Gun violence and kids

Even among psychologists, this is a heated and highly debated topic. Rather than go into my opinion on the presence vs. absence of guns and violence or the presence or absence of mental health treatment availability and violence, I want to focus this blog on how we make our kids feel safe. Akin to acts of terrorism, gun violence has pervaded almost every aspect of our daily life. Over the past month, I have paid direct attention to the news and found at least one violent act occurring involving a gun every few days. Granted, I live in Washington, DC and it is a metropolitan area, but it does not take away from the importance of how this information is getting disseminated to our children across the nation.

During my last year of college I interned at a local news station in Washington, DC. I can remember being surprised that the most important stories broadcasted were ones of violence. When I asked several producers why we focused on the negative and not the large amount of positive items coming into the newsfeed, they reported, “it gets more ratings.” My own personal take away was that the media could develop bias to violence because violence “sells.” So, if this is the case (not ALL news media outlets are like this), we may be bound to see violent material in our news feeds in one way or another. If so, how we do handle filtering that information to our children? Here are some strategies I have found very helpful in addressing this topic with kids:

  1. Know what they are watching (as best you can); you can’t control what their friends pull up on YouTube when they are not in your own care.
  2. Maintain openness with them. You want your child to know that you are there for them to ask any questions they are concerned about.
  3. Do not try to “shovel worries/concerns under the carpet.” What does this mean? Too many times I have seen kids bring up heavy topics with their parents and their parents become so distressed they want anything but that conversation to happen. If your kid is talking about it with you, they NEED to talk to you to digest the information they are getting in a safe manner. Try and tolerate the distress you are experiencing to give them that chance.
  4. Do positive problem-solving. Try and come up with an active plan that makes your kid safe. If they feel they have a solution, they will be less likely to be caught up in worry.
  5. Let kids be kids at the same time. Of our lives, we only have around 10 years to be a kid. That’s only about 12.5% of our lives. Kids need to have fun and be silly to grow and develop. Refocus them on the fun they can have, while not being dismissive of concerns they bring forth.

 

Sleep and Kids

 

There are a lot of clinical issues that patients come in for, but rarely do I see someone just for sleep. However, sleep appears to be a rather HUGE issue in most of my patients with anxiety. A few things I discuss with parents of kids and teenagers regarding sleep getting in the way of anxiety, school, relationships and responsibilities:

  1. Eliminate naps-naps throw off our regular circadian rhythm and can disturb the quality and quantity of sleep overnight. There are exceptions to this rule (e.g., if you just had a newborn baby and they and you need naps (only for a shorter-term duration) or if you are physically ill).
  2. Make sure to go to bed by a decent time. This translates to at least before 1130 if you are a teenager. Teenagers in high school have to get up around 530-630 am. Falling asleep, not just being in bed, but actually sleeping, at 1130 only gives one between 6-7 hours, which is still under the minimal for sleep recommendations in this age range.
  3. Know the normal age range for sleep for your child:
    1. Newborns (0-3 months): Sleep range narrowed to 14-17 hours each day (previously it was 12-18)
    2. Infants (4-11 months): Sleep range widened two hours to 12-15 hours (previously it was 14-15)
    3. Toddlers (1-2 years): Sleep range widened by one hour to 11-14 hours (previously it was 12-14)
    4. Preschoolers (3-5): Sleep range widened by one hour to 10-13 hours (previously it was 11-13
    5. School age children (6-13): Sleep range widened by one hour to 9-11 hours (previously it was 10-11)
    6. Teenagers (14-17): Sleep range widened by one hour to 8-10 hours (previously it was 8.5-9.5
    7. Younger adults (18-25): Sleep range is 7-9 hours (new age category)
    8. Adults (26-64): Sleep range did not change and remains 7-9 hours
    9. Older adults (65+): Sleep range is 7-8 hours (new age category)

(information copied and pasted from the National Sleep Foundation, 2015 studies).

  1. Being tired is not an indication that you need to sleep more (i.e., more sleep won’t necessarily fix that feeling of “tiredness.”)
  2. Maintain a consistent sleep schedule for your kids as best you can.
  3. Limit access to any screens (ipad, tv, computer) at least 1 hour before bedtime (you want to mimic the signs your body naturally receives when the sun sets. If your body perceives light, it thinks it needs to wake up and become activated).

 There are many more sleep remediation points for discussion, but these are some good ones to get covered on your own.

Tolerating uncertainty: It’s hard for kids and adults

Recently, I have taken the plunge and have opened my own clinical practice. Now, I get to practice the skill of tolerating uncertainty, the same set of skills I practice with my patients. Tolerating uncertainty is a very difficult topic to discuss and address in session and it runs commonly across all the anxiety disorders.

How do we go about tolerating uncertainty? In general, I address that while we think we have “control” over our life, we have mostly (95% or more) reactionary lives. If you think about it, there are few instances in which we consciously think about what decision to make, how to react, or what to do. We mostly just react in the moment, but somehow we have a perception that our initial reactions are always within our control. When I have patients confronting this difficult issue, I tell them to examine 5 consecutive days of their life and see the percentage of decisions and reactions they had in which they consciously chose to react or chose a certain path. The numbers usually come back around 1-5% (that fall within conscious or purposeful decision-making).

We also believe that somehow if we are worried or concerned about the things that make us feel anxious, that somehow reduces the chances of the bad outcome happening. Logically, we can recognize that worrying about something (while non-productive) does nothing to prevent a bad outcome from happening, but it can feel much better to feel like you are doing something, rather than just accepting an uncertain fate. Take a look at your life this week and look at all the things you could be worrying about (e.g., your child’s health, being in a natural disaster, etc.) that you are not. Your brain can start to get practice recognizing your “Achilles heel” (that is, where your anxiety resides), and increasing the skills you already have in place managing other potentially anxiety-laden areas.

Also, in case anyone is interested. My new practice is the “Washington Anxiety Center of Capitol Hill” at www.washingtonanxietycenter.com. Come by and visit us!

Bullying: How to identify and what to do

Bullying has been an especially frequent topic in our practice and in the media. How can we identify when someone is being bullied? Is it when someone disagrees with you? Is it when someone makes aggressive physical contact?

Bullying is the same whether we are 30 years old, or whether we are an elementary-aged school child. Let’s examine how to identify when you are being bullied.

  1. Is the child, adolescent or adult speaking negatively behind your back?
  2. Have they spoken about you with constructive criticism or did it have malicious intent (e.g., are they calling you names or are they working out a problem about you with someone else).
  3. Does the person know you well enough to make a comment about you?
  4. Does the person become physically aggressive with you?
  5. Does the person invade your personal space and raise their voice at you, or call you names?
  6. When asked to stop, does the person continue with the abovementioned behaviors?
  7. Do these behaviors happen with frequency? If they are not frequent, did the episode/s have severe consequences (e.g., damaging a professional reputation, social reputation)?

It is important to note that a bully does not have to be someone who repetitively verbally or physically attacks someone else. One instance or experience with a bully can have long-lasting emotional effects and implications. I frequently hear from my patients and their parents, “what do we do? Do we have any power in this situation to change these circumstances?” The answer is, yes you do.

  1. Can you identify the person or persons?
  2. Are you able to speak with them or their parents to discuss your concerns with their behaviors and see if there is an amicable solution?
  3. If #2 did not work, is there a teacher, supervisor, parent, or boss to whom you can express your concerns and develop a productive solution?
  4. If #3 does not work, is there an academic advocate that can work with your child and school to develop a proactive solution without ramifications for the child. Is there a Human Resource advocate that can help work with you to identify a proactive solution that has minimal ramifications for you?

Unfortunately, in dealing with a bully, there can be a “whistle blower syndrome.” You or your child may hear, “well, they must have done something to be treated like this, it’s not a big deal, it’s just normal kid/teenage behavior, just get over it.” Be strong and steadfast. Your mental health and physical safety trump someone else’s need to bully you. Make sure to take care of your kids, teenagers and adults who experience bullying. You have support!

How to be your own health advocate

Although I practice in the mental health field, I have countless experiences of my patients recounting stories to me of failed or disappointed experiences with their doctors, both in the mental health and physical health realms.

How can I be my own health advocate is a common question posed by many of my patients. Here are some tips and questions to think about:

  1. Do you know your diagnoses? Have you asked what they mean?
  2. Do you think that if you ask too many questions you are a burden to your healthcare provider? P.S. It’s not a burden, although there is always balance. Asking 20 questions a week may be overboard, but most of the time we fall on the other end of the spectrum and don’t ask enough
  3. Do you know all the options for treatment?  Do you know what your treatment will entail? yes, I am a firm believer in evidence-based treatments and I do believe they should be the first-line defense. However, I am not opposed to alternative treatments (as long as they pose no harm) and encourage patients to complement their treatments frequently. In this regard, I like to suggest centering, mindfulness activities, like yoga, to help my patients reaffirm their strategies to exist in the here-and-now.
  4. Have you gotten a second opinion on your diagnoses and suggested form of treatment?
  5. If you are getting medication, have you gotten a proper evaluation in order to receive that medication? (All too frequently I hear stories of “i told my PCP that I was sad for a few days and they prescribed me Zoloft.”)
  6. Have you educated yourself? Great resources are http://www.pubmed.com and http://www.clinicaltrials.gov
  7. Do you have your medical records organized and copied for your current provider? (it’s very very very helpful when a patient brings in copies of lab data and/or previous psychological or neuropsychological reports; it helps to give clinicians a more accurate picture of what is currently going on).
  8. Be honest (not just with a clinician, but with yourself).
  9. Your clinician is not there to judge you, they are there to help. Be open with them.
  10. Ask questions. If you do not understand something your clinician wants to know. Treatment does not work if you do not know why it is/not working.
  11. Realize that your clinician is a human too and will definitely make mistakes. It’s a collaborative and honest process on both ends, be willing to work hard and great things can be accomplished.

How therapists want you to talk to them: An inside look

Communication is key in any therapeutic relationship. Many patients believe effective communication means they must verbally convey to the therapist the symptoms they are experiencing and the goals they have for treatment. Yes, those are very essential pieces to successful treatment, however, there needs to be more.

Below I will list out several bullet points that make for an effective therapeutic relationship between therapist and patient and therapist and a patient’s family.

  • As a patient, ask the style of your therapist and their theoretical orientation (e.g., cognitive-behavioral, integrative, psychodynamic, etc.).
  • As a patient, ask how the therapist thinks you are doing in treatment. A therapist should be honest if they believe the patient is no longer benefitting from treatment, or if a different treatment approach should be recommended.
  • If a patient feels that treatment is stagnant, bring this up with the therapist.
  • Get your family, friends, spouse and/or partner involved in treatment. Treatment is much more effective when your support system is in place and knows how to support you using your therapeutic skills outside the treatment setting.
  • Do your research as a patient. A good resource for new, top of the line, evidence-based treatments is pubmed.com. You can also look at PSYCHinfo. Bring new studies into your clinician if you are interested and discuss potential implications for your treatment. We WANT you to be involved!
  • Be your own advocate! So many times I see patients hesitant to question a recommendation by myself or other professional doctors. We are here to answer your questions and make sure you understand your treatment and progress. This is a collaborative process. Asking questions and being involved IS NOT being burdensome. We want you to ask away!
  • Be honest. This is a hard one because sometimes it may be difficult to even be honest with ourselves. If a major stressor in a family is not discussed (e.g., a parent is very sick and a child is being treated), this will directly impact the treatment goals and progress in therapy. Be as honest as you can about your ENTIRE situation.
  • If you feel like you cannot pinpoint it, but you do not get along with your therapist it is important to tell them. Most of the time, potential personality clashes are miscommunications. However, sometimes they are not and therapists can refer you to other clinicians who would be a better fit. As psychologists, we believe this to be a very important piece to treatment and do not take offense if there is not a good “personality fit.”
  • Make sure your therapist is listening to your concerns. How does one know this? You can ask them to summarize your concerns and include them in the treatment plan. Over the years many of my patients have brought concerns to the table that would be deemed non-clinical, but to them, they were ranked higher in terms of importance than the clinical concerns. It is important to convey this to your clinician.
  • Overall, be willing to work with your clinician and give the process the time it needs and deserves. Sometimes treatment takes 1-3 months, other times, it may take 2-3 years.

 

Wishing you well on your therapeutic journeys!

What are the Types of Mental Health Clinicians?

What types of mental health professionals are out there? How can YOU tell the difference?

Below I will describe the types of mental health clinicians that are available in the United States. Hopefully, this can help you better digest the information that is available and who would be appropriate for you to see, if needed.

Psychiatrist, M.D-A psychiatrist is a medical doctor trained in the medical, biological model of psychiatric illness. They are trained to understand how mental illnesses can affect the neurological functioning of the brain, and how medications can address/treat these symptoms. They receive training in therapy, although considerably less than psychologists, unless they pursue additional training. Frequently, they refer to clinical psychologists for weekly therapeutic treatment. They have completed medical school and can provide psychiatric medication prescriptions.

Clinical Psychologist-A clinical psychologist is a doctoral-level clinician who focuses on the assessment and treatment of severe mental illnesses. They conduct usually weekly therapy sessions based on their theoretical orientation. However, unlike psychiatrists, they do not prescribe medications (although some states in the U.S do allow clinical psychologists prescription privileges).

There are two degrees that allow someone to be a clinical psychologist. One is a Ph.D. and the other is a Psy.D

Ph.D.- A clinical psychologist who has their Ph.D. was trained to assess and treat serious mental illness. They are also thoroughly trained in how to analyze, interpret, and write their own research. A Ph.D. clinical psychologist incorporates new research findings into their clinical work, regardless of their theoretical orientation. A Ph.D. in clinical psychology requires extensive research in a master’s thesis and separate dissertation, as well as residency and post-doctoral training. At minimum it takes 5 years to complete, with an average completion around 6-7 years, NOT including post-doctoral training.

Psy.D-A clinical psychologist who has a Psy. D has a doctorate in psychology. These programs usually take between 4-5 years to complete, NOT including post-doctoral training. They are trained as well in the assessment and treatment of serious mental illness. They typically do involve a thesis and a dissertation, but without the heavy research component. These degrees focus on training future clinicians who solely want to be in clinical practice and not be in involved in research. This does not rule them out from research; it just means that persons with this degree are less likely to have a heavy research background.

Counseling Psychologist-A counseling psychologist (Ph.D.) is very similar to that of a clinical psychologist in terms of their clinical training and the focus on training in research. However, in training, counseling psychologists focus on populations usually seen in a counseling center setting, with an emphasis on children, teens, young adults, and families. They tend to see less severe mental illnesses in practice than do clinical psychologists.

LCPC-A licensed clinical professional counselor is a master’s-level clinician. They cannot call themselves a psychologist. They can call themselves a counselor or even a psychotherapist. Their training is usually between 2-4 years, including any post-degree work. They focus on the assessment and treatment of mental illness, and although they can treat severe mental illness, it is less common than with a psychologist.

MSW-A counselor who holds a masters degree (2-3 years of training) in social work can also address and treat those with severe mental illness. Persons who hold this degree are more likely to be working in community-based centers, although some work in counseling centers and more rarely private practice.

Neuropsychologist-A neuropsychologist has received either a Ph.D. or a Psy.D. They received specialized training in residency and additionally 2 years of post-doctoral training to be called a “neuropsychologist.” They study the function of the brain and the populations they assess can have several clinical brain dysfunctions (e.g., Multiple Sclerosis, Brain Tumor, Traumatic Brain Injury, Learning Disability, Metabolic Disorder, Dementia Spectrum, ADHD, etc.).

School Psychologist-This is the one setting (academic environment) where someone who does NOT hold a doctorate degree can call himself or herself a “psychologist.” Many school psychologists have a masters and not a doctorate degree, although some do have a doctorate. The majority of school psychologists work in academic settings (e.g., elementary schools, high schools).

Life Coach/Mental Health Coach-Coaches are not a regulated field or profession, nor does it require any training or a degree or license. A life coach is not a counselor, psychologist, psychotherapist, or health care provider. They are not allowed to provide any psychological services.

Of note: When working with those who practice counseling or psychological services, make sure to check their degree and license. Certifications are NOT sufficient to practice psychological services. I frequently have patients ask for my CV (resume), of which I am happy to provide. If a mental health clinician will not provide you with information regarding their training, degree, and license, be extremely cautious. This is your mental health and you want to make sure you receive the best possible care.

 

 

 

 

 

 

 

 

Is your child really having a panic attack?

Some things I frequently hear from my child patients and parents alike are “I [my kid] is having panic attacks all the time.” After I ask what symptoms they are experiencing, usually only around 2/10 are experiencing actual clinical panic attacks. In order to really start reducing this confusion, let’s begin by defining a panic attack (not an “anxiety attack,” which is a layman’s term). According to the Diagnostic and Statistical Manual of Mental Disorders (5th edition), also known as the DSM-5, a panic attack is “an abrupt surge of fear or intense discomfort that reaches a peak within a few minutes, and during which four or more of the following symptoms occur”:

  1. Palpitations, pounding heart, or accelerated heart rate
  2. Sweating
  3. Trembling or shaking
  4. Sensations of shortness of breath or smothering
  5. Feeling of choking
  6. Chest pain or discomfort
  7. Nausea or abdominal distress
  8. Feeling dizzy, unsteady, lightheaded, or faint
  9. Chills or heat sensations
  10. Paresthesias (numbness or tingling sensations)
  11. Derealization (feelings of unreality) or depersonalization (being detached from oneself)
  12. Fear of losing control or going crazy
  13. Fear of dying

The presence of panic attacks are not a diagnosis in and of itself. However, depending on how frequently they occur, and in what context they appear (e.g., do they appear “out of the blue” or do they occur only in social situations), this clinical information can determine a more serious diagnosis (e.g., Panic Disorder vs. Social Anxiety Disorder).

I frequently hear “my child is stressing out, crying all the time, and is nonsensical when they speak.” While these symptoms can accompany panic attack symptoms, they alone do not count for panic symptoms. If you do think your child is experiencing panic symptoms, they should be getting a proper clinical evaluation by a mental health professional to determine the duration, type, and clinical presentation of the symptoms. This way, they can be properly diagnosed and then treated.

Speaking with your children about Terrorism

With recent events in Brussels, Paris and the Ivory Coast, and current threats in my home area of Washington, D.C., I find this topic is coming up quite a bit in sessions with my patients. So, I thought I would address it to my readers.

Colloquially, I hear a lot of parents saying “talking about terrorism is not appropriate for a child to learn about” and they take the stance of “hear no evil, see no evil.” The problem is, as much as I would love (and I mean LOVE) for that to be reality, whether we discuss it or not with our children, they may hear about it in some form or another from friends, extended family, teachers, news broadcasts, or a random stranger on the street.

So, the question is, if we know that our children may get some exposure to this harsh reality, do we avoid talking about or do we not? If we do talk about, how do we do so? Some questions I hear frequently from my parents with anxious children is: “I don’t want to make them more scared of the world, I don’t want them to be frightened to leave the house, I want them to know the world out there is safe.” These are very legitimate concerns I hope to address.

Terrorism causes fear of an unpredictable nature, or more technically, our ability to “tolerate uncertainty.” When I meet with patients, especially those with pre-existing anxiety, I ask them to look at 7 days of their life, a week, and assess how much control they have over their life throughout the week (i.e., how much time to do you spend making deliberate decisions that are thought out, and decide how you will react emotionally to an event, situation, or another person). In the office, I initially get a response of 70-90%. However, when looking at the actual recorded data over a real-time period of 7 days, the percentage dramatically and consistently drops to 5-15%. This example demonstrates that we believe we have much more control over our life than we actually do. We can also overestimate our belief that we can control bad things from happening AND that if we hear more about an event happening, it is likely to increase the possibility of that event actually happening.

Did you know that your chances of getting hit by lightning is 1 in 700,000 (and in your lifetime is 1 in 3,000), whereas your chances of dying from a terrorist attack is 1 in 20 million? Because we hear more about these awful terrorist situations on the news or from friends, we can have what is a called a “thought-action” fusion. It feels as though the mere thought of dying in a terrorist attack somehow increases our actual chances. Logically, we all know this just is not true, but our emotions tell us something different altogether. It is hard for parents to tolerate the discomfort of knowing the majority of our own lives and our children’s lives are not within our conscious control. However, if we can teach our child to begin to tolerate circumstances such as these, it can have generalizing effects for being able to tolerate uncertainty and distressing situations in the future.

If you decide as a parent to speak with your child about current events, it can be done in several ways. A younger child, ages 3-7, may or may not have been introduced to the concept of terrorism. A way to gage whether they have been already exposed is to ask them, “do you ever hear about bad guys?” Keep it general and more elusive, and let them take the helm of the conversation. They may say, “yes, kids at school are talking about scary things in Paris” OR they may say, “you mean like Ursula from Little Mermaid?” There really is no reason to bring up unnecessary horrors of terrorism to young children if you can be relatively sure they are not thinking about it. However, it DOES NOT mean that you can’t give them skills in place in case they do hear about it in the future. A younger child, ages 3-7, has likely already been introduced to “bad guys” in movies or books. It’s a relatively effective way to frame people who want to hurt others. However, letting them know that you are there to protect them and the world still remains a safe place is important for them to know.

With older children, ages 8-14, you can be more specific (and increasingly complex with older teenagers) when discussing world events. This is an age group that will likely have gotten some exposure to current events. Frame the events in a way that they can understand there are some unpredictable events in the world, but the chances of something happening to you is still extremely small (you can even use the example above). You want to model for them that you do not avoid harsh topics, because when we as parents avoid, it reinforces to the child that there is something legitimate to be concerned over. Sometimes it also helps to develop a specific plan of action in case there is anything that the family ever encounters. Worrying is non-productive if there is no end date in mind, but it can be productive if it leads to problem-solving techniques.

In these strategies, we can help our children tolerate the harsh realities of the world, build their resiliency to stressful events, and their abilities to tolerate distress and uncertainty. Let me know your thoughts on this very difficult, personal, and challenging family topic.

 

 

 

 

 

 

My talk with 4-year-olds on emotions

Going back to my second blog, “Emotional Vocabulary..,” I wanted to update my readers on the “talk” I gave to a group of 4-year-old children and their teachers. I think it is important to mention more about the “process” of interacting with them in effective, positive ways, compared to the content (at least in this particular blog entry). When I met all twelve (yes 12!) 4-year olds, I asked them to sit down in a circle. For parents and clinicians alike, this particular age group poses difficulties in the attention and hyperactivity department. Have you ever witnessed how much food a 4-year-old throughout the day consumes? It is a true testament to how much energy they are expelling. Young children are in constant “move mode” and when they are asked to sit and be still, this is akin to asking Mexican jumping beans to stay still and not fall off the counter. It just won’t happen.

So, if I have to work with young children with lots of energy, it was important that I engage them in different activities every five minutes (give or take a minute). They need constant reinforcement, whether that is a small present (e.g., plastic animals, stickers) or verbal praise. Young children are soooooo responsive to this reinforcement when learning new skills. They also love to be the “teacher” when given the opportunity. I had one child stand up and act out all different emotions (joy, sadness, disgust, fear, anger) and had the other children guess which emotions she was expressing (on a more complicated level, this enables the children to really start practicing emotion recognition, a more developmentally advanced skill). The other children were rewarded for raising their hands AND giving the correct answer. One boy ended up with 3 small plastic animals as a reward after answering all the questions correctly AND raising his hand. Other children were asking why they did not have a small toy, and I responded by saying it was because he demonstrated the proper behavior AND answers. In a small microenvironment, they were learning that positive behaviors could have a positive result. On a side note, this is where parents sometimes can go awry and feel that ALL kids need a toy no matter what (usually this is because they feel bad if the children feel bad). In small doses, not rewarding behavior that does not warrant a reward can have long-term benefits in terms of tolerating distress, increasing motivation, and reducing overall levels of anxiety. All the kids in the class were so responsive and at the end, I told them all that if they all practiced diaphragmatic breathing and problem-solving techniques with me, they could each earn a small toy. Each child was individually singled out for their positive engaged behavior and given verbal praise, followed by a toy (however, this was CONTINGENT upon the prior behaviors).

You may ask, how is this all relevant to me, as a parent? It definitely is! When teaching your child a new skill (e.g., making their bed, or placing clothes in the laundry, not being mean to their sibling, etc.), it is important you first teach the skills step by step, then model the behavior for them (use your acting skills, and then have them practice with you without laughing), then have them re-teach you the skill, all the while loading on the positive, genuine verbal reinforcement. I would recommend that if they can demonstrate this behavior for a longer time frame (e.g., 2-3 days or a week), you consider a small tangible reward. Kids need stimulation and to be engaged. You will get more positive behaviors from them with these skills. If you try it this week, give me a shout and let me know how it goes!