Special Editorial: Meds, meds, meds…Do we really need them or is it all in our heads?

Okay, so the medication debate is not as black and white as the title may suggest.  It sure is worth having, however, as an article that came out this June in APA’s Monitor on Psychology about the inappropriate prescribing of psychotropic medication spells out.

Before I go any further, I am completely aware that medication can be a game-changer for some people, allowing them to function in ways that they simply could not before being prescribed an appropriate medication.  For many others, more than we may guess, medication may not be as necessary or helpful as we are led to believe.  And when it comes to medicating children, I vote for being even more careful with prescribing, especially in light of the fact that many medications have not been thoroughly researched for kids.

So here’s the low down on the article:

  1. Many psychotropic medication prescriptions do not come from professionals that are well-versed in mental health issues (4 out of 5 come from non-psychiatrists).  Primary care physicians know a lot, but they may not know as much as we need for them to when it comes to something as serious as treating a mental health disorder with medication.  And they may not be in the know on other effective treatments, such as cognitive-behavioral treatment, that are non-pharmaceutical.
  2. The placebo effect is thought to be a major player in the effectiveness of anti-depressants.  Current research suggests that it’s mostly people with severe cases of depression that seem to truly benefit from the chemical impact of anti-depressants.  Most others reportedly benefit from simply knowing that they are taking something to help their depression.  (As would be expected, there is controversy about these findings.  One thing seems clear, though.  Cognitive-behavioral therapy continues to get positive results in the treatment of all levels of depression and the skills learned can last a lifetime.)
  3. Misdiagnosis can lead to inappropriate prescribing.  One should make certain that an appropriate evaluation has been conducted and confirms a diagnosis of ADHD, for example, before starting a child on a psychostimulant.
  4. Published research tends to include the studies that show positive outcomes for medication rather than being balanced by the publication of studies that do not.  An examination of FDA studies in 2008 reported that the studies were about half and half with positive to negative results; however, over 90% of the studies published were with positive results.
  5. There is a huge financial incentive, both to doctors and patients, to go down the medication route.  Docs get paid a whole lot more and patients pay a whole lot less, in general, when they pursue medication in lieu of therapy.  And advertising for psychotropic medication can lead to greater public awareness about the existence of a drug, which may contribute to patients pursuing this route more readily than therapy.
  6. Vulnerable populations, including the elderly, foster children, and infants, are prescribed psychotropic medications, oftentimes for off label use.  Foster children were found to be over four times more likely than other children to be on psychotropic meds, frequently more than one kind, including antipsychotic drugs.  In my field, we call these drug cocktails chemical restraints because they are oftentimes used to subdue children with difficult-to-manage behaviors.
  7. ADHD continues to prompt a lot of psychostimulant prescriptions.  Sometimes they are very helpful and sometimes not.  (Cognitive-behavioral therapy has been found to be useful in this area as well.)
  8. Psychologists across the country continue to explore the possibility of gaining prescribing privileges in order to add to the pool of mental health professionals that are well-versed in both medication and non-medication-based therapies.  New Mexico, Louisiana, Guam, and the armed forces have approved programs to train psychologists in prescribing.

And now I step up on my soapbox for a moment.  Ahem…I get why psychotropic medications are so popular, including in teens and children.  We want our kids to feel better, quickly.  And if our pediatrician tells us that we can have that happen with a pill, then we are inclined to listen.  I know that therapy takes time.  It is a process.  And I know that it can be expensive.  Keep in mind, however, that a good therapist will arm your child with skills that can carry them forward with a greater ability to handle a multitude of stressors and situations more effectively.

Of course, there will remain individuals that get better results when medication is added to the treatment plan.  For these children and teens, I implore parents and guardians to monitor them closely for medication effectiveness and side effects and to have regular check-ups with their prescribing physician.  If it is feasible, I also highly recommend seeing a child psychiatrist, at least to get things started.  Regardless of the provider you use, please include something like this in your initial discussions, “I am interested in learning about a variety of options, both pharmaceutical and otherwise.”

And while your medical provider may know a lot, he/she is likely a busy individual that does not have time to read every relevant research article as it comes out.  You can keep yourself informed, however, by doing your own periodic searches, setting alerts for when relevant articles are published, and visiting reputable websites that specialize in what your child is being treated for.

Okay, I’ll climb back down now.  Thanks for reading.  -Anita

Source: Smith, B.L. (2012, June). Inappropriate prescribing. Monitor on Psychology, 43 (6), 36-40.

How to Tone Down Parent Conflict During Separation and Divorce to Help Your Kids Adjust

By Anita M. Schimizzi, Ph.D.

Time and again, research suggests that parental conflict is a strong predictor of how children will do following parental separation and divorce.  Parents’ ability to cooperatively co-parent without exposing their children to ongoing conflict can provide a critical foundation for healthy adjustment.  Conversely, parents who remain hostile toward one another and continue to openly battle are likely to pave the way for their children’s maladjustment.

This makes sense, right?  Children who must face ongoing fighting and conflict between their parents while they also endure all of the changes prompted by their parents’ separation or divorce would probably struggle more and have more anxiety and depression than those children who go through the separation or divorce but do so within a low conflict, cooperative parenting arrangement.  So you may say, “Fine.  I get it.  But how on earth am I supposed to peacefully parent with my kids’ other parent when the very reasons that we got divorced still cut so deep and he/she continues to act like such a [insert your choice of words here]?!”   The simple answer is STAY FOCUSED.

Below, I explain in more detail what I mean by staying focused.  One caveat:  I know that there are situations where some of these suggestions are simply not feasible.  They are, by no means, have to’s but rather pieces to consider, to look at from different angles to see if maybe, just maybe, there is some way to make them happen in a way that benefits your children.

1. Seek support for yourself.  Your relationship with your children’s other parent has now shifted in a dramatic way.  I have never heard of an intimate relationship terminating with the involved parties feeling totally unscathed.  Whether you turn to therapy, family, friends, spiritual leaders, a combination of these, or something entirely different that helps you find your way, it is critical that you reach out and allow yourself to be supported during this time of tremendous adjustment.  Being able to move forward with greater inner peace can do a whole heap of good for being able to effectively parent with your ex-partner.

2.  If at all possible, use a mediator to come up with and agree on a parenting plan.  Do everything that you can to stay out of courtroom battles with your children’s other parent.  This type of litigation can often leave both parents in a state of high conflict and that energy trickles down to your kids.

3. If you are unable to come to a good working relationship with your children’s parent and you do find yourself back in the courtroom time and again, it could be useful to use a certified parenting coordinator.  Your attorney and/or local family court should be able to help you locate one.  Sometimes the family court judge will even appoint one in an effort to help parents develop a less litigious and more cooperative co-parenting partnership.  As with all professionals, there are good fits and bad fits.  Look for a parenting coordinator that you feel really gets you and your children’s other parent and is able to remain level-headed, fair, and focused on the best interests of your children.  Oftentimes, parental hostilities can cloud judgment and it can be extremely helpful to have a neutral third party assist in ironing out differences in opinion and be a sounding board that keeps you focused on your children rather than each other.

4. Look for signs of distress in each of your children.  If you are thinking that your child is doing just fine in the midst of your dynamic with your ex, but you begin to notice some differences in behavior, emotion (including a lack of emotional expression), somatic complaints that can signify stress (e.g., headaches, stomachaches, sleep difficulties), or other changes, it might be time to reexamine the level of tension and conflict.  (Please know that most children will be distressed as they go through this process.  They’ll have ups and downs, but their overall distress should ease up over time.  If it instead starts getting progressively worse, then it’s definitely something that should be explored.)

5. Maintain good boundaries when it comes to your relationship with your children’s other parent.  While it is critical to come to an agreement on the big stuff, like school and health, you don’t need to agree on all of the little stuff.  Each of you will need room to parent as you see fit without the meddling of the other.  For example, you may have different rules about chores.  One parent may want them all done on the weekend and the other may want them done daily after school with none on the weekend.  Neither is right or wrong.  They are simply different and each parent has the right to make that call.

And also on boundaries, remember that you and your children’s other parent are not together anymore.  That means knocking before entering her/his place of residence, or remaining in the car if that is what is asked of you, when you go to pick up your children for their time with you.  That means not bombarding your children with questions about their other parent.  That means talking with your ex in the absence of your children when you need to work something out¸ keeping the discussion where it belongs – with the grown-ups.

6. Demonstrate as much respect toward your children’s other parent as you can possibly muster.  That means using respectful language about and toward him/her, ESPECIALLY if your children are anywhere in earshot…and that means anywhere on your property because they have amazing radars that pick up on this language from long distances and when they seem immersed in activity.  That means maintaining the boundaries discussed above.  Remember, your children’s other parent is a part of your children.  Respecting him/her is a way of respecting your children and making sure that you do not place them in a loyalty conflict, feeling the need to choose between you and their other parent.

7. Recognize unresolved feelings.  If you are a couple of years out and you still find yourself feeling strong feelings like hatred toward your children’s other parent, then you have likely got some work to do to really move on with your life without him/her as your partner.  Your intimate relationship is over.  It is time to forge something that is more akin to a business partnership, where your children and their well-being are the focus at all times.  If you are focused instead on keeping score, denying your children’s other parent’s requests because you don’t want him/her to get his/her way, or caught up in regular arguments, screaming matches, or other hostilities, go back to #1.  Without superhero powers, it is nearly impossible for your children to thrive in the face of this dynamic.

A final word on staying focused as you work toward cooperative co-parenting: on a regular basis, ask yourself “Is this good for my children?”  Pause and really think about that.  “Is this good for my children?”  It can be helpful to keep a picture of your children on hand as you contemplate this and as you work through differences with your children’s other parent.

For readers interested in learning more about what children need during different ages, I still highly recommend Gary Neuman’s Sandcastles book.  Another great resource is Mom’s House, Dad’s House by Isolina Ricci.  This book has a supportive approach and a lot of good information on the grown-up stuff, how to work through the multiple transitions involved in moving through separation and divorce and on to effective co-parenting.  As with any recommendations that I make, please use what fits with who you are and what you need.

Stay focused.  –Anita

References:

American Psychological Association. An overview of the psychological literature on the effects of divorce on children. Retrieved from http://www.apa.org/about/gr/issues/cyf/divorce.aspx

Neuman, M. G. & Romanowski, P. (1998). Helping your kids cope with divorce the Sandcastles way. New York, NY: Times Books.

Ricci, I. (1997). Mom’s house, dad’s house: A complete guide for parents who are divorced, separated, or remarried. New York, NY: Fireside.

Moms, Kids Anxiety

By Anita M. Schimizzi, Ph.D.

We know that maternal depression can have a profound impact on children.  But what about maternal anxiety?  A recent article in the Journal of Abnormal Child Psychology suggests that mom’s anxiety may tend to transfer to her young children.  Before I start, however, let me be clear that this post is in no way intended to blame moms for their child’s anxiety.  Rather, it is meant to provide information and ideas on this possible relationship.

Pass and colleagues took a look at around 60 mothers in the UK who were diagnosed with anxiety disorders (specifically, social phobia with about half also having generalized anxiety disorder) and 60 mothers who weren’t.  They compared information gathered on their children as they were getting ready to begin formal schooling (around 4 ½ years old).  After the children completed the first term of school, the researchers gathered more information from mothers and also from teachers.

At the first data gathering, the children were given a doll play activity (I continue to be amazed with how much children reveal about their inner lives through play) and several school-related scenarios to prompt their play.  Mothers were also asked to report on their child’s anxiety.  At the second data gathering, teachers reported on the students’ anxiety and mothers provided additional information.  Here’s what they found.

Children of anxious mothers gave “anxiously negative” responses during their play at a significantly higher rate than children of non-anxious mothers.  Further, children whose play was classified as anxiously negative were almost 7 times more likely to score in the borderline/clinical range on teacher reports of anxiety/depression and also more likely to score higher on teacher-reported social worry after completing the first term of formal schooling.

While the researchers predicted that there would be significant differences in the children of anxious mothers and those of non-anxious mothers in the areas of attachment (parent-child bonding) and behavioral inhibition (fear and avoidance of unfamiliar situations), the groups did not differ significantly.  In other words, children of anxious moms were just as likely to be securely attached and willing to enter novel situations as those of non-anxious moms.

As is typical in research, the focus remains on the mother-child link rather than bringing dads into the mix so we don’t know if and how dad’s anxiety can impact kids or if his lack of significant anxiety can act as a buffer.  What we see is that there seems to be a relationship between socially anxious moms and kids who view the school social experience in negative ways and are seen as more anxious, depressed, and worried than their classmates.

I have sat across from many parents who have sought therapy for their child’s anxiety only to realize that they themselves harbor many of the same characteristics.  As they launch into self-blame, my response is always the same: nobody is to blame.  Let’s work on understanding this and learn and practice techniques as a family.  And that is my suggestion to readers.  If you, as a parent, find that you have significant anxiety it might be time to take a look at your child, too.  Conversely, if your child seems to have a lot of anxiety, it might be a good idea to see if it also resides in you.  There are so many solid, research-supported ways to manage and decrease anxiety in people of all ages.  And doing so can open up a whole new world of being.

Thanks for reading.  -Anita

Source:  Pass, L., Arteche, A., Cooper, P., Creswell, C., & Murray, L. (2012). Doll play narratives about starting school in children of socially anxious mothers, and their relation to subsequent school-based anxiety. Journal of Abnormal Child Psychology. DOI: 10.1007/s10802-012-9645-4

Race and Spanking in the US: A Spank is a Spank is a Spank

By Anita M. Schimizzi, Ph.D.

Yes, it is no secret how we at child-psych.org feel about spanking.  Nestor and I have both posted on it before.  Still, there remain arguments that spanking is less detrimental for children when cultural context is taken into account.  That is, if spanking is more acceptable and part of the norm within a certain cultural group, then the negative behavioral fallout from spanking is lessened.  Gershoff and colleagues recently published a study in the journal Child Development and their findings suggest that this argument is bunk.

The researchers used data from a nationally representative sample of over 11,000 children gathered in the Early Childhood Longitudinal Study’s Kindergarten Cohort of 1998-1999.  Children included in the study were from one of four racial groups: White/Non-Hispanic, Hispanic, Black/Non-Hispanic, and Asian.  Using data from both kindergarten and third grade for the students, they collected information on spanking, child externalizing behaviors (e.g., arguing and fighting), and parent background (e.g., family income-to-needs, parent education, marital status, and employment status).

Information gathered at kindergarten showed that most mothers (80%) spanked their child at some point, but only 27% reported currently spanking their child.  Fifteen percent of mothers reported spanking their third grade child.  At both points in time, Black mothers reported significantly more frequent spanking than any of the other mothers.  Hispanic moms were more likely to spank during kindergarten than White and Asian moms.  Teacher reports showed that acting out was highest at both kindergarten and third grade for Black students.  White and Hispanic children acted out more than Asian children in third grade.

After controlling for a whole bunch of variables (e.g., child gender and age, family income and size, parent education, marital status, parent employment status, and race), the researchers found that early spanking predicted more externalizing behavior over time regardless of the child’s race.  And here’s an additional interesting outcome: increased acting out predicted more spanking.  So we have a spank-act out-spank-act out cycle.  In other words, the very behaviors that parents try to squelch with spanking increase with spanking and the impulse can be to, you guessed it, spank more!

It is worth speaking further on the findings for Black children in this study.  There is absolutely no refuting the fact that corporal punishment served as a survival technique for African Americans during earlier times in our society.  To not keep one’s child in line could literally lead to far harsher punishment and/or death at the hands of the slave-owner and under the not so distant Jim Crow laws.  It is more than understandable that African American parents would have done anything and everything to protect their children in this type of society.

What we know now, however, is that the desire to immediately put behavior in check through spanking appears to have an unwanted effect over time.  The very behaviors that parents want to end increase instead.  Old habits and doing as we were raised to do are hard to change, very hard to change.  No matter what your race is, it looks like it’s both time and worth it.  What, you may ask, in the heck do we do instead?  You can start with poking around the How To section on the site and see if something strikes a chord.  And please let me know if there is something else that you would like to see.  Post your questions and open up important dialogue with other parents.

Thanks for reading.  –Anita

Source:  Gershoff ET, Lansford JE, Sexton HR, Davis-Kean P, & Sameroff AJ (2012). Longitudinal Links Between Spanking and Childrens Externalizing Behaviors in a National Sample of White, Black, Hispanic, and Asian American Families. Child development, 83 (3), 838-43 PMID: 22304526

Special Editorial: Does your child need therapy? Thoughts on parental fears and why we need you involved

By Nestor Lopez-Duran PhD

Historically, psychiatry has not been kind to mothers. Early (and mostly wrong) ideas about what ‘caused’ emotional/behavioral difficulties and psychiatric disorders made it easy for clinicians to blame parents for all childhood conditions. Autism is a classic example. In the 1940s Leo Kanner, one of the most influential child psychiatrists of the time, stated that children with autism were kept in “refrigerators that did not defrost.” By refrigerators, he was referring to mothers, who he believed were emotionally and interpersonally distant. As most of you likely know by now, Kanner was wrong.

Since then, the attack on parents appears to be relentless. Our media outlets are filled with misinterpretations (and sometimes accurate interpretations) of research findings and statements by clinicians that directly or indirectly blame parental behaviors for their kids’ problems.

  • You cuddle your kids too much
  • You don’t love them enough
  • You are too strict
  • You are too permissive
  • You are too emotional
  • You are not emotional enough
  • You give too much freedom
  • You hover over them
  • You don’t praise them enough
  • You praise them too much

The list is endless.

The consequences of this parental blaming are devastating: parents full of either guilt and shame or anger and defensiveness, and worse, children who don’t get the treatment they actually need.

So I often find myself doing damage control with parents and explaining their new role in helping their kids improve. So today I wanted to share with you what I often tell parents who are either reluctant about therapy or are struggling with making decisions regarding their kids treatment.

  1. Does your child need help? Examine your childs academic, social, family, and emotional functioning to decide whether he needs help. If your kid’s behavioral or emotional difficulties are such that his functioning at home, school, or with peers is impaired, he may need help. You may ask, what is impaired functioning? There is no standard definition, but we usually become concerned when a child is unable to fulfill many of the basic tasks of being a kid: going to school, getting at least Cs in his courses, developing and maintaining friends, regulating his emotions, keeping himself out of trouble with the law, understanding and following basic rules, etc.
  2. Getting help does not necessarily mean medication or years of therapy! Getting help may simply involve an evaluation to determine what intervention, if any, may be beneficial to your child. So it is often less scary if parents think that the first step is simply to seek an evaluation or consultation, without any commitment to go beyond this initial consult. The process should not be any different than when taking your child to the pediatrician for an evaluation if your child is having some physical symptoms. If your child needs help, most of our current interventions are relatively short (20-30 sessions) and the times of keeping kids in never-ending years of therapy are gone (at least mostly).
  3. If you are concerned about your child’s functioning don’t accept a “he is just fine” answer from your pediatrician, especially if the pediatrician only asked you a couple of questions. I am always reluctant to say anything negative about other professionals, but the reality is that many pediatricians have little training in child psychology and psychiatry and especially in the proper evaluation of child psychological conditions. This is not just my perception. A comprehensive national survey of pediatricians revealed that about 70% of pediatricians feel that they lack appropriate training in diagnosing and treating mental health conditions and over 60% felt that they were not competent in proper diagnostic practices . So if you dont agree with your pediatricians opinion that your child is just fine, request a referral for a consultation with a child mental health provider, such as a psychologist, psychiatrist, or clinical social worker.
  4. In many, many, many, cases, what “caused” your child’s condition does not really matter. This is likely a controversial statement, especially with some traditional therapists, but I say it because parents are frequently overly concerned about finding out what “caused” their kids OCD or ADHD. Often parents feel guilty and want to know if they caused the problem somehow or they are seeking answers that help them understand and accept why things turned out this way. The reality is that in most cases the “cause” will never be known. Although good clinicians will have a deep understanding of the historical and current context (family dynamics, peer group, thinking style, etc.) that may contribute to some of the difficulties, what matters right now is what we do from this day forward to help your child improve. Remember, we can’t change the past but we can improve your child’s future.
  5. We can’t help your child without your help. There is very little we can do in one hour of weekly therapy without getting parents, and often teachers, involved in the treatment process. This is because the most effective interventions usually require that we make changes at home and in some cases at school. On that note:
  6. When we suggest a different parenting or discipline strategy we are not saying that what you were doing was wrong or that you caused the problem. There are many, many parenting styles that are effective for most kids. In fact, some researchers even use the term “good enough parenting” to refer to the phenomenon that most kids will be fine regardless of what you do as a parent. But we also have extensive research suggesting that in some cases, such as when a child has a specific disorder, some parenting behaviors are more helpful than others. In addition, the most effective treatments for some conditions require that parents implement specific discipline plans that may be very different from what comes naturally to some parents. So we may ask you to change how things work at home, but not because we are judging your practices or skills, but because we need you to help us implement a treatment that may involve doing things differently. It is really not any different than if your child had a food allergy and the pediatrician recommended that you change your cooking. You were not doing it wrong. You did not cause the problem. But you can help your child by making the changes that need to be made.

In sum, I want parents to know that clinicians want first and foremost to help your child, not to find someone to blame for your child’s problems. We ask you to be involved because that is the most effective way to help your child improve. We need you to be our allies because without your help and support there is often little we can do.

Nestor L. Lopez-Duran Ph.D. is a child clinical psychologist and researcher currently working as an Assistant Professor at the University of Michigan. Follow him on twitter at @nestorlld

I Need a Nap!

By Anita M. Schimizzi, Ph.D.

Have you had one of those days when there just wasn’t a good time to put your toddler down for the blessed afternoon nap?  Did his behavior and emotions look any different than they do after having a nap?  Take a moment to think about how you feel and react when you are sleep-deprived.  It gets harder to think clearly and to be in a good mood.  It’s pretty easy to feel irritable, though, right?  It’s probably not a surprise to you that toddlers would have a similar response to not getting enough sleep.  That’s exactly what the study below found, too.

While sleep studies typically focus on adults, a study in the Journal of Sleep Research by Berger and colleagues looked at 30-36 month olds.  They studied ten healthy children with no assessed sleep problems and looked at the impact of missing one nap.  Parents kept a strict sleep schedule for the toddlers for five days, at the end of which they either allowed or did not allow the daily nap.  They then repeated the same strict sleep schedule for five days and did the opposite nap arrangement (i.e., nap or no nap).

At the end of each five day period, the toddlers were observed in an emotion-related activity where they looked at pictures that typically elicited positive (e.g., baby), negative (e.g., shark), or neutral (e.g., dustpan) emotions.  They then participated in two problem-solving tasks (i.e., puzzles) with a familiar examiner, one of which was solvable and one of which was unsolvable.  These tasks took place about an hour after their typical post-nap wake-up time.

The researchers looked at displays of positive and negative emotions, as well as confusion.  Confusion, they stated, is a “knowledge emotion” that happens during times when there is low comprehension and high novelty and it can drive people to engage in a task and look for solutions. 

Just as they had guessed, the researchers found that skipping just one nap had a significant impact on the toddlers.  When they missed a nap they showed less confusion, or cognitive engagement, and more negative emotions when looking at neutral stimuli.  Missing a nap was also related to more negative displays of emotion in response to negative stimuli. 

And how about those puzzles?  After missing a nap, there was a significant decrease in positive emotions (less joy and pride) during the solvable puzzle and a significant increase in negative emotions (anxiety and worry) and decrease in confusion during the unsolvable puzzle in comparison to when they had a nap.   In other words, what may seem like not a big deal (i.e., missing one nap) looks like it led to less joyful, more anxious toddlers that couldn’t think straight enough to know when something was amiss.

The puzzle tasks are particularly interesting, as the researchers point out, for their similarity to tasks that children who attend preschool/school may encounter.  One of the first questions that I have for parents that have concerns about their child’s school performance, including the ability to stay focused, complete tasks, and regulate emotions, is how the child’s sleep is.  Not enough of it can certainly spell disaster for school performance. 

So the bottom line is pretty clear here.  Toddlers need their naps and a good night’s sleep.  And as they grow older, it is safe to say that your child will continue to need a good night’s sleep on a regular basis.  While this may sound simple, it is not always easy.  Good sleep is not a given, but doing certain things can increase the likelihood of it.  A good place to start for any child is with an established, positive bedtime routine.  For suggestions on getting started, please see Nestor’s previous post on the topic.  In the meantime, know that your child’s naptime and regular bedtime are just as important for parents as they are for the child.  We all need and deserve a break, some time to unwind, and to take care of ourselves.  Thanks for reading.  -Anita

Source:  Berger RH, Miller AL, Seifer R, Cares SR, & Lebourgeois MK (2011). Acute sleep restriction effects on emotion responses in 30- to 36-month-old children. Journal of sleep research PMID: 21988087

It Wasn’t Me: How to Handle Your Child’s Dishonesty

By Anita M. Schimizzi, Ph.D.

Awhile back, I posted about some research done on lying in children.  A very brief explanation of the study was that kids lied more often and more effectively when punishment was on the line.  Because so many children go through a lying phase, or more than a phase, I am writing this post to talk about ways to consider and deal with dishonesty.

Let’s first think about why lying gets under our skin so terribly.  Well, as parents we know that honesty is critical to healthy relationships, to having integrity, and to resolving problems.  Dishonesty can land you in a heap of interpersonal, academic, legal, and/or professional trouble both in the present and in the future and nobody wants that for their kids.

Now let’s look at our goals in confronting our child’s dishonesty.  First, we want to know the truth and we want for our kids to be able to readily share it.  Second, we want for our children to be able to make amends when their behavior affects somebody else, not skirt around the truth and try to get out of taking responsibility for it.  Third, we want for our children to be able to learn from their mistakes.  If they cannot be honest about those mistakes, then the learning is also lost.  You can probably add a lot of other goals to this list.  For this post, I’ll focus on the three above.

Okay, so how can we approach lying while keeping those three goals in mind?  Let’s start with the first goal: obtaining the truth.  This one simply takes a good dose of common sense.  If our kids fear us, fear being punished, fear the lecture, etc., then they will be less likely to come clean.  In Parenting with Love & Logic, the authors talk about the mistake parents make by stating that the child will be better off for telling the truth and then promptly punishing the child once the truth is told (p. 198-199).  Lesson learned: do not tell the truth.  Instead, parents can invite the child to tell the truth and rather than going bananas about whatever that truth is, they can instead thank the child for telling the truth, acknowledge that it was probably difficult to tell it, and then move on to the second goal: making amends.

Now I’ll get to amends in a moment, but I wanted to stay on goal one for a moment because there are likely going to be times that your child simply presses on with a lie.  Oftentimes, this happens because your child has been placed in a situation where he may feel compelled to lie, something Ginott referred to as “provoked lying” (p. 65-71).  Here are some things to consider: accusatory tones, statements, and/or questions will likely result in the lie being defended.  The why’s, how could you’s, and what were you thinking’s can pretty much assure us that our children would rather we didn’t know the truth.  

And one more thing to consider here: if you know the truth please don’t pretend that you don’t.  It is more productive for everyone if you simply state the truth and then move on to the second goal of making amends.  For example, your child comes to you with finger paint on her shirt and you say, “How did that finger paint get on your shirt?!”  Is she likely to respond in the same way as she would had you said matter-of-factly, “You got finger paint on your shirt.  What are you going to do about that?”  You get the idea.

 Now on to making amends.  Here is an opportunity for children to take responsibility for their behavior and it can be done in a way that puts the onus on the child for making a situation right.  How many of us have said these words to our child, “Now say you’re sorry”?  And then what do we usually get?  The empty apology, the humiliated apology, the resentment-filled apology, or some other type of sorry that just does not help in the character-building realm.  Here is another way to approach the situation: “Okay, so you broke the picture frame when you were throwing the ball in the house.  You were probably pretty worried about what I would do when I found out.  Well, how can you make this situation better?”  Having the child come up with and execute a plan can oftentimes yield surprising results.  And if the child struggles to come up with a plan, then you can make a simple offer.  “Let me know if you would like some help coming up with ideas.”  This approach allows your child to remain in the driver’s seat (because we do ultimately want them to be the ones to take responsibility) while also having a wise resource to tap: you.

Putting together goal one and goal two, we have met goal three: learning (and learning the messages that we really want them to learn).  We have allowed our child the opportunity to learn that telling the truth is beneficial and that mistakes can be made and remedied.  True, our behaviors may have consequences that cannot be undone, but at least we will be putting our child on the path of doing everything that he can think of to make things better.

One last thing: when you have a moment to connect with your child after the lying dust has settled it can be a good idea to have a heart-to-heart.  This is a good time to again commend your child for telling the truth and for talking about why honesty is important as well as some of the reasons that people lie.  This talk can be a way to help your child understand himself a little more as well as not feel that something is inherently wrong with him.  As always, this talk does not mean lecture.  It means having a talk something like this:

“I want to tell you again how proud I am that you told me the truth about losing my watch.  I know that I can go pretty bonkers when you lose my things and I can definitely freak out when I find out that you have not been honest with me.  That took some serious courage! 

“As someone that loves you very much, I need to say something to you about telling the truth.  I know how important it is to be honest with people so they can trust you and help you when you need it.  I get why it’s hard sometimes to tell me what really happened.  There’s the bonkers factor, for one, and lots of kids have that same fear about their parents.  They also sometimes feel really embarrassed or upset and don’t think that they can make up for what they did so they don’t want anyone to find out.  I promise that I will do my best to not lose it when you tell me about something not so great that you did and I really hope that you’ll feel more okay about telling me about what’s going on.”

Thanks for reading!  -Anita

Sources:

Cline, F. & Fay, J. (2006). Parenting with love & logic: Teaching children responsibility (updated and expanded ed.). Colorado Springs, CO: Pinon Press.

Ginott, H.G. (2003). Between parent and child: The bestselling classic that revolutionized parent-child communication (revised and updated ed.). New York: Three Rivers Press.

ADHD Outcomes: Being Rejected Can Have a Bigger Impact than Having Friends

By Anita M. Schimizzi, Ph.D.

As with any childhood disorder, we want to know what can protect the child from long-term negative outcomes.  When it comes to ADHD, studies demonstrate all sorts of long-term problems that we would rather prevent, such as delinquency, depression, and anxiety. 

As I mentioned in a recent editorial, data from the Multimodal Treatment Study of ADHD (MTA) revealed some surprising results about long-term outcomes for children with ADHD.  Among the results include a finding that what we typically do to treat ADHD (medication and/or psychosocial treatment) does not significantly improve peer problems.  And long-term peer difficulties can lead to a host of externalizing and internalizing problems that can last into the adult years.

A recent study published in the Journal of Abnormal Child Psychology looked at two different areas of peer relationships in children with ADHD: peer rejection and friendship.  The authors predicted that children with ADHD that were rejected by peers and did not have friends would suffer poorer outcomes in adolescence.  They further predicted that having friends would help lessen the impact of peer rejection and thereby lead to better outcomes.  Their results revealed a surprising finding: friendships did not have the protective impact that they thought they would find.  Peer rejection was the big dog in negative outcomes, period.

Mrug and colleagues used MTA data to look at peer rejection and friendship in about 300 children with ADHD that were in 1st to 4th grade and received treatment for 14 months.  They then studied follow-up data 24 months and six and eight years later.  They took a look at things like ADHD symptoms, delinquency, alcohol use, cigarette smoking, marijuana use, depression, anxiety, and global impairment (defined as impairment across emotional, behavioral, interpersonal and task-related functioning).

The findings revealed that rejected youth were more likely to have higher rates of cigarette smoking, delinquency, anxiety and global impairment at the six-year follow-up and higher rates of global impairment at eight years.  These findings occurred even if the child had a reciprocal friend at the 24-month follow-up.  An interesting tidbit, at the six-year mark the kids with at least one friend were more likely to smoke cigarettes, which the authors suggest may be due to a tendency to be drawn to other rejected youth that are more likely to engage in antisocial behavior.  All of these findings occurred even while controlling for a bunch of other factors, such as ADHD symptoms.

The researchers discuss a variety of reasons that may have led to these outcomes.  One, children who are rejected lose out on important social interactions regardless of whether they have learned new social skills in treatment.  Without the opportunity to practice them in real-world situations, the child is left right where he started in the social arena.  Two, childhood friendships can shift quickly and a child that had a friend at the 24-month data collection may have not had that friend or any others for long enough to act as a buffer for peer rejection.   Three, peer rejection tends to be long-lasting and experiencing it over the long haul can lead to a sort of cyclical effect where rejected kids withdraw and/or act out in order to cope with the inner turmoil that being rejected can cause, which then leads to more rejection.

I understand that this study paints a pretty bleak picture for long-term ADHD outcomes, but the authors also offer some sound recommendations. 

  1. Keep teaching all of those important social skills and make sure to couple the teaching with real-world experiences where they can be practiced.  (Role plays can only take you so far.)
  2. School is a big part of the child’s world, but not the whole world.  Find social opportunities outside of school where children can make friends.
  3. Monitor kids and teens for the negative outcomes mentioned earlier (e.g., depression, anxiety, delinquency) and intervene early and meaningfully.

I’ve stated it before and I’ll state it again.  Open the doors of communication so a child that is rejected by peers can at least find acceptance and understanding with an adult.  It matters. 

Thanks for reading.  -Anita

Source:  Mrug, S., Molina, B., Hoza, B., Gerdes, A., Hinshaw, S., Hechtman, L., & Arnold, L. (2012). Peer Rejection and Friendships in Children with Attention-Deficit/Hyperactivity Disorder: Contributions to Long-Term Outcomes Journal of Abnormal Child Psychology DOI: 10.1007/s10802-012-9610-2

Special Editorial: Shooting Holes in the Argument for Ritalin

By Anita M. Schimizzi, Ph.D.

I became intrigued by an article that I read a few weeks ago in the NY Times and I keep finding myself coming back to it as I work with parents.  The topic?  Medication may not be as magical in treating ADHD as we had all hoped.

Now before I go any further, let me make clear that I am not a medical doctor and I am in no way trying to urge parents to discontinue their child’s ADHD medication.  I am, however, suggesting that parents continue to inform themselves of research findings in this area so they can discuss new information with their child’s treating physician and make informed choices as a result.

Dr. Sroufe, the author of the article and professor emeritus at the University of Minnesota’s Institute of Child Development, argues that the research world has a pattern of focusing on short-term effects of ADHD medication and fails to pay enough attention to long-term effects. 

It has been well-established that medications like Ritalin and Adderall can improve concentration and focus in individuals with ADHD.  These short-term effects can render a child once known for climbing the classroom walls able to sit and focus on reading.  Score one for medication!  (By the way, Dr. Sroufe states that these effects ring true for everyone and not just those with ADHD.) 

Dr. Sroufe goes on to look at the effects of long-term use of stimulant medication, and these don’t sound as fabulous.  He tells us that the positive effects lessen over time as people develop a tolerance to the drugs.  He also argues that the upsurge in behavior problems that parents report when they take their child off stimulant medication is actually due to withdrawal effects in a body that has become accustomed to the drug.  

Here’s the juicy part.  Dr. Sroufe reports that no studies have been able to support long-term benefits of using ADHD medication in the areas of behavior, academic performance, or relationships with peers.  “What?!” you may ask.  In fact, a long-term, well-conducted study that he cites from 2009 looked at a large group of children (almost 600) with attention problems that were placed into one of four groups: medication alone, medication + cognitive-behavioral therapy (CBT), CBT alone, or no treatment.  While initial results tooted medication’s horn, the results diminished over time to the extent that by eight years there were no detectable benefits to medication use in the areas of behavior and academics.  “Double what?!” you may now ask.

Argument is also made for a profound environmental component to the development of ADHD, effects that Dr. Sroufe says the research community has not addressed because the focus has been placed on brain and biological research.  And, Dr. Sroufe states, medication is no cure for environmental causes of ADHD symptoms.  For example, exposure to trauma can change the way our brains operate and the way we think, feel, and behave.  In fact, many trauma-related symptoms look a whole lot like what we see in ADHD.  A psychostimulant may help the traumatized child focus better at school, but does it address the trauma? 

In my own work with children with ADHD and their parents, I find that the most work gets done when there is a meaningful shift made at home and at school.  More structure, more predictability, more skills to help regulate emotions, plenty of fresh air and active play, changes meant to soothe and to ease anxiety and distress, improve adult-child communication and increase self-care in academic and social settings.  I could go on and on here.  My point is that there really are an astounding number of ways to change the experiences of children with ADHD.  Yes, medication may help and it sure is quick.  Over the long-term, we may need to be considering a whole lot more than that, though.

Thanks for reading.  –Anita

Source: Sroufe, L.A. (2012 January 28). Ritalin Gone Wrong. The New York Times.  Retrieved from www.nytimes.com

My pediatrician wants my toddler to be in therapy!

By Nestor Lopez-Duran PhD

The American Academy of Pediatrics recommended a few years ago that all young children, including infants, be screened for possible delays in their social and emotional development. Traditionally pediatricians have been concerned primarily with the physical development of children. However, as we became more aware of the importance of kids social functioning for later development, pediatricians began to pay closer attention to childrens behaviors and emotional functioning. In fact, many pediatricians are now conducting screenings of all children to flag kids who appear to have behavior problems or have delays in their social or emotional functioning. When the evaluation suggests that a kid is at-risk due to the presence of some of these concerns, pediatricians usually recommend that the child receive intervention, such a seeing a child therapist who provides services for young children. In some cases the therapist works directly at the pediatricians office but in many cases the child is referred to someone in the community.

What is a parent to do?

When presented with this recommendation, many parents agree and seek intervention for their kids, while many others decline the recommendation, either because they believe it is not necessary or that the intervention would not do anything.

However, the evidence that these interventions work in improving social and emotional functioning continues to increase.

For example, this month the journal of the American Academy of Pediatrics published a study that examined 3,169 children (ages 6 months to 3 years) who were screened at a pediatricians office. Of these kids, about 711 or 22% were considered at-risk in that they showed signs of significant delays in their social or emotional functioning or had behavior problems, as reported by their parents in a screening questionnaires. Slightly more boys (25%) than girls (19%) were considered at-risk. These children were then offered the option to participate in an early intervention program that included either more monitoring, some intervention at the pediatricians office, or a referral to outside services in more severe cases.

285 parents declined the offer to participate in the intervention and 426 parents accepted the intervention. The authors then examined a group of kids who received a re-screening during a follow up visit (after the intervention). Specifically 170 children had this second evaluation. Of these, 67 (40%) came from the group who had declined the recommendation for intervention while the rest came from the group that accepted the intervention. This allowed the researchers to compare the kids who had the interventions with those who declined the intervention.

Did the intervention work?

About 56% of the kids who received the intervention showed a significant improvement in their social and emotional functioning. However, declining the intervention was associated with a 75% reduction in the probability that the child would show significant improvement during the second evaluation. The only exception was for kids with autism-style developmental delays who were referred to outside specialists and who unfortunately did not show improvement during the second evaluation.

Does this mean that the intervention worked? Most likely. The results clearly showed that the kids of parents who accepted the intervention were more likely to improve than the kids of parents who declined the intervention, which suggests that the intervention was effective for many of these kids. However, there are other possible explanations. For example, it is possible that families who accepted the intervention were more concerned about their kids and thus more likely to make other efforts to address these delays, such as making changes at home, seeking resources, etc, which may have resulted in the improvements. In this case, maybe it was not be the intervention, but the actions of the parents who agreed to the intervention, that resulted in improvements.

So should you accept the pediatricians recommendation for intervention? I would say YES. The evidence for the effectiveness of these early interventions is growing and I am yet to see evidence for any possible negative consequences that may come from receiving these early interventions.

Cheers, Nestor.

The reference:
Briggs, R., Stettler, E., Silver, E., Schrag, R., Nayak, M., Chinitz, S., & Racine, A. (2012). Social-Emotional Screening for Infants and Toddlers in Primary Care PEDIATRICS, 129 (2) DOI: 10.1542/peds.2010-2211