Holiday Behavioral Therapy

Please Pass the Whine

They say there’s no place like home for the Holidays, but sometimes the holidays can be quite stressful. Meeting with family can be a nice situation that turns naughty if the kids are not behaving. Candy, sleep deprivation, and getting kids out of their normal routine can lead to some serious behavior problems that put a stain on that special time of year.

Here are some helpful tips for reducing behavior problems during the holidays. Let’s talk about prevention first: 1. Make sure your kids are getting plenty of sleep. It’s enticing to let the kids stay up later, skip the naps, but even missing an hour of sleep for a couple days can put some kids into a tailspin of bad behavior. Politely tell your family that sleep is a very big priority for your children and that they have a specific bedtime. You may have to plan your bedtime routine to start a little early to accommodate for the grandparents kissing good night and adjusting to new surroundings. 2. Make sure your kids are getting quality nutrition despite the yummy holiday dishes. Meals heavy in simple carbohydrates and low in protein can lead some kids to get wild or crash after the sugars get sucked up. Artificial colorings, particularly red food dye, can make some children more hyperactive and defiant. 3. Make a game plan before the get-togethers. Talk to your kids about your expectations for behavior before the event. Practice proper behavior by role playing common scenarios. Use positive reinforcement for behaviors that you desire. For example, you can say, "Ok guys, we are headed to grandma's. We really want you guys to have a fun time. Let's work on saying please, thank you, yes ma'am, no sir. I have a bunch of quarters in my pocket and every time I hear you being polite that equals one quarter. If an adult compliments you on how polite you are being, I'll give you two quarters." At the end of the event, you pay up and everyone goes home happy (hopefully).

What do I do if my kids misbehave at dinner? 1. Don't set your expectations too high. Kids are gonna be kids especially when they are over-stimulated and out of their normal routine. In fact, one of my top disciplinary recommendations is to ignore as much negative behavior as possible if it's just minor and annoying. Many parents feel as if they are being judged by their family for their effectiveness as parents. There is a tendency to over-correct your children when around family, but if kids aren't used to this at home, it probably won't work. 2. That said, don’t be afraid to discipline. If you use time out at home, use it at grandma’s. Take your kids to a quiet place, look them in the eye and tell them what they are doing wrong and what you expect. My rule of thumb for time out is one minute per year of age. During time outs, kids should sit in a chair with no talking, and parents should not give them any attention once the timeout has begun. At a holiday gathering, it may be best to do the timeout in a bedroom away from other family members that might distract the child or undermine the effectiveness of the timeout. 3. Forgive and forget. Let your kids know that we can all move on and get over it, we still love you and we want to make the best of the rest of our time with family. Happy Holidays to everyone in Northwest Arkansas!

I highly recommend the book Predictably Irrational by Dan Ariely. In this book, Dan explains how we think we are able to make rational practical everyday decisions, but we are driven to make irrational decisions by both internal and external forces of which we may not be very aware. One chapter about dishonesty has me thinking about my work with teenagers. This chapter concludes that the further one is from committing a direct offense against someone, the easier it is to be dishonest. It also concludes that everybody lies and cheats a little bit when 1. given the opportunity2. when there are low likelihood of consequences and 3. when it's about something small.

Many of my parents complain about their inability to trust their teenager. Whether it's sneaking out, having sex, doing drugs, being home on time, many teens are dishonest to their parents about their actions. In general, teenage dishonesty comes more in the form of "lying by omission" (leaving stuff out), rather than "lying by commission"(telling a bald-faced lie). In my experience it is harder for a teen to be able to to tell a complete lie to a question like, "Have you ever smoked marijuana?" But they will definitely fudge on a question like, "How often do you smoke marijuana?" (My usual rule of thumb is to double the answer to that question) . When the answer comes back "once a month", I usually think "twice" is probably closer to the truth. So my main points are 1. don't trust your teenagers and 2. don't think they are the devil's spawn when they lie to you. Lying is natural and normal. If you catch your teen in a lie, don't put them in the "I know the truth and you need to tell me now or you are in big trouble" corner. They will continue to lie. Tell your kids what you know, point out the facts and be direct. They will tell you an answer that approximates the truth, leave a couple things out and probably minimize their misbehavior, compare themselves to everyone else, and make up a ton of excuses, but then you can move on to a consequence and but the issue behind you. If the stories don't add up, just agree to disagree on the exact facts of the matter. Too many parents get hung up on the complete truth being told, and I think you have to approach these situations with the reality that the complete truth will probably never really come out. In my experience, the process of nagging the truth out of your kids leads to more distance, less openness, sneakier behavior and more secrets being kept.

Tricks of the Trade

I am constantly bombarded by requests to prescribe the newest, latest medications. But I am here to tell you that the newest and latest is not the greatest. The pharmaceutical industry as many of you know is primarily driven by marketing. Now I have many friends in the industry and I hope I don't offend any of them. However, I think the public deserves a bit of advertising to forward the use of time tested treatments. Pharmaceutical reps and direct to consumer advertising should not drive prescribing practices, and doctors and patients should make the final decision for medication. Many times, a good 'ole $4 cheap generic is just as helpful (or hurtful) as the $200 brand name drug. I'm a big proponent of generic meds

One of the recent tricks of the trade is the introduction of medications that are purified versions of older medications. Most medications contain a mix of molecules of the drug that are mirror images of eachother, like a right and a left hand. One of the "mirror images" is more active in the body than the other. The industry is able to take an old drug and purify it to only the active ingredient and create a new patent allowing them to continue to charge brand name prices for the medication. Common examples are Lexapro and Focalin which are no more effective than their older brothers: Celexa and Methylphenidate.

Another trick is the introduction of fancier coverings for meds. ADHD stimulant meds are essentially made from only two medications (methylphenidate and amphetamine). But there are over a dozen brand names. The main difference between the medications is their "delivery system" which basically means how the pill is coated.

My message to the average consumer is DON'T PAY ATTENTION TO ADS, COMMERCIALS, AND BILLBOARDS when it comes to medicating your kids. Find a good doctor and have a nice long talk about the options and choose the one that makes the most sense medically, financially, and ethically.

All that is Depressed is not Sad

I'm busy seeing kids at the clinic, and one question that keeps coming up (more from kids than parents) is "So you think I'm depressed? But I'm not sad." Teenagers often do not identify with the symptom of sadness that sometimes goes along with depression. They may identify themselves as more like these: moody, irritable, angry. Parents of depressed children often talk about their kid's "mood swings" which leads many to wonder about bipolar disorder. However, the vast, vast majority (and by vast, I'm talking 90%) of the kids that I see with "mood swings" have something other than bipolar disorder. The odds are that most of these children have a depression or anxiety problem (or both).

In the diagnostic criteria for Major Depressive Disorder, you don't actually need sadness to make the diagnosis. Other symptoms are just as important as the mood. The biggie is called Anhedonia- which literally means "lack of pleasure". Kids with depression find very little to be happy about, are very hard to please, don't get excited about stuff that used to be fun. Anhedonia is not exactly like sadness, but it is like a lack of happiness or enjoyment for life.

I just had a article on Anxiety Disorders in Citiscapes magazine (see below). This area is near and dear to my heart as I think myself as well as multiple members of my family have suffered from anxiety of different types. So many children are misdiagnosed with behavior problems, ADHD, and other problems that are better attributed to anxiety disorders:

Anxiety in Children

Fear is a normal part of human life and all children experience normal fears on a regular basis. Without fears, our children would be unsafe. Reckless, fearless behavior is certainly never healthy for a child. But some children have an inborn tendency toward too much fear or excessive reactions to fearful situations, and this fear impacts their ability to function in school and home. These children have anxiety disorders.

Anxiety disorders are the most common psychiatric diagnosis of childhood with about 10% of all children meeting the criteria for any anxiety disorder during school age. Unfortunately, most children with anxiety disorders do not get treatment. Many children cope with their anxiety internally and never tell anyone what’s really going on. Some families decide to wait and hope they’ll grow out of it. Some fear the stigma of going to the doctor about an anxiety problem. Some fear that medication will be the only answer. Many anxiety symptoms get mislabeled as defiance or ADHD, and treatment for these conditions can sometimes lead to worsening anxiety. The cause of anxiety disorders is thought to be a mixture of genetic and environmental factors, but anxiety is fundamentally a biological disorder. Anxiety is an inherited trait and is highly genetic; so many anxious children have anxious parents and even grandparents.

There are several common types of Anxiety Disorders. These diagnoses overlap and children can have features of more than one diagnosis at a time.

Generalized Anxiety Disorder (GAD) in childhood was formerly called overanxious disorder of childhood. GAD is marked by excessive fear and worry for more than 6 months. GAD has no specific triggering event and can be present in multiple settings like school, home, and church. Children with this disorder find it very difficult to not worry.

Post-traumatic Stress Disorder (PTSD) is triggered after a traumatic event such as physical or sexual abuse. Children with PTSD are bothered by recurrent memories of the event, always on guard, and avoid talking about the event.

Obsessive Compulsive Disorder (OCD) is characterized by the presence of persistent unwanted thoughts or worries that are paired with a behavior that helps the anxiety go away temporarily. Common obsessions include worries about germs and safety. Common compulsions include hand-washing, counting things, and checking windows and doors. Obsessive compulsive disorder is thought to be more common in boys.

Specific phobias are noted for their disabling and irrational fear of common situations which severely limits a child’s ability to function in the world.

Social Anxiety Disorder is marked by persistent fears of embarrassing oneself in public. Children with social anxiety avoid crowded situations or places that might lead to rejection or humiliation. Most children with this disorder are calm at home or around familiar people. The prevalence of social anxiety increases with age in childhood.

Separation anxiety disorder is diagnosed when children have excessive distress when they are away from their parents. They fear that the parents may be hurt while away or not be able to pick them up. Separation fears are normal in infants and toddlers, but are a problem in school-age children.

The common symptoms of an anxiety disorder fall under these categories: Concentration problems, Restlessness, Irritability, Muscle Tension, Energy, Sleep problems. Children may have problems with concentration and attention due to distraction by worry or fears. Many children with anxiety have trouble being still; they might pace or move around due to increased worry. Children with anxiety get angry easily about small frustrations or are very difficult to please. Body aches are common as well as headaches, stomach aches, and other physical complaints. Children with anxiety disorder complain of low energy and fatigue easily. Sleep Problems including difficulty falling asleep, sleeping too much, refusal to sleep alone, or waking in the middle of the night are all common.

Treatment of childhood anxiety always begins with therapy. Many older children are helped by individual therapy to learn coping skills for their worry, anger and low mood. Family therapy is very helpful to learn ways that the family can help to increase the child’s ability to tolerate difficult situations. Family therapy may also help the adults in a child’s life who often suffer from anxiety themselves. Many therapists incorporate play or art into sessions to help younger children open up in a nonthreatening and natural way. Cognitive behavioral therapy (CBT) has been shown to be the most effective therapy. This type of therapy involves getting kids to think about the way they think and to change their behavioral reactions to tough situations. In CBT, graduated exposure with response prevention is a common technique. This involves gradually exposing the child to the things that they fear and working on coping with the anxiety in a controlled way. Medications are also a helpful option when therapy has not helped enough or the problem is severe. Medication should be used in conjunction with therapy. There are multiple professionals within the Northwest Arkansas Community who have expertise in childhood anxiety disorders. Clinical social workers, professional counselors, psychologists, and psychiatrists can help with assessment and therapy for anxiety disorders.

For more information about anxiety disorders and treatment:

www.nami.org

www.apa.org

www.psych.org

www.aacap.org

www.ocfoundation.org

Helping Your Anxious Child by Sue Spence PhD

Anxiety Disorders in Children and Adolescents by John March MD

Your Anxious Child by John Dacey

Matthew Crouch MD is a child and adolescent psychiatrist in private practice in Fayetteville.