Podcast: Let’s Talk About Child and Teen Mental Health

Today we talk to Dr. Lisa Coyne about child and teen mental health—discussing ways to navigate various conditions in kids and teens, methods to cope with anxiety around school, and strategies to develop a close bond with our children.

Lisa W. Coyne, PhD, is an assistant professor of psychology in the Department of Psychiatry, part-time, at Harvard Medical School, and is a senior clinical consultant at the Child and Adolescent OCD Institute (OCDI Jr.) at McLean Hospital.

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Episode Transcript

Jenn: Hey everyone, welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Wherever you’re joining us, good morning, good afternoon, good evening, and thank you for joining us today. If you haven’t been with us before, I’m Jenn Kearney. I’m the digital communications manager at McLean Hospital and I’m super excited because I think Doctor Lisa Coyne is amazing.

If you’ve already been listening to us go back and forth, she is clearly a very easy person to talk to, and as a psychologist, clearly very good at her job. I feel like I unearth things about myself just based on what she’s saying. So, she’s absolutely wonderful.

And then for people who are unfamiliar with Lisa, if you’re joining us for the first one of these sessions, Lisa Coyne is a psychologist and senior clinical consultant at the Child and Adolescent OCD Institute, otherwise known as OCDI Junior, at McLean Hospital. And if you are joining us just now, she’s also a really wonderful person. As you can tell, she’s very easy to talk to and super empathetic. One of my favorite things about her is that she has multiple dogs. So, she’s basically-

Lisa: I do, you might hear them. I apologize in advance.

Jenn: Oh my gosh, it’s great. She’s living my best life over there because I have no pets and I would do anything for a puppy at this point, but I could talk about dogs for hours. That isn’t why people are on here. So, Lisa, I’m going to kick it off by asking a couple of questions that were emailed to me in advance.

Lisa: Let me say that one thing you asked me to say before. So just really quickly-

Jenn: Yes, please.

Lisa: For folks who are listening, this is probably obvious to you already, but this does not constitute treatment or medical advice. So, my job and one of the things that’s really important to me as a clinician, especially, I’m very grateful to work with McLean and for McLean on this platform because one of my values is to help you guys become really educated consumers about what are the best psychosocial or behavioral treatments for the things that you or your family might be struggling with.

Another, just reminder, I’m not an MD, so I cannot give you guidance on medications or anything like that. I can educate a little bit from what I know ‘cause we often work hand-in-hand with psychiatrists as well. There’s a lot of wonderful ones at McLean.

So that’s it. So other than that, ask me anything. The dog’s names are Peaches, Lemon, yes, fruit-theme dogs, and Dougal, The Doog, we call him, and one of them is a therapy dog who’s worked at McLean. Anyway, Jenn, sorry.

Jenn: Wait, okay, so my first question, and then I will actually ask the ones are, which one is the therapy dog?

Lisa: Peach. She was a re-home. She is the sweetest dog ever. She’s got terrible health issues. She’s got a hole in her heart and she’s got pulmonic stenosis and she’s just the best snuggler. She’s also the evil genius of the three. So, she’s the one who, you can almost see the gears turning about how she’s going to plan to steal that bagel off the counter. And the minute you trust her or you turn your back, it’s gone. So evil genius, great snuggler, therapy dog.

Jenn: That is fantastic. So, the first question I was asked was, “If my 15-year-old is being overly sulky lately, how can I get through to them and talk to them about it without making it sound like I think they’re exaggerating how they’re feeling? I know that things can be really hard as a teen even when they’re small problems, but I don’t want to be patronizing or come off that way.”

Lisa: That’s a really beautiful question and whoever asked that, I want to let you know, I have also a 15-year-old boy, and so I feel you. So, I think one of the things that helps when you have teens is just kind of to step back and give it a context. They’re at this developmental period where they are going to seek autonomy and independence, and that’s also a scary thing sometimes. In addition to that, their whole world has been through, all of our worlds have been thrown into disarray, but especially for them, they have a story about what the teen years are supposed to be like. That story is getting rewritten in real-time. All of that, so that’s the context, the broader context.

And then the other thing is, they’re developing private worlds with their friends that we as their parents are not privy to. We don’t know necessarily what’s going on. So, what I would do is I would keep in mind those things and I would think about, not asking them for information, but rather observing to them and offering every so often a listening ear, and it might go something like this. So how are you doing? I just wanted to check in with you because it seems like, I’m just noticing you’re quieter than usual lately. I just want to let you know I’m here if there’s anything that you need, okay? So that’s like really gentle. I don’t want to pry, and I’m here. I don’t want to pry, and I’m here. So that’s one thing you can do.

Second thing is, when you’re talking with them, lots of times when people are struggling, no matter the age, our first thing we want to do is help and fix and make it better. That’s not always the best thing. The very first and best thing is, something that we can all do, and that’s to listen and to empathize, and try and really see it from their perspective rather than from our own perspective. So, the things that my 15-year-old worries about, I’m like, what are you worried about? That’s silly. That’s the first thought in my mind, and that would 100% cause them to shut down, 100%. So, what I might do is say, that sounds really hard. Do you want to tell me a little bit more about that?

Second ingredient is, we are their role models as parents for how to express their emotions and we’re also their role models for whether it’s okay to be vulnerable. So, something like: Wow, that sounds really hard, I remember something like that when I was a teenager, and I struggled too. How are you doing with that? Just little tiny self-disclosures to make a space for them to kind of come out of their shell and talk to you, that’s what I would do.

Last thing that’s useful is, it’s such a strange thing that everyone’s home together all the time and I know that we’re starting to reopen. Seems like other places in the country, thank goodness we are in Massachusetts, this little group here, and maybe some of you listeners are not from Massachusetts. Some of you may not even be from the U.S. ‘cause McLean I know is known internationally.

So, there are variations across countries, but in some places, cases of Coronavirus are rising, which means we may or may not be looking at increased restrictions sometime in the future. Who knows? It’s a lot of uncertainty, but since we’re all together in the house, one thing that’s really helpful is to help everyone feel like they’re important to the family. Give them a small role. There’s research suggesting that engaging teens in family meals, in having a task, like your job this week is to take out the garbage every week, or your job, could you watch your sister for me for an hour every day so I can do whatever I need to do?

Small things that are doable go a long way and they prevent or they’re associated with the reduction or the prevention of risk behaviors later on in adolescence. It’s also just nice that everybody feels important and parents don’t bear all the burden and kids feel like they’re not relevant to the runnings of the family. So that was a very long answer, but I hope it helped.

Jenn: I mean, it was very good answers, so that was-

Lisa: I’m trying to be thorough.

Jenn: I would say that that was both quality and quantity. So, you’ve answered more than just that one question. You’ve probably answered several that other folks have had.

Lisa: That’s good. I just thought of one more thing. Can I add it on?

Jenn: Yeah, go for it.

Lisa: Terrible. So this is sort of an indirect way to keep connected with your kids, but I don’t know about you all who are listening, but, wow, we’re online playing video games quite a lot, not me, but the kids online quite a bit. So, one thing you might do, and there are some, I can’t think of the exact websites, but there’s lots of guidance out there for how do you manage screen time.

One thing you could do is either you can have a family screen time plan where they’re in certain rooms, there’s no screens, so like, wherever you have dinner, wherever you have breakfast, whatever table, there are no screens at that table, or you can pick a chunk of time during the day and say, during this time, nobody in the family is going to be on a screen. You can do whatever else you want, but there are no screens.

So, for example, in our family, we’re experimenting with 5:00 pm to 10:00 pm because that’s the time, there’s dinner activities, there’s opportunities to help, there’s opportunities for conversation, the dogs need to be walked, all of that. So, thinking about, can you set some limits in a non-judgmental way where everybody, as a family, sticks to the same stuff, and that can help too. So, you can play around with that and see if that helps.

Jenn: Speaking of behavior and non-judgmental ways, that actually carries pretty nicely into the next question. Specifically, this is a behavior with a child who is five years-old, often having trouble getting to the bathroom before he has an accident. Sometimes he just holds it, other times he doesn’t, then sometimes he has trouble aiming.

This parent said that they feel like they don’t have the tools to deal with this compassionately because they find themselves often getting very frustrated. The son does have an autism diagnosis, but unsure if they have anything to do with this and their concerned about when he starts school that wetting his pants would be traumatic, but what can they do to not respond with judgment and validate that they might be having trouble without both of them feeling overwhelmed in the process?

Lisa: That’s such a great question and I really appreciate the family that’s asked that ‘cause it’s hard to talk about some of these things. I love that, whoever this family is, like, sort of acknowledge, “it’s really hard for me to deal with this in a compassionate way,” because that is something that’s so, so normal to feel and I want to really kind of commend you on saying that because it’s the kind of thing that we as parents sometimes have a hard time talking about, so well done.

The first thing I would do, so if you are able to do this is, I’m going to recommend that you find somebody to help you assess exactly what the issue is. This is if you feel like getting help for this outside of your family, and then I’m going to talk about what you guys can do.

So, the first thing is, I would consider looking into what we would call a BCBA, a board-certified behavior analyst. That is a type of mental health or behavioral practitioner that we don’t often talk about or think about, but they’re extremely skilled and extremely useful. What they do is they assess very carefully what are the things that are maintaining this problem, what are the factors, and what are the consequences of that, so they can kind of really get a sense of the why this behavior is occurring. Once they know that, they intervene to change those maintaining factors, such that you can kind of make some headway. So, the BCBAs are really, really excellent, and that’s one way you could go. This is exactly the kind of problem that they would be very helpful with.

So, for you guys as parents, what could you do? So, the first thing is, meet yourselves where you are. It’s a tough problem, and I can tell from the way you asked it that it’s scary ‘cause what’s motivating you guys is, oh my gosh, I want to protect him from being embarrassed when they go to school, and what if this gets in the way? I can feel the sense of urgency in the question. So, the first thing is to notice that, let yourself feel that, and that’s okay, but let’s think about not letting those feelings drive what you’re going to do next.

So, the simplest thing to do when we want to see more of something, so there’s two ways to think about this. One way to think about it is, how do I stop the problem? The other way to think about it is, how do I see more of the good behavior we already see? Sometimes there are accidents. Sometimes they don’t make it to the bathroom. Sometimes it’s hard. Sometimes they do make it to the bathroom. So, what can we do to make that happen more frequently?

Now, as parents, sometimes the first thing we do is we think about solving things by stopping the problem. That’s not always, in fact, it’s almost never the best way, or the most helpful way to deal with things. So, what I would suggest is this: you might think about setting up, if it’s possible, a really simple schedule. Get a sense of how frequently that little one goes to the bathroom. If this little one is on the autism spectrum, one thing we know is that keeping things very simple and having routines can really help adherence, can really help behaviors grow and continue.

So, for example, we’re going to try out going to the bathroom every two hours. I don’t know if that’s the right duration for you guys, but just like clockwork. And what I would do is, even if the little one doesn’t have to actually urinate or defecate, that’s okay. We go to the bathroom and we try, and great job trying, thank you so much. And then you get some sort of reward, whether the reward is you telling them they did a good job, you telling them that you’re really proud of them, or maybe they get to play with their favorite toy or maybe they get some downtime from whatever work that they’re doing, and that’s what I would do.

The other thing is, with accidents, you will feel upset and you will feel not compassionate as you put it, and that’s okay, but I would be very careful to be very neutral when you’re addressing those. I would not give it tons of attention. I would encourage to the degree that is possible for the little one to kind of unpeel their clothes, put them in the hamper. You lay out new clothes, you let them get dressed by themselves, or you set them up with whatever kind of washing needs to happen, and be very neutral, but we’re going to really amp up the positivity around these other bathroom trips.

Now the things that a BCBA can help you with are: What are the factors that are leading to the accidents? Is it: I don’t feel like going to the bathroom? I’m not noticing I have to go to the bathroom. I’m engaged in something I really like doing and I don’t want to stop it. Is it, I’m scared of the bathroom. There are so many different reasons and that’s why I’m suggesting consulting with someone who’s a BCBA. But the very basic things that you can do are doing that positive reinforcement.

If I might tell you a book that would be very useful for this age, and it is one that I’ve used with my kids when they were little, I have referred it to hundreds of parents over the years and it’s translated into like, I don’t even know how many different languages, it’s a really old book and the illustrations are silly, but it’s been around forever, and it’s great, it’s called, “SOS: Help for Parents A Guide to Everyday Behavior Problems”. It is by a guy named Lynn, L-Y-N-N, Clark. It’s about $15, you can get it on Amazon. It really breaks down the principles of how do we teach behaviors we want to see and how do we be careful about inadvertently reinforcing behaviors we don’t want to see. So, I would start with that book and that will be in line with the suggestions I’ve given you. So good luck.

Jenn: Perfect, thank you, and we’ll also put a link to that book on the recap web page. So, when we send it out with the video, you’ll be able to access that. When it comes to kids struggling, some of them are having meltdowns when they go in public with their families, saying things along the lines of, “I’m scared of germs.” Some kids are even afraid of masks and their parents wearing them. So, there’s been some conversation around families feeling stuck as to how to reassure kids, but also make them feel more comfortable leaving the house. Do you have any resources or thoughts that you could share with those families?

Lisa: (laughs) Yes. That would be an area that I’ve worked, fears and anxieties, that’s my wheelhouse. So, first of all, it’s very normal. That’s another thing to notice that, like for kids to be anxious about this and to feel a little reluctant about families wearing masks. The reasons for that can be many and it’s really going to depend on kids, but in general, there’s a couple of things that are going to be important to think about overall with this.

The first thing is, just like with the very first thing we talked about, problem solving is not going to be the right first step, empathy is. I get it’s really scary. Yeah, these masks are weird, aren’t they? So, empathize, even if you’re like, why would you be scared of a mask? We’re totally safe. Yes, but try and see it through the perspective of a little person.

The second thing is we’re going to have to scaffold some bravery-based behaviors. So, when child anxiety in general shows up, this is how anxiety works. For adults, we have physiological arousal, there’s three pieces to anxiety. Your body just mobilizes to run and move you away from a threat. So, increased heart rate, all of these other things. We have an emotional response, we label this as anxiety, and we also have a cognitive response. Like, oh my gosh, I’m having the thought, this is dangerous. So, I’m going to avoid this situation. So, the problem isn’t necessarily the anxiety, but it might be the avoidance, and it might be so in this case.

Now, for kids, it’s really important to recognize that their anxiety, while those pieces are the same, it’s functioning a little bit differently because it’s about social signaling. Young animals aren’t in charge just themselves of getting themselves out of a threatening situation. They’re signaling so their parents see it and can help. So sometimes when you have an anxious kiddo, you will feel pulled to reassure them about everything. Tell them, “it’s okay,” let them avoid it. “Oh, we won’t do that. That’s too hard. I guess I won’t wear the mask now,” all of that, and that’s second nature to us. Sometimes that’s helpful, but a lot of the times it isn’t because it reinforces that kids should be scared of things.

Now when there’s a barking dog that could bite your child, encourage avoidance. Oh, and you can see my dog, hi, Dougal. That’s Dougal in the back speaking of dogs. But if it’s a mask, you don’t want to necessarily encourage that. So what kids are going to need is some scaffolding. How do we help them be brave when they’re frightened of masks? So, if kids are scared of you wearing a mask, you might start with having it around your neck. You might be silly about it and be like, oh, that’s a funny mask. You might have dolls in the house or animals and we’re going to put the mask on the animal, we’re going to put the mask on the doll, we’re going to draw pictures of us wearing masks. Do you want to decorate your mask? What if we put sparkles on your mask? I’ve got some sequins and glue.

Actually, that’s a great idea. I’m going to go do that to my mask, but you can do lots of things like that and you can empathize and model that masks are not always convenient or comfortable. I hate them, like when I’m walking around outside and I also want to keep my neighbors safe. So, I might say, yeah, gosh, it’s hot out, and I really don’t love wearing this mask, but you know what? I’m proud because I’m keeping my neighbors safe. Model, model your own discomfort and how you as a parent cope with it. So that’s one thing.

For fears of going outside, that’s a tough one and that’s another place to reinforce that it’s normal to be scared, and also, here are the things we can do to keep ourselves safe. And as long as we’re doing these things to keep ourselves safe, it’s okay to go out, and rehearsing that. Now, there’s a balance between encouraging and coercing kids to do things that are frightening. You don’t want to lean towards coercing because the more you push, sometimes, the more they’re going to push back. So similar to the example with the bathroom stuff that we were talking about, you want to reinforce going out. Can you go out for ice cream? Can you go out to a favorite place? Can you break it down into smaller steps? Could we go outside? And could you stay in the car and we leave the windows closed?

And then we’ll go take a drive and we’ll get a milkshake or something, it’s not always food, but you can see I really like ice cream. Sorry about that. Can you pair it with something that your kiddos are going to enjoy? Can you break it down into small steps and build it over time? I recognize that this isn’t always going to be possible ‘cause maybe you have to go to the doctor. Maybe you have to go for an appointment that’s non-negotiable. You have to do what you have to do.

So be gentle with yourself as a parent if you’re in that situation and it just has to happen. You will feel frustrated, probably, anxious for your child also, and it could be a big production. So, one of the hardest things as a parent is feeling what you’re feeling and not acting on it and not letting it be unhelpful in directing how you react to your child. So be proactive about that, but just know that whatever you’re feeling is 100% okay, 100% normal.

Jenn: So I feel like there’s a lot of that answer that can be rolled into this next question about, how do we prepare teen with anxiety for the unknowns of next school year because they’re preparing to be away from home for the first time. I think a lot of that validation and understanding-

Lisa: So big.

Jenn: Definitely I feel like it’s applicable here too.

Lisa: Absolutely. So basically, in a nutshell with that one is, how will you know how to prepare them for something that none of us really know what it’ll look like? So, the idea here would be to help them make friends with uncertainty. For kids who are anxious, for kids who are on the autism spectrum, for kids with OCD, for kids who are more comfortable knowing what is the next step, this is going to be a hard one, but that’s the work and that’s the sort of core idea is, how can we support exploration and curiosity about uncertainty? How can we help kids learn to appreciate, not just sit with, but kind of notice, acknowledge, accept, hang out in ambiguity, ‘cause we as humans don’t tend to like that.

We like things in our little bento boxes, organized. I know what’s going to happen next, I know exactly the steps I need to plan. So, I think part of this, the flip side of this is like, ah, as a parent, you want to be able to tell your kids what to do. And here’s the thing, we just don’t have the answers. So, I think making a space to have conversations about it is really going to be helpful and really acknowledging and helping them hold that uncertainty as kind of just a state.

Now in the uncertainty, there’s a lot of opportunities that present themselves: opportunities for growth, opportunities for discovering like, what is it that I want to do? How will this happen? And if it makes you guys feel any better, I have another young person in our house, she’s 20, she turns 21 this August, and we’re in active conversations about this very thing and she is also on the anxious side as well, and she prefers to know what’s happening.

I take a very collaborative approach because I’ve found that it’s first of all consistent with what we know about adolescent development. I make lots of space for the emotional tone of those conversations. Sometimes they’re heated. Sometimes I get it wrong. Sometimes I get yelled at. We all have feelings, that’s okay. So, I don’t love it, it’s not the main thing that we’re working on. So, make a space for collaborative conversations and ask lots of good questions if you’re going to let your young person choose for themselves and let them know you’re thinking if you’re choosing for them what kind of the next step is.

It’s around that when do you kind of give that autonomy? Mine is not an adolescent anymore. So she’s a young adult, and I’m trying very hard to help guide decisions without telling her what to do, but if it’s anybody younger than that, we might actually be more directive and say, you know what, we just don’t have the answers. It’s really hard. Here are the things I’m thinking about. Here are the conditions under which I’d be comfortable with you choosing x or doing x, and here are the things that are in our control that will help keep you safe when you transition back to school, or whatever it is. It’s okay to ask for help. It’s okay to set up help at the school that they’re going to in advance.

I highly recommend that. Make sure that whatever the mental health staff there are, know what’s going on so that they can support and help the transition. If your young person is working with a therapist now, make sure that your young person brings this to their therapist, and if they are reluctant to do that, ask for their permission for you to do so.

And then one last thing, it’s really helpful to think about what things are actually in our control and what things are not. Many are not in our control, but the one thing that’s always in our control is what we choose. So being open to all the information and sort of leaning into and embracing the uncertainty of it so that you can kind of, in a really mindful way, gather your own information and make an informed decision about what you want to do. That we have control of, but outcomes, we don’t, and that’s a tough one. So, I hope that was helpful.

Jenn: I think the learning to live in ambiguity and lean into that discomfort is something that is really helpful, even not as a teenager. I mean, this is such an anxious time for so many people and so many people are experiencing anxiety for the first time because they’ve finally encountered something that they don’t know what the outcome is going to be. None of us do, no one. I mean, the last pandemic was, in this country was the Spanish flu 100 years ago.

Lisa: Right.

Jenn: It’s hard to have anybody say, here’s what the outcome is going to be. So-

Lisa: I know.

Jenn: Yeah, it’s definitely challenging.

Lisa: Yeah.

Jenn: But, in regards to wanting to have that rigidity, structure, that confidence in knowing what the outcome is, we’ve had a couple questions about OCD. One of them in particular is, “How is it different between children and adults?”

Lisa: How is it different? It’s actually pretty similar in a lot of ways. In younger children, like young, young children, there are two points of onset for OCD that are very typical. Most frequently you see it develop in adolescence, but sometimes, not uncommonly, it develops in earlier childhood. When it develops in early childhood, sometimes it’s hard for kids to understand what it is and what’s going on. They don’t really know. They’re really, really reluctant to tell anyone about it, and they may not have the ability to really describe what they’re thinking or feeling, or understand it.

So we as practitioners, and I actually work with kids and adults in our practice at McLean, so one of the things that we would want to know is or we would kind of think about in treating kids is, what’s the level of skill here and is there anything that we need to teach to make sure that we can support them where they need to be supported? The other thing that’s a major consideration and actually it’s funny ‘cause the literature and the research literature developed in adults, but it is 100% relative or salient in families of children and teens, and that is that when you have OCD or when you have an individual who’s struggling with OCD, it changes the behavior of the people around them.

None of us like to see people we love suffer. So, it’s a really normal response as a partner, friend, parent, grandparent, aunt, uncle, sibling, to step in and try to help the person with OCD feel less uncomfortable, less anxious. This can look like things like giving lots of reassurance or making sure things are really clean or not doing certain things or doing things in a certain way. Now, while that’s a very understandable response, it’s an unfortunate one because it reinforces the OCD. It reinforces the young person or adult’s sort of attachment to the idea that I need to be doing these rituals.

There’s a word for this, we call it accommodation, not in the sense of school accommodations, but in families, or in partners, where accommodation is defined as, helping someone engage in rituals, such that they feel less anxious, but in doing that, we’re feeding the OCD. So that’s something to watch out for.

Last thing I would say I suppose is, and again, I’m not a psychiatrist, they are fewer medical treatments for OCD in young people. The evidence-based treatments medically are SRIs or SSRIs. So, there’s a smaller array of those kinds of things that are used, I think, or that are actually specifically researched with children and teens. The other thing is we don’t really know the long-term effects of them on the developing brain.

So, the gold standard treatment for OCD is of course, exposure and response prevention, a behavioral treatment, with acceptance and commitment therapy also, an exposure-based treatment that many practitioners are starting to incorporate into their exposure and response prevention. So, when you’re searching for providers, make sure, so let me send you to The International OCD Foundation web page. There’s a really lovely page that they have put together that helps consumers really assess whether their provider knows what they’re doing. Lots of people say they treat OCD and don’t have specific training.

It’s not enough to have someone say, “Well, I do CBT with anxiety broadly, so I can do OCD treatment,” maybe, but maybe not. So, you want to ask questions like, what percentage of your practice is about OCD? What kind of CBT do you use? Do you use exposure and response prevention? Do you assign homework in between sessions? Do you do exposure in sessions? So those are all questions and the IOCDF has a page about that and tons and tons and tons of resources for kids, teens, adults, et cetera.

They’re actually doing a really lovely series of town halls on OCD, led by Ethan Smith, who’s an OCD advocate, and a good friend of mine actually as well, where every week he’s online and he is talking to either clinicians who treat it or OCD sufferers themselves so they can talk about their experiences. So that’s a great thing to check out if you’re interested. A lot of McLean folk actually have been on that, Jason Krompinger for one, Nate Gruner, myself, there are others. So absolutely, check that out.

Jenn: Terrific. Before we actually get into the next question, which is about recommendations for finding evaluations, I did just want to say that I am sorry for calling it the Spanish flu. I do realize that that is not the correct term to use. It is the 1918 H1N1 flu pandemic. So-

Lisa: I think I did it too, Jenn, and I’m glad you said that too ‘cause I wouldn’t have caught that, and thank you. That was really awesome.

Jenn: Just trying to be more cognizant of the language I’m using. So completely (chuckles) not appropriate on my part.

Lisa: Yes, we are sorry.

Jenn: So, my apologies.

Lisa: Me too. So, if that was offensive to anyone, I do apologize as well. We are learning and it is important to us to make sure that we are... This matters to us. So, we want to make sure that we’re using right terms.

Jenn: I didn’t actually receive that in any of the Q&A, but did just want to recognize-

Lisa: You just thought of it, yeah, good.

Jenn: Not appropriate language. So, apologies and thank you for understanding that we’re learning as we go, which is, coming from a place of privilege, learning as we go and hopefully won’t do it again in the future, but always trying to improve.

Lisa: Amen.

Jenn: So, I did want to ask about recommending, finding an evaluation for preteens who may be struggling with the onset of depression-related disorders.

Lisa: Okay. So, there is an excellent website, Division 53 of the American Psychological Association, that is a great sort of clearinghouse of information about evidence-based treatment strategies, and also evidence-based assessment. What I would do, I would start with looking for, so the type of mental health practitioner that’s trained specifically in assessment and testing would be either a psychologist or a neuropsychologist.

Neuropsychologists do all sorts of different kinds of evals, but they also do psychodiagnostic evals. Psychologists may not do neuropsych testing, but they can absolutely do and are trained in diagnostic evaluations. So, I would look for those two kinds of practitioners. Usually, if you wanted to find or get an evidence-based way of testing, you would want someone who would give sort of a structured clinical interview, there are numbers of them out there that are used for this purpose for children and adolescence, along with some self-report measures, which are things that your child, depending on their age, might complete on their own, and also, parent report measures, which you would fill out based on your observations of your kiddo.

With things like anxiety and depression, or what we call the internalizing symptoms, we, as outsiders, aren’t necessarily going to be the best informants on that. Your child is because they have access to that. We only can observe from the outside, and it’s not unusual for there to be a mismatch sometimes between what parents think is going on and what kids think is going on. It doesn’t mean one of you is right and wrong. it just means that you’re looking at different pieces of the issue.

I don’t know where this person is from, but I would look for psychology practices in your area that specifically do diagnostic assessment for kids. And of course, if your child is struggling with significant functional impairment, and what that means is, you’re noticing that they’re really struggling in more than one environment, at home, no one’s at school, but maybe in accessing school, with friends. If you’re starting to see things like that, you might even want to start with just your pediatrician as a first point of contact and see if they have people who do assessment that they can refer you to ‘cause sometimes there’s a good relationship and communities between a pediatrician or a practice, and then psychologists.

Jenn: Yeah, I think that’s definitely encompasses all the questions.

Lisa: Oh, good.

Jenn: So perfect. “How would you suggest disciplining a child who doesn’t care about consequences?”

Lisa: That’s a very broad question. And again, so disciplining means different things to different people and I also think that when it’s confusing. When you can’t figure out what motivates a kiddo, it may seem like they don’t care about consequences, but more frequently, we haven’t figured out what consequences are motivating. We just don’t have all the information.

So just like with the very first question that was asked, sometimes the first thing that we reach for is, how do I stop something I don’t like? How do I punish it? And the way my good friend and colleague in Australia, Darren Kearns has described it, he says, “You know, how are you going to grow anything if you keep chopping down the tree?” So, I want you to think about punishment as chopping down something. That doesn’t mean it’s going to teach or let something grow.

So, what I would think about is, what are the things that I want to see more of, and how do I reinforce those? And reinforce means encouraging them to continue, intensify, strengthen, and a reinforcer, not to be like so nerdy here, but why not? I mean, my goal is to help you guys be educated consumers, a reinforcer can be anything that increases the intensity, frequency or strength of a behavior. Reinforcers are defined not by any inherent properties it has, but by how it works.

So, ice cream, big reinforcer for me, maybe not so for someone else. So, I would think about, what do I want to grow here? And how do I encourage it? How do I shape it? How do I reinforce it? One other thing, I guess I would say is, how do I shape it? So how do I look at successive approximations of the behavior and reinforce those? So, praise the process, not the outcome.

And then for you, for whoever had this question, not motivated by consequences, BCBA is, again, that’s what they do is to help you figure out what are, and a consequence, to define that, means, really, if I’m going to define it very broadly, it’s the way it’s used kind of in the treatment literature, is anything that happens after a behavior. It’s the effect of that behavior on the environment. Sometimes it’s a consequence someone wants more of. Sometimes it’s a consequence someone wants less of. So, a BCBA can help you figure out: What are motivating consequences? What might be something that will help this behavior grow? It’s always more fruitful to grow something than to work on stopping something. Good question, hard question. You guys are trying to stump me today.

Jenn: Before I actually get to the next question, since we do have so many of them and we are going to try to get through as many as possible, do you have a time in which you need to jump off? Want to be cognizant of how much time you have.

Lisa: Just noon, yeah.

Jenn: Okay. So, I think we can get through a few more questions. I do know there were a couple about screen time usage and we’ll actually be doing a session with you this summer about “Ask Me Anything” about kids and screen time. So, we’re actually going to hold on to those for that session and you will get an email about when it will be available to register for. So, we’re not ignoring you.

Lisa: Awesome.

Jenn: There’s a question that came up. “My daughter began menstruating at eight-years-old and her ability to manage her emotions around that time is becoming more difficult as she gets older. How can I help her navigate these emotions? She often changes between depression, hyperactivity and anger.”

Lisa: That’s hard and eight, so young, and skills in, okay, so let’s define our terms too. So, regulating emotions doesn’t mean increasing, decreasing, managing emotions. What it means is, I can have emotions in whatever shape, intensity or form, and I can also behave in a really effective, adaptable way. So, it’s about flexible effective behavior in the presence of whatever emotions are there, and that’s a concept that we call psychological flexibility, or emotional agility if you’re coming from a different literature.

So, with your little one, I think that the basics would be, helping her notice the predictability of, this is a thing that happens monthly and around this time things are happening. That would be the first thing, help her recognize that. Number two, I would address the basics. So, baseline factors that contribute to poor emotion regulation are things like disruptions and sleep. (Lemon barking) Oh, that’s Lemon. That’s the puppy. She’s really cute, but we won’t talk about her. So, disrupted sleep. Even small disruptions in sleep have been linked with issues with emotion regulation. Have you eaten? Low blood sugar. Are you tired, hungry, irritable? Are you overstimulated? Are you bored? So, look at those baseline conditions and let’s see where we’re at with those, and managing those can go a really long way.

The other thing too is, be proactive as a parent, ‘cause it’s much harder to manage this kind of stuff in the middle of it, as it’s happening, than to be proactive. So, recognize that around this time she’s going to start to get emotional. What do we need to do? How can we sort of minimize other stressors in her life? How can we begin modeling how we talk about emotions? And for moms who may still be menstruating themselves, you can talk about that yourself and model like, Oh, my mood goes down, and I notice I feel my emotion’s really big. Like, what’s your first clue? How do you know your emotions are starting to get big? What do you need from me? How can I support you? And things like that ‘cause it’s going to be something that, there’s not going to be a quick fix for this.

This is a lifelong thing. And frankly, I think all of us are learning this all the time as we approach new situations of increasing uncertainty and risk. So I think helping her choose things that will be helpful if she really is feeling intense emotions and she’s really not behaving in a way that you find acceptable is asking her to take some space in her room, asking her to take some space somewhere else in the house where you feel comfortable, but being proactive, I think is how I would do that. And then modeling, again, how you handle your own emotions, making a space for expression and emphasizing that this is something that’s going to happen every month and stinks. Most women don’t love it, just is a thing, it just happens, and how we handle that over time.

Jenn: Great. “How would you recommend helping a child who carries resentment toward their parents around circumstances that couldn’t be avoided?” This person says, “Our child still holds things against us many years later, and we don’t feel that this is normal or healthy.”

Lisa: Right, that’s a hard one ‘cause I don’t know what the specifics are, but that’s one that sometimes, if there’s a family issue, it doesn’t hurt to get help from a family therapist who can help broker these kinds of conversations. I think whenever there’s a disagreement like that or there’s a difference in perspective, some ingredients that may be useful to you will be making a space where you can take your child’s perspective.

And while it may not be acceptable to you, what they’re thinking, that’s their truth. So, trying to say, this is right or this is wrong, it’s something that I think we would all fall into, but it’s not necessarily going to be workable or helpful. So the first thing would be empathizing and go, Oh, gosh, I don’t agree with how you see it, but I totally get that that’s how you see it and that’s your truth, and given that, I get that what you’re thinking and saying make sense. Would you be willing to listen to my perspective on that? Here’s my perspective. I’m modeling, seeing it from your perspective, would you be willing to take mine? And maybe not, but I thought I would ask. So, finding a way that you can meet in the middle and empathize.

The other thing is to kind of step above it and go, I don’t know that we’re going to ever agree on this, but here’s one thing that’s really important to me right now. Think about, what’s the most important thing here? Is it figuring out who’s right or is it, I miss us as a family being together in a way that feels joyful, and nurturing and connected. And I wonder if there’s a way we can get back to that in some way. Now, as you’re listening to this, you’re probably thinking like, Oh my god, how am I going to do that? That’s not going to work. Maybe, and that’s exactly one of the things that would send me, for example, or anyone, I think, to seeking some guidance from therapists who can help you have those conversations and help kind of manage that a little bit. So that would be my advice for that.

Jenn: And we have had at least half a dozen more questions, but we really only have time for one more. So—

Lisa: Oh, bummer.

Jenn: For everybody, I know, for everybody-

Lisa: Sorry, guys.

Jenn: The good news is though, I can actually share this a little bit earlier, Lisa, you and I are going to be doing bi-weekly sessions for-

Lisa: We’ll be back. (laughs)

Jenn: At least the remainder of the summer. So, we are doing another “Ask Me Anything” session with Lisa in a couple weeks, the beginning of July. So, some of these questions that are pertinent to the topics we have coming up, we will take note of them and start those sessions with those questions, so they will get addressed. So, the last question I have for you today, Lisa, is, “Recently my seven-year-old girl participated in group bullying behavior in an online format.”

Lisa: What kind of bullying behavior?

Jenn: Bullying.

Lisa: Okay.

Jenn: So, group bullying.

Lisa: Group bullying, okay.

Jenn: Yeah. “We took away privileges, but wanted to know what are some educational ways to respond to continue to address this type of behavior?”

Lisa: Okay, I’d have to think about books and things like that, but a couple of things are important. At that age, at age seven, that is an age when kids are learning how to be with their friends, and friendships at that age are more like play dates, starting to emerge into friendships, but you can see sort of this, even at that age, that I’m going to do what other people are doing. So, it is important to kind of find out I think, like how this behavior started.

If it’s a group bullying situation, who was the ringleader? What happened with that? And what does that look like? So I think, for you as a family, having a talk about family values, like we don’t value as a family hurting others, that’s not our family value, and acknowledging sometimes kids engage in these sort of unsavory behaviors because they fear the repercussions of not doing so. For example, if I don’t do what these kids do, am I next? Am I going to be culled from the herd? Is that scary? So, having some conversations about like, what led to this, like what happened? Like how did you feel when you were doing this? Did you feel good? Were you kind of like, (grunts) I don’t like doing this, but I’m scared not to do this? Is it a meanness? Is it like, I just don’t like that kid, they’re a jerk.

So each of those different kind of situations would lead me to have a very different response, but I think the baseline is, reinforcing what we call prosocial behaviors, and prosocial behaviors mean things like sharing, collaborating, kindness, being polite, all of those things, modeling them in your family, reinforcing them in your family, and having a really strong statement that we don’t treat our friends this way, period, we just don’t, helping broker other friends if this is a group that regularly does this.

Other things you can consider doing is depending on the extremity of this, if it’s a group in a school, I have done things like this before in the past, where I’ve reached out to the principal or the vice principal, and I’ll say, “I’m passing this along to you, this is happening. And I just want to let you know. Do with it what you will.” So when I see instances like that, and if it’s happening in a school setting, I make sure that the school folks know it so that they can address it ‘cause it may be happening at school too in real-time.

So, I would start with those things, but I would most importantly understand the context in which these behaviors are arising and model some other behaviors. You might want to talk to talk to the other parents as well and say, Are you aware of this? I know as a mom, like I would hate hearing it, but I would really want to know if my kids ever did anything like that because that would not be okay with me and that is really not a family value. So, I think we’ll leave it there, Jenn. Does that sound okay?

Jenn: Yeah, I think that’s great. And-

Lisa: Alright.

Jenn: There was a lot in your last answer I think that’s valuable even to adults. First of all, prosocial behaviors. We’re all going through tough times. We can all be really nice to each other. Something that stuck with me, I was listening to, actually I watched the CNN and Sesame Street where Van Jones said that-

Lisa: Love Van Jones.

Jenn: “Hurt people hurt people,” and a lot of it is getting to the root of why people are acting the way that they are and I think that that’s super valuable. Even as an adult, that’s something that we can take forward to be more prosocial, inclusive and kind. And I do know we’re at the hour. You are going to have to jump off. I just have to say thank you so much. You are wonderful, per usual.

Lisa: Very welcome.

Jenn: It feels like two months never past where we didn’t see each other.

Lisa: So nice to see you, Jenn.

Jenn: So, thank you. So, thank you so much for all of this and everybody who-

Lisa: My pleasure.

Jenn: Everybody who joined us today, thank you. So, Lisa, thank you again.

Lisa: Very welcome, my pleasure.

Jenn: Everybody in the audience and-

Lisa: And thanks for the great questions, guys. That was really awesome. Thank you. (chuckles)

Jenn: And like I always say, be nice to one another and wash your hands and be safe. Have a great day and thank you, everybody. Bye.

Lisa: Bye, everyone. Take care.

Jenn: Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.

Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to educate about, encourage compassion around, and reduce the stigma related to mental health and wellness. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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