Leading Teens to Counseling

By Dr. Jan Hittelman

Q: How do I get my unwilling teenager to talk to someone, such as a therapist?
Sign me, Concerned Mom

A: The pivotal challenge in creating getting your teen to meet with a counselor is getting them to willingly attend the initial session. Who wouldn’t be uncomfortable with the prospect of sharing personal information with a complete stranger? Particularly when you know you’re “not crazy,” don’t particularly like the idea and are other-referred (aka, dragged in by your parent). Luckily, there are steps that you can take that will greatly increase your chances of success:

Do your homework. A common mistake is to pick a random therapist, have it not work out, and have your teen more resistant than ever to see “another shrink.” Make sure that the therapist you go to is licensed and experienced. You can check a psychotherapist’s license status online at: www.doradls.state.co.us/alison.php. Next, try to make sure that he/she has experience working successfully with adolescents. You can accomplish this by getting recommendations from friends, coworkers or community professionals (your pediatrician, school personnel-guidance counselors, school interventionists, etc.). In addition, don’t be reluctant to first interview the therapist over the phone or in person. Ask about their experience working with adolescents and how they would approach treating someone with symptoms like your child is exhibiting. Does this seem like someone your teen could relate to?

Empower  your teen. It is important to give your teen a voice in the decision making whenever possible. After explaining why you feel that talking to someone is important, consider sharing the decision making with him or her. For example, say: “While you need to go to this initial appointment, we can talk together afterward to decide together if continuing would be a good idea.” Any effort to respect his voice in the decision-making process will increase his investment and eventual benefit.

Provide him with an out. One reason that teens (and others) resist the idea of counseling is that there is a concern that it may go on forever. During the initial meeting, I suggest to parents that they make an agreement with their teen to attend four to six additional sessions. If he doesn’t feel that it’s worth his time and (his parents’) money, he can rethink it at that point. That doesn’t necessarily mean stop altogether, but reevaluate it.

Reinforce his efforts. Along the way, make sure to let your teen know that you’re proud of his efforts. This would ideally start with that initial session and continue throughout treatment.

Parents Need to Grow Up Too

 By Jan Hittelman

Is anyone really ready to be a parent? There’s a shared experience among most new parents; a sense of disbelief that the hospital staff will simply let you walk out with a newborn child. It’s like giving a set of car keys to someone who hasn’t learned how to drive. Yet our parenting has a profound impact not only on our children’s development but also on our own. The challenges of parenthood provide us with an opportunity to grow as individuals. Like our children, we also have developmental tasks. From the first moment, we have no option but to be role models. How and what we model is totally up to us. The same is true of the relationships we develop with our children. If our primary focus is disciplining undesirable behavior, then our long-term relationship with our children will be negatively impacted. It takes conscious effort to focus more on the positive within our children and within ourselves. This brings us back to the developmental task of parenting. Our own level of emotional development impacts the relationship we develop with our children. The more emotional, social, and behavioral issues that we are struggling with, the less capable we will be to develop a healthy relationship with our child (or others). Thus parenting provides us with the opportunity to mature and address issues that we may have previously avoided. But the choice is ours. If we choose not to deal with our own anger problems, for example, we will likely have a higher level of conflict with our already challenging adolescent. If we regularly drink alcohol, our ability to positively impact our child’s view on substance abuse may be compromised. Sometimes our toughest challenge as parents is not our children’s behavior, but our own.

As parents it’s natural to focus on and correct children’s behavior. We rarely consider, however, how our own day-to-day behavior impacts that of our children. Children are extremely sensitive to their parents’ subtle moods, actions, and words. They internalize these characteristics as they develop their own identity and approach to the world. Of course our children bring their own emotional, behavioral, and social issues, in addition to what they learn from us and others. But even if they have significant issues from birth that are uniquely their own, our behavior will still have a significant impact.

Consider channeling your desire to be a good parent into taking better care of yourself by identifying and addressing your own issues and challenges. The better adjusted and happier you are, the healthier your parent-child relationship will be.

Teenage Wake Up Call

 By Jan Hittelman

Over the last several years, this column has discussed the effects of sleep deprivation on high school students. Adolescents are usually sleep deprived for two reasons; increased metabolic rates that make it difficult for teens to get to sleep until 11pm on average and early start times for high school. Research indicates that adolescents typically require 9+ hours of sleep each night. Sleep deprivation negatively impacts school performance, as well as physical and emotional well-being. There’s also an increased risk of accidents, which are the number one cause of death for teens. Not to mention how difficult the “morning routine” can be when adolescents are literally too tired to wake-up.

While we cannot do much about their metabolic rate, we can do something about school start times. Many school districts across the country have shifted to a later start time and have seen a multitude of benefits.

In December of 2009, the Boulder Valley School District (BVSD) formed a committee to look at this issue. They subsequently submitted their recommendation to Superintendent King. According to Dr. Rhonda Haniford, Centaurus High School Principal and committee co-facilitator, “The District’s position is that they are supportive of principals exercising flexibility. They support schedules that allow students to start later”. While this falls shy of changing the start time throughout the district, it does provide students and families with the opportunity to request a later start time from their local high school principal. In other words, it’s a start.

Hopefully, BVSD will do a good job educating parents regarding this policy change. If enough parents opt for the later start time, one day we may see all of our adolescents finally benefiting from a good night’s sleep.

Here are a few ways that you can help your teen get a healthy night’s sleep:

• Contact your local high school principal now to find out if your school will be offering this option in the fall.
• Minimize caffeine products like coffee, tea, soda, and chocolate, especially later in the day.
• Consider moving electronics out of the bedroom (TV, computer, cell phone, iPod, etc.) or agreeing on shutting everything off by a certain time.
• Avoid eating, drinking, and exercise within a few hours of bedtime.
• Encourage completion of homework earlier in the day.

For more information: www.sleepfoundation.org

In Search of Treatment for Depression

 By Jan Hittelman

Last month’s column focused on teen depression. A reader whose son has suffered from depression most of his life took exception to the following statement: “The good news is that depression is highly treatable. Talk therapy, medication or a combination of the two has been shown to be highly effective.” Her story poignantly depicts the challenge that many families experience in trying to obtain effective treatment.

Initially she “noticed he was having more and more of a problem with depression that would not “lift”, and it had gotten so bad I really feared that my beautiful, kind, shy, and intelligent son would kill himself”.

At first she tried to utilize her health insurance. Her son was initially diagnosed with Attention Deficit Disorder and placed on stimulant medication. His depression worsened. Subsequently he was switched to a different medication, but indicated that her son “felt like a zombie.” She added, “Their “talk therapy” sessions were 20 minutes long and consisted just of drug monitoring, no cognitive behavior therapy, which is the most effective therapy for depression”.

She subsequently brought him to a licensed psychotherapist and noted some improvement, but “after another six months, my son no longer wanted to go because he felt “nothing was getting any better… During this time, my son had flunked out of college.” He subsequently attended Front Range Community College and his mom notes that “Being held accountable by an entity who NOTICED him (at FRCC) and also having a very good advisor there, who also noticed him and leveled with him, has helped. Time has helped. Getting a job and moving away from home has helped him more than anything… He is now doing better and has learned a lot of skills and lessons along the way.”

She sums up her son’s experience as follows: “Drugs have never helped my son except to briefly make him feel slightly disoriented. And “talk therapy” is something apparently only those with money receive”.

I applaud this challenged mom for her ongoing efforts to assist her son. While their journey has been challenging, I wonder how much more challenging it would have been if his depression went unnoticed. This is often the case, as children and adolescents who are depressed can present with irritability instead of a sad mood. One must also wonder how her son would have responded to a more effective treatment strategy. Finally, there is a powerful message as to the importance of caring individuals noticing him and putting effort into assisting him at his school.

We can learn a lot from this parent’s story. While dealing with depression can certainly be a great struggle, we must do everything that we can to try and address it. It is also clear that as a community we must make sure that resources exist to provide effective treatment for our family, friends and neighbors regardless of their ability to pay. Finally and perhaps most importantly, we each need to care enough to notice and let those in pain know that we care.

Saying the F Word More

 By Jan Hittelman

Determining the root causes of most psychological disorders can be quite challenging and complex. It can be like detective work — getting a thorough history, identifying the specific symptoms and exactly how they present, interviewing the client and family members to really try to understand it through their eyes, assessing potential genetic predispositions, ordering various tests and evaluations, etc. And even after doing all that, the underlying reasons for the disorder can remain elusive. There is, however, one exception: poor anger control. Almost every child, teen, or adult that I have assessed who presented with anger issues had difficulty expressing their feelings. Despite being very angry, they were very unassertive. Their unexpressed feelings build up like a pressure cooker. Inevitably they explode, usually over something fairly minor, to the shock of those around them. Their reaction tends to be disproportionate to the (current) situation, because it is a result of a multitude of negative feelings that have been bottled up and never appropriately expressed. Of course there are other issues to address (e.g. poor coping skills, low frustration tolerance, family history/modeling, etc.), but unassertiveness is a key issue.

There is one important caveat to diagnosing anger symptoms and that is to rule out underlying depression. For children and adolescents, depression can present as irritability rather than a sad mood, which is more common in adults. If depression is fueling the anger, then the depression must first be treated.

Anger issues are more common in males than females because our culture continues to propagate the myth that it is a sign of weakness for boys to cry or show their feelings. Consequently, many boys/men lack the skills to do so. Fortunately, there are research-proven anger management techniques that if practiced can dramatically reduce the intensity and frequency of angry outbursts. Will they still occur? Probably. That’s because anger is a normal emotion. The key is how we handle it. Here are some simple strategies to better manage anger:

• Say the F word more! I love telling clients this, because they almost always respond by saying: “Oh, I already use that a lot”. We then discuss the other F word; feel. This leads to more in-depth discussions about assertiveness.
• Stop blaming others for your problem. Until we take ownership, we’re not going to take responsibility and make the necessary changes.
• Change your thinking. It is not the events that occur but how you evaluate or think about them that defines your emotional reaction.
• Be aware of triggers. If you know what your triggers are you can prepare yourself in advance.
• Learn relaxation techniques. When you start feeling agitated use that as a reminder to do something relaxing.

Utilizing these techniques will help you be in control of your anger, instead of your anger being in control of you.

ADHD: Effective Diagnosis and Treatment

By Jan Hittelman

Attention Deficit Hyperactivity Disorder (ADHD) is estimated to affect 3-7% of school-age children. For many, these challenges continue into adulthood. There are three types of ADHD; “Predominantly Inattentive”, “Predominantly Hyperactive-Impulsive”, and a combination of the two (“Combined Type”).

Over the years there have been valid concerns that many children are inaccurately diagnosed as having ADHD. This is problematic in part because medication is often prescribed to treat the disorder. It has been shown that some children, who were initially diagnosed as ADHD, were actually in the early stages of having Bipolar disorder and the ADHD symptoms were a function of the manic component. In these cases, prescribing stimulant medication can actually trigger manic episodes. There have also been instances where children were initially diagnosed with ADHD and it later was determined that their concentration problems were actually a symptom of depression. Finally, there are large numbers of children that were simply misdiagnosed and did not need to be put on medication at all.

To accurately diagnose ADHD there need to be several indicators that together confirm the diagnosis. These would include: feedback from parents, teachers and children themselves; objective evidence based on standardized psychometric tests constructed to assess for ADHD; and meeting the specific criteria developed by the American Psychiatric Association. Too often these critical steps are skipped and medication is prescribed.

As a parent it is important to work with mental health professionals who have expertise in diagnosing and treating children with ADHD. Too often ADHD medication is administered by a primary care physician instead of a psychiatrist, who has specialized training in administering and monitoring psychotropic drugs. While psychological testing can be time-consuming and expensive, it is a critical component in reaching an accurate diagnosis. In addition, tests that specifically measure ADHD can be used to monitor and adjust dosage levels to ensure maximum effectiveness.

In my experience, when a child is accurately diagnosed with ADHD and put on the proper medication regimen, the results can be dramatic in terms of their newfound ability to focus in school and reduce their impulsive behaviors. In addition, behavioral strategies to help strengthen the child’s social, coping, and problem solving skills are often an important component of an overall effective treatment plan.