Tag Mental Health

Summer: Great Time to Have Your Kid/Teen Get a Mental Health Evaluation

black kid skateboardFor many kids and teens (and by association, parents) the summer represents a reprieve. Of course, there is no school. But, other responsibilities usually lessen as well. For this reason, stress can lighten by a large margin; symptoms that your child may have demonstrated during the school year can either evaporate or lessen to manageable levels. This can cause just about any parent-lunatic to convince himself/herself that all is well now.

Yes, kids can grow out of symptoms with time and maturity. However, unless there has been some dramatic and substantive change (e.g., peace was rendered in a significant relationship that had been troubled, treatment caused a significant breakthrough), it is unlikely that your child or teen has grow out of a problem, or problems, in the matter of a few weeks. It is more likely that the abatement of school-year based stress has caused the problem(s) to go underground and that such are likely to return, in a stronger and more entrenched variation, in the fall. (In my clinical experience this often happens by the first report card and nearly always by the holidays.)

This makes the summer a great time to get an evaluation, and for at least four reasons:

  1. Being under less stress will make it easier for a child psychologist to two boys thumbs upaccess the reasonable side of your child or teen.
  2. If your child or teen demonstrates problems at both school and home, the summer affords the opportunity to focus on home-based challenges exclusively. This portends to leave everyone feeling stronger and better equipped to deal with school-based issues in the fall.
  3. If your child suffers from mood disturbance or anxiety symptoms, it can be much easier to assess and treat such in the summer. Actually, the same thing goes for most kinds of problems (e.g., difficulties with attention, disordered eating).
  4. With the decreased stress, it may be easier for everyone to better appreciate and discuss your child or teen’s strengths.

glasses and bookThe only typical downside to a summer evaluation is that it can be more challenging to get teachers to complete behavior rating scales. However, my experience is that most teachers are generous with their time as long as you approach them in a respectful manner. Here’s a sample ask: “Dear Mr./Ms. X, I’ve arranged for Dr. Y to evaluate Aiden so that I may better understand his opportunities for growth. Dr. Y. has indicated that your opinion is very important in helping him to do a good job. I appreciate that you are off in the summer, so if you don’t have the time to fill these forms out, no worries. But, if you can fill them out I would be most grateful!”

I hope you will consider an evaluation if your child or teen has been demonstrating problems either now or during the last school year. Doing so will leave your child or teen less likely to number among the majority of those youth who need mental health care but do not get it. (For a referral click here.)

 

How Can I Tell if My Kid is Depressed?

depressed stunningAccording to the National Institute of Mental Health 9% of teens suffer from depression each year while 11% of youth suffer a depressive disorder by age 18. Moreover, suicide is the third leading cause of death among those aged 15 to 24. This entry will describe common symptoms and signs of depression in youth. (Please keep in mind that depression runs on a continuum; a kid may be suffering from depression, and need treatment, but only have some of the symptoms indicated below.)

Mood disturbance: Kids who are depressed have impairing sadness and/or irritability that is persistent (i.e., two weeks or longer). When a kid’s depression is manifested as irritability, it is easy to mistakenly conclude that primary problem is defiance.

Sleep disturbance: Not being able to get enough sleep or oversleeping are both signs of depression. What can make this tricky for teens is that school and extracurricular commitments can make it so that the teen doesn’t get to bed late anyway. Moreover, parents may retire before their teen and may not realize that s/he is struggling with sleep. (For guidelines on how much sleep is recommended, across age groups, enter the word “sleep” in the search bar above).

Appetite disturbance: Like sleep disturbance, depressed kids will tend to either over or under eat. Changes in weight and waistline are common.

Poor motivation: Most kids need help learning to do things when they don’t feel like it. But, kids who are depressed experience a steeper climb up that mountain.

Anhedonia: This is the clinical word for not being able to experience joy when crying childengaging in activities that are typically pleasurable. This can be especially frustrating for parents who have endeavored to engineer a positive change in mood.

Concentration problems: Just about all kids who are depressed will experience some degree of concentration problem. (Sleep disturbance and concentration problems are to a child psychologist what fevers are to a pediatrician: there’s a problem there but it can be due to a number of different things.)

Suicidal thinking: This kind of thinking runs along a continuum. On the one end are having vague thoughts that it’d be okay to die without any specific plans or intent to take action. On the other end is generating a lethal, specific and doable suicide plan.

Here are two common myths about teen suicide: asking a kid whether s/he is having thoughts of self-harm promotes suicide (not true) and all kids who make a suicide attempt mean to die (not true also). For more information on suicide, and talking to a teen about this, use the search bar above.

Negative thinking: Youth who are depressed tend to think, “Everything sucks. It’s my fault and it can’t be changed.” This promotes what is called “learned helplessness,” meaning that a kid can become so overwhelmed that s/he won’t take obvious and straightforward steps to feel better. Feelings of hopelessness, worthlessness and guilt are also common in moderate to severe cases.

teenagainstwallVarious kinds of mental confusion: In addition to concentration problems, youth with severe depression can start confusing what is real and what is not. They can also start to form beliefs that are highly distorted.

Though not present on the diagnostic criteria there are a couple of other common indicators:

Parental burnout: Parenting a kid who is depressed can be exceptionally frustrating and difficult. Not only do intuitive interventions tend to not work (e.g., verbal reassurances), but they tend to make matters worse. This can cause a parent to feel helpless and incompetent.

Parental disputes: As most parents tend to have different parenting styles, it’s natural to believe that if only the other parent would do things differently, the kid’s depression would lift. For this reason, the youth’s depression takes a toll on the parents’ relationship. I’ve witnessed a number of marriages get better simply by effectively treating a kid’s mood disorder.

Running in the family: Depression typically results when stress activates a pre-existing genetic vulnerability. The more mood disorders run in the family, the less stress it may take to activate impairing symptoms.

Sadly, and sometimes tragically, most youth who are depressed do not get distressed teen girltreatment for it, even though effective treatments are available (e.g., cognitive-behavioral therapy). If you are in doubt about whether your child or teen is suffering from depression, by all means treat that situation as you would if you were in doubt about the presence of a cavity. For databases of treatment providers near you, click here. Also, and as is the case across all service professions, the quality of mental health care varies. Sometimes adequately credentialed therapists are not prepared to evaluate and to treat juvenile depression in a manner that is informed by contemporary research findings. For this reason, parents do well to be informed consumers. To learn more about what constitutes effective mental health care for youth, see Chapter 10 of my parenting book or search the pages of this blog.

 

 

 

 

What is Cognitive-Behavioral Therapy?

stressed boyCognitive-behavioral therapy (CBT) is often the talking treatment of choice for juvenile anxiety, depression, and various kinds of problems that result from poor stress coping. The word “cognitive” refers to strategies that deal with thoughts and thinking. The word “behavior” refers to strategies that deal with behavioral choices. This blog entry will review some of the major strategies that often comprise CBT.

Externalizing the problem: kids and teens develop a name for their anxiety, depression, or the primary problem area. As Stephen King once wrote: “Monsters are real, and ghosts are real too. They live inside us, and sometimes, they win..” Youth are taught that their symptoms of anxiety and depression no more constitute their personhood than symptoms of diabetes or asthma define the personhood of someone suffering from those conditions. Moreover, youth are taught to recognize how their internal enemy attacks them and what specific and effective countermeasures they can deploy.

Behavioral activation: this strategy involves arranging to do fun things on a regular basis. When youth are depressed or stressed out they often get into a rut where they wait for a good mood to do something fun. This CBT strategy teaches a youth that s/he can manipulate his or her mood by forcing himself or herself to do something that stands to be pleasurable. Youth are also taught that fun activities that are novel, social and involve physical activity tend to be the most effective (e.g., to avoid getting into a rut with fun activities as well).

√ Physiological calming: this is a term for learning how to relax muscles in theboys praying back to back body and to belly breath. Most youth overestimate their ability to relax their bodies. In CBT they learn strategies for becoming super relaxed. Moreover, they learn that a relaxed body and anxiety are like oil and water: they just don’t mix. Some practitioners also employ methods for measuring a youth’s success (e.g., through the use of biofeedback).

√ Coping or happy thoughts: this strategy involves developing a list of true and adaptive thoughts that promote positive feelings. Kids are taught that they can swap out uncomfortable thoughts just like they can swap out uncomfortable jeans.

√ Thought testing: this is a strategy for determining whether a painful thought is true or not. Anxiety and depression attack thinking and cause a youth to believe painful thoughts that are not true. This technique is very helpful for helping youth to determine what painful thoughts are real (and which can be subject to problem solving) and which represent their internal enemy’s lie (and are to be disempowered).

Teen girl√ Problem solving: this strategy is useful when a problem is distressing a kid or teen. When suffering from anxiety or depression problems can become super magnified and overwhelming. This very powerful strategy disempowers over reactions and produces adaptive coping responses.

√ Exposures: this strategy involves having anxious youth deliberately put themselves into developmentally appropriate situations that make them anxious, in a measured and gradual way, so that they can use their CBT tools to accomplish mastery and to dominate their internal enemy.

It’s common for parents to be taught how to coach and reinforce the CBT techniques. Moreover, multiple strategies can be done together as a family (e.g., physiological calming, problem solving). The CBT might also include other techniques for specific problems affiliated with anxiety or depression (e.g., response prevention for OCD). Moreover, sets of related strategies than be imported into the CBT depending on the problem(s) the youth has. For instance, social skills training can be used for youth who struggle making and maintaining friends, behaviorally oriented family therapy can be used for defiant youth who refuse to practice their CBT techniques and strategies from positive psychology can be used to produce experiences of happiness and meaning (e.g., the use of gratitude, personal strengths, acts of kindness).

The research supporting the efficacy of CBT is well developed and suggests that mom and daughterparents would do well to consider making this treatment available for any child or teen who suffers from anxiety,  depression or an assortment of problems involving poor stress coping. To find a qualified provider near you click here.

Regarding Stress and Stress Coping: Adults and Teens Look A Lot Alike

teen girl pushing hand to headThe American Psychological Association’s Stress in America survey came out this week. Since 2007, APA has conducted a national survey of the stress American’s experience. This year’s survey places a special focus on teenagers. The full report can be found here. Below are some key assertions and the data points within the survey that support them.

Like adults, teens feel overwhelmed by stress

• On a 10-point scale, teens report that ≤ 3.9 is a healthy amount of stress. However, they rate their stress to be a 5.8 during the school year and a 4.6 during the summer.

• The following is true of 1 out of 3 teens: they report that their stress has increased in the past year, they expect their stress will increase in the next year and they feel overwhelmed.

• Teens reported that one out of four of them feel stress at the highest levels (an 8, 9 or a 10 on the 10 point scale) during the school year.

• Adults report that ≤ 3.6, on the same 10-point scale, represents a healthy level of stress. However, they report their stress averages a 5.1. Moreover, 37% of adults report feeling overwhelmed in the past month, 1 out of 3 believe that stress is having a strong impact on their physical and mental health and 84% report that their stress stayed the same or increased in the past year.

Teens worry about the same sorts of things as adultscharacter burdoned by books

Both teens and adults report worrying the most about their vocational lives and financial matters. For example, these are the top stresses reported by teens: high school (83%), life after high school (69%), and their family having enough money (65%). For adults the top three stresses are money (71%), work (69%) and the economy (59%). (By the way, the fourth rated stress among teens is balancing their time, at 59%)

Teens experience similar symptoms of stress as adults

• Only 41% of teens report that they handle stress well, compared to 35% of adults.

• The top symptoms teens report experiencing secondary to stress are irritability (40%), anxiety (36%), fatigue (36%) and insomnia (35%). This is very similar to the profile reported by adults: irritability (41%), lack of energy or motivation (39%), anxiety (37%) and feeling overwhelmed (37%). (It’s also telling that 51% percent of teens report that someone tells them they seem stressed on at least a monthly basis.)

Teens commonly use the same poor coping strategies as adults

teen video game playing•The following are some of the top strategies for responding to stress that are traditionally ill advised, at least if used as a lead strategy: playing video games (46%), going online (43%), and watching TV or movies (36%).

• Teens report some behavioral responses to stress that also increase the risk of poor stress coping: eating unhealthy foods (26%), skipping meals (23%) and neglecting school (21%). Moreover, half of teens who report being under high levels of stress indicate that they don’t get enough sleep.

Tell me how teens’ potentially maladaptive responses to stress compare to adults’ (i.e., what follows in the next four lines are adult numbers):

√ 62% use screen time to manage stress (42% watch ≥ 2 hours a day of TV)

√ 17% exercise daily; 39% skipped physical activity because of stress

√ 38% have overeaten to manage stress; 30% skipped a meal because of stress

√ average 6.7 hours sleep/night; 20% report that their sleep is sound

• Moreover, these trends seem to be even more true among parents. That is parents, as compared to non-parents, report higher rates of eating unhealthy foods due to stress and sleep disturbance.

Stress management strategies work!

• Teens who are physically active report lower levels of stress (i.e., those who soccer character, coolexercise ≥ 1/week report at average stress level of 4.4–on the 10 point scale mentioned above– compared to 5.1 for those who don’t engage in that much physical activity).

• Teens whose body size is within expected ranges report lower levels of stress (i.e., those with a BMI of 18-24 report a 4.4 stress level, while those with a BMI ≥ 25 report a 5.2.).

• Teens who get healthier doses of sleep report lower levels of stress (i.e., those who sleep ≥ 8 hours a night report being at a 5.2 while those who sleep less indicate they are at a 6.5).

• Teens who report higher stress levels also report engaging in more sedentary behaviors than those who report lower levels of stress (e.g., 54% versus 24% surf the net to manage stress).

Take home messages

I have three take home messages this week:

missing puzzle piece#1: Parenting from the cross sucks. When our kids show needs (and when don’t they?), we tend to act like we have none; over time, this reeks havoc on us and them. (This is why self and relationship care is one of the 10 science-based parenting strategies I stress in my parenting book).

#2: There are plenty of things we parent-lunatics can do to promote stress management in our teens. For my top nine, see the blog entry I guest wrote on APA’s blog.

#3: Why suffer needlessly? Let’s treat ours and our kid’s mental health as we do ours and our kids’ dental health whenever there is a complication: see a pro. For a list of referral databases, click here.

Elements of Quality Mental Health Treatment for Youth

billboard2 copyI find that many parents have little idea what to expect when taking their child or teen for mental health services. In my last blog, I described elements of a good mental health evaluation for a child or teen. In this entry I will describe elements of quality outpatient mental health treatment. (Please keep in mind that some of these elements may not be present in your child’s or teen’s care but s/he may still be receiving good treatment.)

√ A diagnostic impression is shared. The insurance company is usually getting this information, so you should too. More importantly, having these words allows you the opportunity to educate yourself about the condition(s).

√ The clinician has discussed how he or she arrived at the diagnostic formulation and the the primary scientific findings pertaining to such (e.g., causes, prevalence, outcomes).

√  The clinician shares specific information regarding which treatment(s) is/are   therapy etchingrecommended. This should include giving you the name of what each treatment is called; again, this allows you to educate yourself about the science behind the intervention. The clinician also does well to include, in instances when more than one intervention is recommended, which intervention is treating which problem or diagnosis; a discussion of the prognosis is also usually advisable.

√ The clinician endeavors to answer all of your questions, either at the time that you ask or later, including telling you when the available science does not allow a question to be answered well or thoroughly.

√ The clinician develops measurable treatment goals in collaboration with you and/or your child or teen. These goals need not be (and usually are not) a comprehensive listing of what will be worked on. But, they include signposts that help you to know (1) if the treatment is working and (2) when you are done.

therapy with teen√ The clinician is comfortable with, and even encourages, you and your child or teen to express differences of opinion regarding what s/he is stating or recommending.

√ The clinician follows the agreed upon treatment plan and doesn’t make changes without getting your informed consent.

√ The clinician tracks progress, keeps scheduled appointments, doesn’t take phone calls or check his or her phone during the appointment (unless you’ve agreed to an exception), meets the entire time, remains both pleasant and alert and gives you sufficient notice of any extended vacations or breaks from treatment.

√ You get the sense that the clinician cares about your child or teen and his or her success.

√ You are kept informed about progress. While the clinician may not share information that your child or teen wishes to keep confidential, s/he should keep you informed in general terms. If the treatment is behavioral in focus, it is also commonly recommended to teach you how to coach and reinforce the skills your child or teen is learning.

√ If there are problems at school, the clinician should be available to collaborate with school personnel; sometimes this may warrant attending an in-person meeting at the school.

√ The clinician may recommend things you can do to augment the work (e.g., overwhelmedread a book, attend a support group meeting).

√ The clinician is not shy about bringing up sensitive topics, including if s/he believes that your getting mental health care for yourself could be helpful.

√ Appointments are scheduled at a pace that is consistent with how the treatment is usually prescribed (something you can easily learn yourself with a little leg work).

√ While your insurance company may dictate what is covered and what isn’t, you should never get the sense that the insurance company is dictating what is diagnosed or what treatment(s) is/are being recommended.

Good luck! To find a clinician near you, click here.

What Does a Good Mental Health Evaluation Look Like?

billboard2 copyIn last week’s blog I discussed why the summer can be a great time to get a child or teen a mental health evaluation. This week I will review the elements of a good child or teen mental health evaluation. At the end I will offer a few qualifiers.

(I recently ended a term co-chairing the Pennsylvania Pediatric Mental Health Task Force, a collaboration between the Pennsylvania Psychological Association and the Pennsylvania Chapter of the American Academy of Pediatrics. That task force endorsed the standards I am reviewing here.)

A good mental health evaluation for a child includes the following elements:

• A family interview. “Family” can be legitimately and differently defined across clinicians. For me, it is the youth of concern and his or her parents and stepparents. If the adults cannot be interviewed together (e.g., there is too much resentment) this can be spread across interviews. I find it very difficult to get the relevant information, while building a trusting relationship, in less than 90 minutes. This is an essential part of the evaluation as it is exceedingly difficulty to accurately understand a child’s or teen’s symptoms independent of the context in which that youth resides.

• A youth interview and/or play session. Each child or teen has a great deal of useful line of kidsinformation to share. However, s/he may not be able or willing to do so with his or her parent(s) in the room. This is true even among youth who are not psychologically minded or inclined to cooperate.

• The completion of parent, teacher and child behavior rating scales. These scales allow a clinician to measure whether a youth’s symptoms and strengths are atypical among children or teens of his or her age and sex. The available research also suggests that parents, teachers and kids each possess important, complimentary and unique information about a given youth’s functioning.

• A review of academic records. This includes report cards, state achievement testing and relevant special education or disciplinary records. Sometimes parents believe that the school life is not a problem but records suggest that there are important opportunities for growth there. Moreover, such records can present the clinician with information that allows him or her to develop a more nuanced understanding of a kid (e.g., how often a child is tardy or absent, academic strengths and weaknesses).

defiant boy• A review of any relevant medical, psychological, welfare or forensic records that exist on the youth. I tell families that work with me: “If you’re in doubt regarding whether a document could be important for me to review, include a copy of it.”

• A behavior rating scale that screens for parental wellness. The research and my clinical experience both suggest that the number one complicating factor in mental health treatments for youth is the mental health status of his or her parent(s). (You can find numerous articles on this blog pertaining to the connection between parent and kid wellness.)

I have seven qualifiers for these remarks:

1. Other evaluation tools may also be needed to render a reasonable diagnostic formulation (e.g., psychological testing, medical evaluations, speech and language evaluations).

2. There may be clinical contraindications for doing some of the procedures I have reviewed here. However, if such contraindications exist they warrant discussion.

3. Here’s the elephant in the room: limits on insurance coverage often drive medicalsymbolanddollarsstandards instead of the other way around. Too many times I’ve heard clinicians lament that they do not do what they believe is clinically warranted because an insurance company won’t pay for it. Yes, that can be a harsh reality (actually, a very harsh reality). But, parents (and sometimes the youth too) deserve to hear, from the clinician, what the clinician believes is an advisable evaluation plan. Then the parents can decide, once they are informed regarding the pros and cons of their choices, whether they wish to proceed in a truncated fashion (i.e. what the insurance will cover) or do as the clinician recommends. (For my blog entry on paying for mental health services, click here.)

4. Here’s the elephant’s sidekick: child and teen clinicians are busy people who often have large caseloads (put this statement all in caps for those child clinicians working within agencies). A given child or teen clinician may feel too busy to do an evaluation the like of which I’ve described here. If so, this also deserves a frank discussion so that parents can make their own decision about who to see. I have no problem with a clinician doing a truncated evaluation. I do have a problem with a clinician doing a truncated evaluation without informed consent.

character checking off checkboxes5. A diagnostic formulation can hit the bullseye without all of these elements being included. Heck, if a parent honestly answered my questions for 10-15 minutes, and I were to develop a formulation based only on that interview, I might end up being right a good amount of the time. However, I’d be wrong, or importantly incomplete, in an unacceptable number of instances. This is why due diligence is warranted.

6. The evaluation standards I’ve reviewed here include a cost-benefit analysis. (If that weren’t the case, I’d recommend psychological testing for every child and teen.)

7. A good mental health evaluation on a child or teen will offer a thorough review of his or her strengths. And, this will be a central aspect, not just a preliminary or sidebar feature.

There are numerous other issues I haven’t covered here (e.g., what are the signs that a child might need a mental health evaluation, how can one parent get this done when another is resisting it, what’s a good way to approach a school or teacher about participating). But, you can find these topics addressed either in other blog entries (use the search bar at the top right) or in my parenting book Working Parents, Thriving Families: 10 Strategies that Make a Difference.

Next week I will review methods for active partnering and participation with your child’s or teen’s mental health professional. For now, good luck, and click here for referral information.

10 Tips for Avoiding an Affair

woman rejecting man's kissOne of the quickest ways to threaten the viability of a family is to have an affair. This entry offers 10 tips for avoiding one.

Tip #1: Be humble. Realize that an affair can happen to anybody. Affairs just don’t happen to people in problematic marriages, though they certain can. The key is to realize that anyone can lose control if enough of the wrong circumstances line up; one does well to stop the progression before it passes the point of no return.

Tip #2: Through water on the spark. If you start feeling titillation towards another person do something to kill that. Putting some distance between you is always a good idea (e.g., stop having contact, make sure you are never alone together, don’t complain about your spouse to this person or encourage the same from him or her, avoid mixing contact with substance use). Another strategy is to tell a wise friend, therapist, or clergy person about it, with an eye towards having them say back to you what you already know. Pre-affair flirtations are like mushrooms: they thrive in the dark. Throwing light on them makes them ill.

forgivenessTip #3: Spice up the fun and sex you have with your spouse. There is a concept in psychology called “hedonic adaptation.” It means we all start losing pleasure in doing things that become too routine or familiar. Novelty in having fun and sex enhances your interest in your spouse and weakens pre-affair titillations. I can’t tell you the number of times I’ve seen it happen that someone gets bored with their spouse, has an affair, marries that second person and then gets bored with that person as well.

Tip #4: Fix any impairing psychological pain in your life. Affairs can be used like medicine for mental agitations. If your mental health is troubled, seek out a upset black woman, white backgroundconsultation with a qualified mental health professional. You may be amazingly surprised at how helpful this can be. It can also have way fewer side effects and be much less costly than medicating your pain with an affair. For a referral click here.

Tip #5: Explore accounts of people who have been cheated upon by a spouse. Perhaps you know someone who’d be willing to tell you what it’s like to have his or her spouse cheat on him or her. If not, there are plenty of accounts to be found on the Internet. As a marriage therapist, I find many people are surprised by how much pain it causes their partner. Being connected to this awareness, instead of avoiding thinking about it, throws water on pre-affair sparks.

Tip #6: Explore accounts of people who have cheated. I can’t tell you how many times I’ve known people who felt wracked by guilt over an affair, and were really surprised by how much so. Such individuals often end up feeling in a terrible bind: if they don’t tell their spouse they feel a horrible, crushing guilt. If they tell their spouse it could end the marriage.

marriage counselingTip #7: If your marriage is stuck, seek out a consultation with a skilled marriage therapist. If the foundation in a marriage is strong, marriage counseling can go a long way to getting things back on track. In my experience there are four characteristics of a marriage that is working well: the couple has fun together on a regular basis, the sex life is mutually satisfying (in its frequency and nature), arguments don’t get toxic and couples share what matters in their lives. For a referral for someone who can help get you there click here.

Tip #8: Reflect on what the pain from divorce is like. Engaging an affair significantly increases the likelihood of a divorce and few human experiences are more stressful or painful than that. Moreover, if you share children you could find yourself having to co-parent with someone who feels significant hurt and anger towards you, even years later.

Tip #9: If you believe you wouldn’t feel guilty over an affair, can keep it black couple arguingsufficiently secret while continuing to be in a relationship with your spouse (very few can and it takes tremendous energy to do so) and are seriously thinking about moving forward with one, please seek out the services of a mental health professional. This profile suggests that you may be suffering from some very significant interpersonal problems, even though you may not be in conscious distress. The alternative is to put yourself at high risk for facing some of the common painful consequences that affairs tend to bring.

Tip #10: Do what you can to keep stress from getting toxic. It’s remarkable to me relaxed character in a coconut hot tubhow often this profile keeps stress from getting out of hand: getting a recommended night’s sleep, being physically active on a daily basis, maintaining a healthy diet, and having fun with friends regularly. A regular spiritual and/or meditation practice can also be very helpful, which may or may not mean practicing a specific religion. And, if you really want to get into it, try implementing strategies from positive psychology (e.g., see the book The How of Happiness or multiple blog entries on this site).

I hope these tips are helpful and I welcome others to share theirs.

What Can I Expect If I Take My Child to See a Psychologist?

upset characterA recent national study indicated that by adulthood about 90% of youth will have qualified for a mental health diagnosis at one point or another. However, only about 20% of these kids get any kind of mental health care. So, if your child is showing some distress s/he is in a huge club. But, if you’re getting him/her help for it, you are in an elite club.

Different mental health professions may go about their work in different ways. This blog entry is meant to characterize how an evidence-based psychologist might proceed. (While there are always exceptions, psychologists are the doctorally trained mental health professionals who most commonly provide talking treatments.)

The first thing the psychologist will do is an evaluation. These are the elements I believe constitute a cost-effective, evidence-based evaluation (each of these elements has been endorsed by the Pennsylvania Pediatric Mental Health Task Force):

• A family interview (who is in this interview can vary but often both birthboy umbrella pointing parents and the child of concern are included)

• An individual interview with the youth of concern

• The completion of behavior rating scales

• A review of relevant records (e.g., school records)

• A feedback session that reviews a diagnostic impression, addresses key issues (e.g., causes, prevalence, prognosis) and recommends a treatment plan

What follows are some common concerns I’ve heard from parents who are considering getting mental health care for their child.

If I take my child to see a child psychologist s/he might suffer self-esteem damage (e.g., mom thinks there is something seriously wrong with me).

boy head on handExperienced psychologists know that this is a concern and have procedures in place for helping (e.g., assessing for your child’s strengths, making the experience enjoyable). Moreover, the symptoms that are troubling your child are far more likely to be causing, or to cause, self-esteem damage than interacting with a highly trained, caring and kind adult.

I’m not comfortable signing up for a long course of treatment.

Most research-supported treatments, for most problems, are designed to be short-term. Sure, there are instances where a longer course of care is indicated. In medical pediatric practice short-term treatments are more common than longer-term treatments; the same thing is true in mental health pediatric practice.

Treatment is too expensive.

I’ve been doing this work for over 20 years. I’ve never seen an instance where aconfused child way wasn’t afforded to those with the will to be persistent. Please see this blog entry for a list of strategies. Moreover, the toll from untreated symptoms can be devastatingly higher.

I don’t want to weaken my child (e.g., encourage senseless whining, create dependency, promote externalizing responsibility).

Evidence-based psychotherapy is designed to make itself obsolete as soon as possible, to promote healing and to instill resilience. Alternatively, psychological symptoms often weaken functioning, dampen the human spirit and lower the ceiling on interpersonal, educational and vocational outcomes.

My kid doesn’t want to come in. There’s no point in doing this if s/he won’t cooperate.

black kid skateboardMost kids and teens are neutral or opposed to the idea of mental health care. Actually, if a kid is interested in counseling it suggests either that he or she is very psychologically minded and/or is in a great deal of pain. I tell parents new to my practice not to worry about this. It’s their job to get their kid to my office. It’s my job to make the time worthwhile.

The final chapter of my book Working Parents, Thriving Families, goes into much more depth on this topic, including describing what the most common evidence-based treatments entail and how to tell if your child is getting quality care. Please also see these related blog entries:

Seven Common Myths About Counseling

Signs that a Kid Needs Mental Health Services

Mental Health Concerns are Nearly Universal by Ag2 21

Ignoring Kids’ Mental Health Needs is Expensive

I’ll close by stating that I travel widely within my profession. My experience suggests that the average child psychologist is an extremely devoted and mission-driven person who really cares about kids and doing right by them. If you’d like to check this assertion out for yourself, click here.

What About When Kids Sexually Abuse Kids?

upset and angry little girlCNN reported on a story this week regarding 4-5 year old children performing sex acts on each other at a preschool in California. While I’m not in a position to comment on that story, I would like to take the occasion to discuss some parenting implications.

Where does one draw the line between normative and troubling behaviors?

Kids are naturally curious about their bodies and the bodies of other children. For them to comment about such, make jokes, “play doctor” and engage in other expressions of curiosity is normative. Some elements that would make this troubling would be as follows:

√ One of the children is significantly older than the other one. A difference of three years is often used, though there are exceptions (e.g., in Pennsylvania the legislature has set a cutoff of four years between teens who have sex).

√ One of the children is forced to do something that s/he doesn’t want to do.

√ An adult is present.

√ Someone gets hurt, either physically or mentally.

√ Someone gets penetrated.

What might cause a child to abuse a peer?

Research and my clinical experience suggest three causes that are more likely upset girl from behindthan others (of course there may be more than one cause and this list is not comprehensive):

• The perpetrator has himself or herself been the victim of sexual abuse or sexual over-stimulation. The act of sexual acting out can be a child’s way of trying to cope with the trauma of having been a victim himself or herself.

• The child is suffering from juvenile onset bipolar disorder. Hypersexuality is one of the symptoms of bipolar disorder when it has an onset in childhood (which is not the same thing as saying that all children with bipolar disorder are hypersexual).

• The child has a serious case of childhood onset conduct disorder. Children with serious variants of this disorder organize their inner world around aggressive and violent themes. In these instances the sex act is a way of being violent towards and/or dominating another child.

What are the signs that a child has been sexually abused?

child helpmeIt isn’t really possible to be comprehensive as kids are too variable both in the ways they become symptomatic and the degree of trauma it takes for them to become symptomatic. That said, these are some of the more common symptoms:

√ Sudden onset of disturbance in regulatory habits (e.g., sleep, appetite). This can also be manifested by the undoing of previously accomplished developmental milestones (e.g., a child starts wetting the bed).

√ Exaggerated startle responses; this refers to jumping or acting startled upon experiencing routine or casual touches.

√ Intense fear expressed when it comes to approaching situations or people that are reminiscent of the abuse.

√ Sexual acting out.

√ Suddenly and persistently acting like the undead (i.e., having flat affect and disengaging from life).

√ Sudden and persistent mood disturbance (i.e., sadness, anxiety and anger).

Can you share six strategies that parents can use to prevent sexual abuse?

1. I believe the top prophylactic strategy is the maintenance of a good and diverse mom and childconsistent sex education program in the home. This should begin as young as your child can have a conversation with you. Obviously, you’re going to pace yourself on what you share when. The overall goal is to be the first one to cover a given topic (e.g., I don’t want a song or a peer to be the first one to introduce and define a sexual behavior or issue to my child). This is a blog entry with related content: Communicating with Teens about STDs

2. Make sure children are appropriately monitored when they come together. I discuss this extensively in Chapter Three of my parenting book, Working Parents Thriving Families (WPTF). Related content can also be found in these blog entries:

Teens Are Going to Have Sex and Drink, You Can’t Control That…Not!

10 Tips for Parenting Your Progeny’s Online Life

Recent Research: Teens Need Parents to Monitor Them

3. This is somewhat redundant with the first recommendation, but establish what good and bad touches are, what your child should do if approached for such and what your child should do if s/he experiences such. Part of this could be creating various vignettes for your child and asking him or her what s/he would do in those situations.

4. Ask the appropriate school administrator how they handle bathroom trips and character checkmarkactivities. Partner with them on making sure that the monitoring and access are effectively managed. (You’d also want to ensure that there are not other occasions for children to be unmonitored for an extended period of time.)

5. Ensure that your child is appropriately monitored when not in school and in your home (I cover this extensively in the chapter I mentioned above).

6. Do “special time” each week with your child. This keeps the communication channels open. I discuss this extensively in Chapter One in WPTF. For a handout on doing special time click here.

What do I do if my child has suffered sexual abuse?

Get an evaluation done by an appropriately experienced mental health professional ASAP.  For instance, Children’s Advocacy Centers are spread across our country. To find one near you, click here.

Are Meds Alone Sufficient to Treat My Child’s Psychiatric Symptoms?

teenandmedicationMany parents wonder about the efficacy of using only medication to treat their child’s psychiatric condition. While a full treatment of this question far exceeds the scope of a blog, it’s possible to briefly summarize some important themes and issues.

Clinical work limited to an initial interview and medication therapy risks misdiagnosis.

This is an example of an evidence-based, cost effective and clinically effective, outpatient evaluation for a child’s or teen’s mental health symptoms (assuming medical causes have been ruled out): a family interview, an interview alone with the youth, the collection of parent, teacher and child behavior rating scales and a review of relevant records. This is complex business and I worry about the accuracy of a diagnostic formulation if one or more of these elements is missing. Moreover, it is possible for a child to improve on a given medication without the child actually having the disorder that the medication is supposedly treating (e.g., low doses of stimulant medication will often improve the concentration of any child, regardless of whether or not that child has ADHD. Of course, sometimes it isn’t possible to do more than a brief interview and a medication trial, but if it’s possible to add the other elements that would probably be advisable in most instances.

Treatment with medication alone is rarely indicated.medication

There are some mental health conditions in youth for which medication treatment will almost always be a part of an evidence-based treatment plan (e.g., ADHD, bipolar disorder, schizophrenia). However, the best designed research studies on these conditions almost always indicates that evidence-based talk therapies (usually behavioral treatments) significantly improves the efficacy of the medication treatment (e.g., decreasing the dosage of medication needed, speeding along the management of the symptoms, strengthening the degree of  improvement, reducing the odds of suicidality). Moreover, in the very large majority of instances, children with a psychiatric diagnosis have at least a second diagnosis as well, and many of these co-occurring conditions are either best treated with evidence-based talk therapy alone or are  better treated when evidence-based talk therapy is added to the treatment plan.

Certain diagnoses, while perhaps improved with medication treatment, may not need such if evidence-based talk therapy is tried first.

teenfamilytherapyFor example, for mild to moderate depressive disorders and anxiety disorders, cognitive-behavioral therapy or other evidence-based treatments (e.g., interpersonal therapy for adolescent depression) may sufficiently manage or heal the presenting symptoms without the need to add medication therapy to the treatment plan. While these treatments take more effort than swallowing a pill, they may be preferred by parents who wish to avoid artificially altering their child’s brain chemistry when talking treatments may do the job as well or better.

There are many instances when the science on medication treatments leaves important questions unanswered.

There are many unanswered questions about the pros and cons of providing childmedicationmedication therapy to very young children as there are regarding the long term consequences of being on the same medication and the degree to which medication treatments alter the development of a youth’s brain. If a child needs medication treatment in order to avoid significant here-and-now impairment, most would agree that such questions often need to take a back seat.  But, if a youth’s symptoms can be effectively treated either by not taking a pharmaceutical, or by taking a lower dose, that would appear to be a preferable choice in many instances.

The short-term conveniences affiliated with medication treatments should give us all pause.

I believe the best available evidence would support the position that effectively moneyandpillsdelivered talk therapies for youth spares money, aggravation and pain over the long run. However, in the short run, talk therapies may offer more hassles (e.g., additional costs and inconveniences) than medication treatments. Moreover, considering only short-term costs may create incentives for decision makers (e.g., insurance companies, clinicians with capitated insurance contracts, hectic parents) to gravitate towards treatment plans that only include medication therapy. Such factors should cause us all to pause and reflect on both the available scientific evidence and issues affiliated with longer term consequences.

A take home point is that it is usually a good idea to have a mental health professional on your child’s treatment team who is aware of the relevant science and clinical practicalities and who can help you to effectively navigate your choices. If you’re interested in speaking with a psychologist more about these matters, please click here.

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