Tag therapy

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.)

 

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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.

Treating Anxiety in Youth: CBT, Medication or Both?

anxious teenAnxiety disorders in youth are common; between one fourth and one third of teens develop one by the end of adolescence. Examining treatment issues with this population, the landmark Child/Adolescent Anxiety Multimodal Study (CAMS) just published its 24 and 36 week outcomes (i.e., article dated 3/2014). This multisite study, that included 488 children aged 7 to 17 (average age of 10), compared cognitive behavioral therapy (CBT; a talking therapy) to sertraline (SRT; an SSRI medication), to both together (COMB), to pill placebo in the treatment of Generalized Anxiety Disorder, Social Phobia and Separation Anxiety Disorder. (Youth with other anxiety disorders, or with co-occurring problems such as depression or pervasive developmental disorders, were not included.) I will first review some key findings and then suggest some take home points for clinical practice.

• At 12 weeks, or the immediate conclusion of the study, this is the percentage of children who were rated to have a positive treatment response across the four conditions: COMB: 81%, CBT: 60%, SRT: 55% and pill placebo: 28%. At that point in time the combined treatment was determined to be moderately superior to the other three conditions.

• At no point in the study were there statistically significant differences between the CBT and medication treatment conditions.

• At week 24, the superiority of combined condition over medication alone and anxious childCBT shrank (COMB: 81%, CBT: 69% and SRT: 68%).

• At week 36, the superiority of the combined condition over medication alone and CBT shrank further (COMB: 83%, CBT: 72% and SRT: 70%).

• For both of the preceding two points, the magnitude of the differences at week 36 varied across the various outcome measurements.

• Quoting the authors: “…only 5% of youth receiving COMB and only 15% to 16% of those receiving monotherapy failed to achieve responder status at any point during study participation.” And, “although COMB appears best for prompt benefit, all 3 treatment conditions appear beneficial at 6 months.”

Take home points for clinical practice

therapy etchingThese results support what I, and many of my child clinician colleagues, have tended to recommend in the treatment of youth suffering from one of the aforementioned anxiety disorders. These recommendations are as follows:

• If wanting the most aggressive approach, consider medication therapy and CBT.

• If concerned about adding a psychoactive agent to a developing brain when there may be viable alternatives, consider starting with CBT alone unless the anxiety symptoms are in a severe range (e.g,, a child cannot get to school), to see if the talking treatment will be sufficiently effective.

• If a child is taking a medication, consult with the prescriber about the possibility of tapering off the medication once the CBT skills have been learned.

• It would usually not make clinical sense to treat a child with medication alone, though unusual circumstances could suggest otherwise (e.g., CBT is refused or not available).

• The CBT protocol used in this study was the “Coping Cat” program. However, other established CBT programs for children would likely also have value.

• The authors note that their results are similar to the results found in treatment therapy with teenstudies of juvenile depression. This suggests that similar clinical guidelines may also apply in the treatment of youth suffering from juvenile depression.

To read the abstract for this study, click here.

For a referral for mental health care, click here.

For an article on affording mental health care, click here.

I’d like to offer a closing thought for those parents who have a child or teen suffering from an anxiety disorder: in my clinical experience this is one of the most treatable kinds of problems that a kid can have. So, I strongly encourage you to take your child or teen to a mental health professional who can delivery quality care (for a more thorough review of what good mental health care looks like, please see Chapter 10 of my parenting book). After all, why have your baby suffer needlessly?

Tune in next week when I will post an article that describes cognitive behavioral therapy.

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.

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.

Signs that a Kid Needs Mental Health Services.

About 14-22% of children in the United States suffer from a diagnosable psychological disorder. Add 20% to that number if you include youth who suffer at sub clinical levels. However, only about 20% of these children get effective care. And, even when they get it they’ve often had to suffer for years first. This occurs even though the research on the effectiveness of child psychotherapies is very positive. What would we conclude about our culture if this were true of our childrens’ dental health instead of their mental health?

I’m writing this blog entry to try to review key indicators of when a child might benefit from mental health services. There are four primary areas of functioning that one can consider: relationships with adults, relationships with peers, academics and mood.

Relationships with adults: The key issue is whether the youth gets along reasonably well with adults. Of course this includes parents/parent-figures and teachers. But it also includes coaches, extended family, bosses, etc. If the youth is frequently in conflict or frequently avoidant or detached from any significant type of relationship with adults, an evaluation may be warranted.

Relationships with peers: Kids need to be able to form friendships, and get along effectively, with other kids who are doing well. For example, if a teen’s close friendships are primarily with those who often get into trouble, abuse substances, or are significantly symptomatic, a significant problem may be present. Likewise, if a child or teen is avoidant, aggressive, controlling or otherwise routinely rejected or ignored by most other youth, this is of concern.

Academics: This is one of the trickier areas to describe tightly. The central issue here is not grades, though grades consistently falling in the C and lower range would generally indicate that a problem exists (assuming that the teaching and curriculum are appropriate). The central issue here is the youth applying herself or himself when she or he does not feel like it.  Developing this psychological muscle (i.e., task persistence when internal motivation is required) is one of the most important developmental tasks of childhood. So if a child is not applying herself or himself, or experiencing significant turmoil or failure in academic pursuits, an evaluation is likely warranted.

Mood: The key issue is whether or not the youth is content. Happiness is great. Contentment is the bar however. If the child is consistently sad, angry or anxious for a significant portion of his or her waking day, this is signaling a need for professional attention. It is often the case that a parent may be confused regarding what a child or teen is thinking or feeling. Thus, problems with sleep, appetite, concentration, connectedness with the world or physical activity can be signs of a problem. (There may also be absences of experiences of joy, but more for kids with depressive disorders than anxiety disorders. )

As I write this blog, there are 42 ways that youth can be diagnosed with a mental health disorder. So, this is hardly a comprehensive post. However, if a child is getting along well with others, is doing well in school and seems content, that child may be fine. The only significant area I’ve left out is experiencing success in one or more extracurricular pursuits. While a lack of positive experiences in the latter area is not, by itself, necessarily indicative of a problem, a child who lacks for such experiences may be more vulnerable to attacks on self-esteem.

I hope you will share this blog post with those who could use it. If you would like to read about common myths about mental health services, click here. For ideas on how to afford care click here. And, finally, to find a lean-mean-healing machine in your neck of the woods, click here.

Resources for Suicide Prevention

As this month is suicide prevention month, I am guest blogging at the American Psychological Association’s Blog http://www.yourmindyourbody.com. My post regards suicide prevention in youth. Click here to read it.

I also did a live radio interview, on the same topic, for the Harrisburg, PA PBS radio station. To listen to it, click here.

Seven Common Myths About Counseling

The large majority of adults and kids who might benefit from psychotherapy do not receive it. For example 14-22% of U.S. children meet criteria for a diagnosable psychological disorder, but only about 20% of these kids get effective care. And, even when kids get effective care they usually suffer for years before getting it. Similar statistics are available for adults. This is beneath us as a culture and often yields dramatically painful and unnecessary outcomes (e.g., suicide is the third leading cause of death among people aged 15-24, depression has a higher mortality rate than cardiac disease, etc.).  This post reviews some of the common myths I’ve found that serve as barriers to understanding and healing.

If I enter therapy I might become too dependent on the therapist. Therapy will never end.

The goal of psychotherapy is to foster healthy independence, not unhealthy dependence. So, the aim of evidence-based psychotherapy is to reach measurable treatment goals as fast as possible. Indeed, the chief job of the competent therapist is to make her services obsolete.  While some problems require longer treatment, many do not.

Counseling costs too much money.

Most health insurance polices cover the lion’s portion of psychotherapy. Clients end up being out of pocket only for the part not covered by the insurance company. In addition, the costs are considered a medical expense and may be deductible from taxes. Studies also suggest that trips to a counselor can dramatically reduce trips to the medical doctor, sick days and an assortment of other expensive problems (e.g., divorce, addiction, etc.). Plus, think what it would be like to be rid of any significant psychological pains that inflict you or a loved one. What would that be worth? Finally, there are options for low fee services all across the country; for example, if your local university has a graduate program in the mental health professions they may have a low fee training clinic (the average fee in the clinic I direct is $10/visit), community mental health centers exist across the country, etc.

Only crazy people are in therapy.

This is really a bunch of nonsense. Putting aside the meaning of the word “crazy” for a moment, choosing to be in therapy is often a very rational act. It seems much more irrational to avoid therapy, because of silly myths, when therapy might be helpful in important ways. Effective therapy helps people to identify new methods for overcoming emotional pain and solving life’s problems. What is crazy about the pursuit of such learning?

People who spend significant time and resources on therapy are being self indulgent and selfish.

If effective therapy does anything, it increases a person’s freedom to love. Did you ever try to give to others when you have a sharp toothache? The same thing applies with psychological pain. Those who have been healed in counseling are in a position to be able to love others more and better. How can this be considered selfish?

I’ll get better eventually anyway.

According to studies on counseling, effective psychotherapy promotes healing and recovery. It may not be helpful to wait years for change. Even if change does come, the same problem may resurface later if the central issues have not been sufficiently resolved. Psychotherapy provides a way to confront and resolve problems at their source. It also provides tools for dealing with future problems. Moreover, a competent therapist can direct you to the evidence that supports the methods that he or she is prescribing.

Being in therapy is a sign of weakness. Strong, effective people don’t need help solving their problems.

Maybe in a Rambo movie. In the real world more vulnerability is often found in the person who fears acknowledging human limitations and faults and is unwilling to take the steps necessary to overcome them. Counseling is no panacea and not everybody is a candidate for counseling. However, those who can acknowledge the possible need for counseling may be stronger, and more secure in themselves, than those who cannot.

If I take my kid in for an evaluation, he’ll get the idea that there is something seriously wrong with him.

Experienced child therapists both know that parents are concerned about this and have developed procedures that minimize this risk (e.g., making sure to assess for your child’s and family’s strengths). Besides, a child or teen with a legitimate behavioral or emotional problem is much more likely to think that there is something wrong with him/her, and to have that reflected in others’ eyes, if she/he does not get help. Also keep in mind, as is the case in medicine, that behavioral and emotional problems are much more easily understood and resolved sooner rather than later.

If you are wondering if counseling might be of benefit to you or a loved one, why not look into it? A competent therapist will be able to evaluate whether or not counseling is advisable and, if advisable, what it might be able to accomplish and how long it might take to complete. What do you have to loose, really? (If you’d like a referral in your community, click here.)

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