Sunday, December 14, 2008

Childhood Anxiety

Anxiety is a problem that not only adults deal with but children also. It is estimated in some studies that as many as 3% to 17% percent of children may be experiencing anxiety of some kind. There are many kinds of anxiety including obsessive-compulsive disorder (OCD), generalized anxiety disorder, social anxiety, specific phobias, post-traumatic stress disorder, and a very common one for children, separation anxiety disorder. It should also be noted that many times when children have anxiety, often they have a parent who suffers from some kind of anxiety also.

Now it should be remembered that some anxiety is normal in children development. For example, many toddlers experience some anxiety when separated from their parents and this anxiety peaks when the child is about 18 months. Also, many children have vague fears such as fear of the dark or of bugs, etc. The point at which it becomes a disorder is if the fear is excessive beyond what would be expected for the child’s developmental level and whether it significantly affects the child’s functioning. It should also be noted that very common symptoms of anxiety are physical complaints such as stomachaches and headaches. The pain experienced is real; they are just caused by psychological factors.

In my own experience, I have found that a main factor that maintains the anxiety for people (both kids and adults) is avoidance. In other words, as people avoid their fears, or avoid what is causing them anxiety, the worse the anxiety gets. Conversely, I have also found that as people face their fears, or in other words, do what they are afraid of, the anxiety will improve. This is often called exposure, and when combined with other techniques, like developing good coping strategies, relaxation and breathing techniques, and support from others, people can usually cope and overcome.

A good example of this comes from my own life. While growing up, I was really afraid of spiders (no thanks to my older sister who held me down and threw spiders on me!). Whenever I was faced with a spider, I would avoid it and subsequently this fear continued until I was a young adult. Then, I married a woman who made me go and kill spiders rather than avoiding them. Anyway, I had to face my fears and subsequently spiders don’t bother me much anymore. The take home message is the same: face your fears!

Sunday, November 30, 2008


A great question was asked about bullying; particularly how to help victims of bullying and their self-esteem. Bullying can take many forms: it can be verbal or physical, happens to both boys and girls, can be perpetrated by boys or girls, and can be about anything from physical appearance to personal beliefs. Frequently, victims of bullying have few friends and may identify themselves as lonely. As would be expected, victims of bullying often have low self-esteem and may experience other problems such as depression or anxiety. Interestingly, perpetrators of bullying frequently come from troubled families, have their own problems in school, and may have parents who are not significantly involved in their lives.

There are a number of ways to help deal with bullying and its effects. First, parents need to recognize that bullying happens in a number of different contexts. For example, it can happen on playgrounds, at school (in halls or on buses), in the neighborhood, etc. Cyber-bullying, or bullying over the internet has recently received a lot of attention and can have just as many negative effects on an individual as in-vivo, or real-life bulling. Therefore, if a child is being bullied, parents need to recognize when and where the bullying is taking place.

The next step to help reduce bullying is to help the child who is being bullied to make friends. Parents can accomplish this by setting up play-groups or teaching the child skills to help them make friends. Talking and working with other parents with children who could be potential friends for their child to encourage new friendships may also be helpful. Further, talking with the child’s teachers about the problem so they can be aware and monitor for bullying and to also help with forming friendships with classmates can be extremely beneficial.

As mentioned, victims of bullying may suffer from low self-esteem. It is important that parents work to build up the child’s self-esteem by praising them often for their accomplishments and commenting on their strengths. Find opportunities for the child to build on the strengths and talents they already possess. Finally, a very important skill is to teach the child specific pro-social skills and coping skills to deal with the cause low self-esteem rather than avoiding it. As children are able to successfully cope with the bullying through the aforementioned strategies, not only will it reduce the frequency of the bullying, but increase the child’s self-esteem also.

Thursday, November 20, 2008


Many times, people have asked me if ADHD is a real disorder, or if it simply a result of some other condition, such a poor parenting. Such a question usually is asked because the person is not familiar with the disorder or doesn’t know anyone who has truly been affected by it. Attention Deficit/Hyperactivity Disorder or ADHD is probably the most common reason that parents take their kiddo to a mental health professional and is also one of the most common behavior disorders in school-aged children. ADHD is a real and specific disorder characterized by symptoms of restlessness, over-activity, trouble staying seated in class, blurting out answers, disorganization, losing needed items (such as pencils/papers), forgetfulness, inattention, and distractibility . Sometimes, people will ask about ADD or Attention Deficit Disorder, which is a specific subtype of ADHD (the Inattentive type; there are actually 3 subtypes).

It is estimated that ADHD affects between 4-7% of children, and is much more common in boys than girls. ADHD usually extends from childhood into adolescence, and often from childhood into adulthood. Complicating the clinical picture, there are a number of other disorders that often occur in association with ADHD. These include Oppositional Defiant Disorder (ODD), learning disorders, depression, anxiety, etc. Further, many of the symptoms of ADHD, mimic or overlap the symptoms of other disorders; for example, difficulty concentrating is a common symptom of depression. Fortunately, a number of assessment tools and measures are available to qualified professionals to assist in diagnosis and subsequent treatment, as well as identifying any other disorders.

Once a child has been properly diagnosed by a qualified professional, an appropriate treatment plan can be proposed and implemented. The best approach is usually a combination of medication, behavior management, family treatment, and educational interventions. Failure to utilize treatment may lead to emotional distress for the child, peer problems, behavior problems at home, school, and the community, school failure, and family distress.

Sometimes people are concerned that they are simply “medicating the real problem” and are scared to use these medications. For most people, these are very safe medications that have been studied extensively on children and help significantly. Although I do not prescribe medications in my practice, I often use the comparison of a child needing glasses. If a doctor told you your child needed glasses, you would probably do a number of additional things (help the child listen better, sit closer to the front of the class, learn to ask questions when necessary, etc). Regardless, it is likely that glasses will help the child significantly. The same goes for ADHD: there are a number of behavioral interventions that can be very helpful, but a medication can help too. For more information about ADHD feel free to send an email or leave a comment!

Thursday, November 13, 2008

Rules for Parents

In my last post, I noted that parents are responsible for setting rules and consequences for their children. Well, many parents don’t know that there are specific “rules for parents”. Paul Jenkins, PhD, one of my supervisors and a good friend listed these four rules for parents:

1) Take care of yourself
2) Take care of the team
3) Love your kids
4) Discipline your kids

It should be noted that these rules should be followed in order. Specifically, when a family is stressed (including parents or children), the first rule for parents is to take care of themselves. A parent can’t care for their child anymore than they can care for themselves. Second, parents need to take care of the team. Who is the team? In most cases, it is your spouse, but may include anyone who helps you care for your kids. In almost every case, your relationship with your spouse is more important than your relationship with children. Rules three and four go hand in hand but require balance: too much love and not enough discipline and kids end up with problems. Conversely, too much discipline and not enough love and kids end up with problems.

Many times while working with parents, they appear tired, stressed and burned-out. Often, they are surprised when I tell them to take some time for themselves (such as go out for dinner, do something you enjoy, or something relaxing). If they feel guilty, I explain that if they feel better, they will be much more helpful for their kids. Then, I tell them to go on dates with their spouses or significant others. Then we work on love and discipline. If you parents will follow these rules in order, you will be amazed at how much better you will feel and how much better your kids will do too!

Tuesday, November 4, 2008

What Do You Control?

There is an important principle that is implied in my last post that I need to clarify: the issue of control between parents and children. I have had many patients ask me “how do I get my child to make the right choice?” after being frustrated with a choice their child made despite the parents having used appropriate reinforcers and punishers. The simple answer to this is: you don’t. Now, before you throw up your hands in frustration, it is critical to specify what you control and what your child controls.

Parents control two very important issues for their children: the rules and the consequences. Within the limits of the law, parents can set almost any rules they want for their children and the subsequent consequences for following or breaking the rules. These rules should be based on promoting the child’s safety, success, and happiness. Similar to the rules, consequences must be within the limits of the law (thus preventing abuse!) but may include things like access to their parents’ “stuff” such as use of TV’s, computers, permission, etc.

Although they do not control the rules or consequences, children still have an important aspect of control: choice. Or, in other words, they can choose to either follow the rules or not. Thus, even though parents may establish the rules and consequences, the child still may choose to make a poor choice. Now, it should be recognized that the child often does not like or agree with the rules or the consequences, but this is not in their control. Interestingly, because of this, many children may think their parents are forcing them to do something because the child does not like the consequences that will come from their choice; however, they still have the ability to choose and therefore are not being forced.

I like to compare families and homes to miniature countries. The parents, as the government of the miniature country, set the laws and the consequences. The child chooses to follow the laws or not. For example, if I was driving down the freeway, I may notice a speed limit sign (the rule). Now, I did not set the speed limit, I may not agree with it, and I may not even like it. Further, I may not want the speeding ticket that would come from getting caught for breaking the speed limit (the consequence). Both the speed limit and the consequence are not under my control, but I still have a choice: I can follow the speed limit or not. The same principle applies for children and parents with regard to rules and behavior.

Sunday, November 2, 2008

Now what do I do?!

After my last post, two individuals asked a common question about discipline: “So, what do I do when my child does ___?” You can fill in the blank with whatever the most recent naughty, frustrating, or aggravating thing that your child just did. Although this is a relatively simple question, the answer can be quite complex. This is because children are different from one another in terms of motivation and therefore what affects one child to behave a certain way, may not have the same affect on another child. For example, one child may be very motivated by a piece of candy, while another will be motivated by time they can spend on the computer. Different kids respond to different things and therefore parents may need a variety of tools in their “discipline toolboxes”. Keep in mind that “fair” and “equal” doesn’t mean “the same”.

Two important tools for changing behavior are reinforcers and punishers. Both can be very effective if you understand the role that each plays and when to use each one. A reinforcer will increase a behavior, while a punisher will decrease a behavior. In order for a reinforcer to be effective the child must demonstrate the desired (or “good”) behavior after which the parent can reinforce it so the likelihood of it happening again increases. A punisher becomes effective if the child displays an undesired (or “bad”) behavior the parent wishes to decrease or eliminate. When the child performs this behavior, the punishment is designed to decrease the chances of it happening again. An important thing to remember is that lack of reinforcement is not a punishment, and lack of punishment isn’t a reinforcer. Also, the most effective reinforcements and punishments occur immediately after the behavior, are constant, and frequent.

The next question is, “how do I find out what will work as a reinforcer or punisher for my child”? First, I am yet to meet a child who is not motivated by anything, be it reward or punishment (but I have heard lots of parents tell me this!). A common motivator for most preadolescent children is the parent’s attention. Verbal praise from a parent can be a powerful reinforcer (again, increasing a behavior). Removal of attention (i.e. time-out) where the child does not have the parent’s attention can similarly be a powerful punisher (again, for decreasing a behavior) if used correctly. As for the individual child’s motivators, if parents will notice what the child does in their free time, you can usually identify what can be an effective reward or punisher. For example, my son loves video games while my daughter loves to play outside. Removal of video games for my son is very effective in gaining compliance, while this would be useless for my daughter. On the other hand, removing her privilege of playing outside is effective for her. Different kids, different motivators!

Wednesday, October 29, 2008

So, Whose Fault is it?

In my work, I am often asked the question “How often are the problems that the children are having the fault of the parents?” Even the parents of the child having the problems will often assume that they "must be doing something wrong” for their child to be experiencing such issues. Further, parents may often experience guilt while thinking they have done something (or didn't do something) that is causing the problem. Interestingly, I have found that most often (not always, but most often) the parents have not done anything to cause the problems the child is experiencing and their guilt is undeserved. Now, this doesn’t mean that the parents can’t do anything to help fix the problem; it simply means that they probably didn’t cause it. Just because one can be part of the solution, doesn’t mean that that they were the cause of the problem to begin with.

This is often particularly true in the case of psychopathology, or specific disorders that children may be experiencing. For example, a child with ADHD (yes, it is a real disorder) often has symptoms that the parents did not cause. However, a significant part of effective treatment for is what the parents do in response to the child’s behavior (i.e. using effective behavioral management strategies). Therefore, the parent becomes part of the solution, although they didn’t cause the problems.

Another fun way of looking at it is an example of a child making a mess in their room (or any other room for that matter; even the best, most attentive, aware parents have kiddos that make messes!). Is it the parent’s fault the child made the mess? No, but the parent often ends up directing the child to clean the mess, helping the child clean up the mess, or doing it themselves. In any case, the parent is helping to solve a problem she/he didn’t cause.