowest child and teen firearm deaths have rates much higher than what peer countries experience. In 2020 and 2021, firearms were involved in the deaths of more children ages 1-17 than any other type of injury or illness, surpassing deaths due to motor vehicles, which had long been the number one factor in child deaths. In 2021, there were 2,571 child deaths due to firearms—a rate of 3.7 deaths per 100,000 children, which is an increase of 68% in the number of deaths since 2000 and 107% since a recent low of 2013. While the rate of firearm deaths among children has increased since 2000, the rate of motor vehicle deaths is now significantly lower than it had been. The number of motor vehicle deaths among children in 2021 was 49% lower than in 2000, though it did grow during the pandemic by 22% from 2019. Though fewer in number than firearm deaths among children, deaths due to poisonings, which include drug overdoses, have also grown, increasing 186% since 2000 and 103% since 2019. Provisional CDC data from 2022 indicate that firearms continued to be the number one factor in child deaths for the third year in a row. Because peer countries’ mortality data are not available for children ages 1-17 years old alone, we group firearm mortality data for teens ages 18 and 19 years old with data for children ages 1-17 years old in all countries for a direct comparison. On a per capita basis, the firearm death rate among children and teens (ages 1-19) in the U.S. is over 9.5 times the firearm death rate of Canadian children and teens (ages 1-19). Canada is the country with the second-highest child and teen firearm death rate among similarly large and wealthy nations. As might be expected, teenagers have higher firearm mortality rates than children. In the U.S., teens ages 18 and 19 have a firearm mortality rate of 25.2 per 100,000, compared to a rate of 3.7 per 100,000 for children ages 1-17 in the U.S. Even so, the child firearm mortality rate in the U.S. (3.7 per 100,000 people ages 1-17) is 5.5 times the child and teen mortality rate in Canada (0.6 per 100,000 people ages 1-19). If the child and teen firearm mortality rate in the U.S. had been brought down to rates seen in Canada, we estimate that approximately 30,000 children’s and teenagers’ lives in the U.S. would have been saved since 2010 (an average of about 2,500 lives per year). This would have reduced the total number of child and teenage deaths from all causes in the U.S. by 13%. The child and teen (ages 1-19 years) firearm mortality rate varies by state in the U.S. from 2.1 deaths per 100,000 in New York and New Jersey to 17.6 deaths per 100,000 in Louisiana. Even in New York and New Jersey, which have the lowest child and teen firearm mortality rates among those with available data, the rate is still over three times that in Canada. Because there is no comprehensive national firearm registry, it is difficult to track gun ownership in the U.S. Instead, we look at the correlation between the number of child and teen firearm deaths and the number of gun laws in U.S. states (based on the State Firearm Law Database, which is a catalog of the presence or absence of 134 firearm law provisions across all 50 states). States with more restrictive firearm laws in the U.S. generally have fewer child and teen firearm deaths than states with fewer firearm law provisions. Even so, these states on average have a much higher rate of child and teen firearm deaths than that of Canada and other countries. Among comparably large and wealthy countries, Canada has the second highest child and teen firearm death rate to the U.S. However, Canada generally has more restrictive firearm laws and regulates access to guns at the federal level. In the U.S., guns may be brought to states with strict laws from out-of-state or unregistered sources. Source: Kaiser Family Foundation

In recent years, many people have experienced poor mental health, with over 30% of adults in the United States reporting symptoms of anxiety and/or depression in February 2023. Substance use and death rates due to substances have also worsened in the U.S. – drug overdose death rates increased by 50% from 2019 to 2021 (21.6 vs. 32.4 per 100,000), primarily driven by fentanyl. Further, after a brief period of decline, suicide death rates increased in 2021 but remained just below the peak death rate in 2018 (14.1 vs. 14.2 per 100,000). Increases in drug overdose deaths and suicide deaths have disproportionately affected many people of color. Negative mental health and substance use outcomes have also affected youth and young adults. This increase in mental health and substance use issues comes at a time when resources are already strained, and people with mental health diagnoses often face barriers to care. Among adults with symptoms of anxiety and/or depressive disorder in 2022, over 20% report needing, but not receiving, mental health counseling or therapy. In the state fact sheets below, we examine state and national-level data on mental health and substance use. We find that mental health and substance use outcomes and coverage vary from state to state. Share of Adults With Symptoms of Anxiety and/or Depression, February 1 – 13, 2023 Source: Kaiser Family Foundation