Self Injury

I see an alarming number of children that harm themselves, and this is one of the most difficult behaviors for parents to understand. Self injury can take many forms from overt physically violent behaviors like cutting, burning to less violent forms like overdoses and substance use. I like to give parents and kids a basic framework from which to think about self injury.

In non-technical terms, the 4 categories basically look like this:

1. "It feels good"

2. "It stops a negative feeling"

3. "It gets me attention"

4. "It gets me out of something"

"It feels Good"- some kids describe a rush of pleasure when they injure. I don't really see this description very often. Of course, this is the major motivator behind substance abuse and dependence.

"It stops a negative feeling"- Most of the kids I see identify this as their number one motivation. Many kids who self-injure are depressed, anxious, or they have experienced some type of trauma. They feel horrible or their thoughts are intolerable, and they have learned that the self-injurious behavior temporarily distracts them.

"It gets me attention"- This is another major motivator, but it's the one kids are least likely to admit. Whether conscious or not, self-injury is an attention-grabbing behavior. Parents need to be very aware of how their own reaction to self-injury could actually be rewarding self-injury. Kids also use self-injury and the threat of it to manipulate parents, friends, and their boy/girlfriends.

"It gets me out of something"- Many of the circumstances that lead up to self-injury involve a kid being in trouble, feeling overwhelmed, threatened or trapped. Many of the kids I see started out using self-injury in a moment of desperation and then continue to use it under less severe circumstances because it worked before. Self-injury takes away a parent's power, afraid to challenge the self-injuring child for fear they will repeat the behavior.

So those are the basic theories. I hope this helps some parents out there. With this knowledge, the next step is to get the kids working on alternative behaviors, understanding their own motivations behind the behavior, exploring their sources of stress, improving communication before they get into that overwhelmed place. For parents, we need to work on identifying the underlying issues that might be overwhelming a child, examining the ways in which a parent might actually be reinforcing the self-injury.

If you or your child are dealing with this problem, please seek help with a local mental health provider.

Child Fitness

Obesity in children and adolescents has nearly tripled since 1980. Obesity is theoretically the easiest medical problem to fix and it is up to parents to fix it. Obesity is the result of consuming more calories than we expend. Losing weight is simple- burn a few more calories than you consume and you will lose weight. We live in a world with too many calories that are too cheap.

Diet

I get lots of questions in my office about diet and nutrition for behavioral disorders. I try to keep my answer as simple as possible: DON'T GIVE YOUR KIDS JUNK. I also typically recommend more protein (especially fish), more fruit, more vegetables, less bread. Processed foods containing preservatives, artificial flavors, high fructose corn syrup, and artificial colors are probably the worst things to feed children. Whole foods such as fresh fruit, fresh vegetables, lean meats, nuts, fish are the kinds of foods nature intended us to eat. If I ever plug any supplement, it is Omega-3 fatty acids from fish oil.

If you want a longer explanation of my thoughts on diet, I suggest reading the book "The Paleo Diet" by Dr. Loren Cordain. The theory behind the paleolithic diet is that many of our modern ailments are attributable to our physical inactivity and modern diet. By modern, I mean the typical grain-based diet that began around 10 thousand years ago. Prior to the discovery of modern agriculture, humans ate what we could hunt and gather, and what we could prepare without much cooking. There was no bread, no chips, no potatoes, no pasta, no cookies, etc. The only sugar we ate came in the fruit and vegetables. Insulin levels remained very low eliminating the possibility of type II diabetes. Calories were low, exercise was plentiful, so obesity was virtually impossible. Artificial colors, flavors, and evil high fructose corn syrup weren't invented until the mid-20th century. All the vitamins and trace minerals we ever needed are contained within the basic foods of the paleolithic diet.

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.