Defiance in a Young Child Needn’t Be Tolerated (usually)

An important study was published a couple of months ago in the Journal of the American Academy of Child and Adolescent Psychiatry titled “Psychosocial treatment efficacy for disruptive behavior problems in very young children: A Meta-analytic study.” The first author is Boston University professor Dr. Jonathan Comer. This study of studies examined 36 studies investigating 3,042 children. The high points from this study support the headline for this entry.

Backdrop for the study

The authors first reviewed some key findings in the research literature:

• About 10% of preschoolers meet criteria for a disruptive behavior disorder. These conditions exist across cultures and are associated with debilitating outcomes (e.g., profound family disruption, continued psychopathology).

• The rates of psychotropic medication treatments for preschoolers has experienced between a two and five fold increase despite the fact that “…controlled evaluations of the efficacy of antipsychotic treatment for early child disruptive behavior problems have not been conducted…(and) potential adverse effects of antipsychotic treatment in youth, including metabolic, endocrine, and cerebrovascular risks, have been well documented.”

• While only a minority of children with disruptive behavior problems have ever gotten evidence-based treatment, there is evidence of a decreasing trend of kids getting needed mental health care.

Results

When considering if interventions work, researchers calculate an effect size. A “0” score means no effect; .2 means a small benefit; .5 is a moderate benefit and .8 represents a large benefit (what one well known statistician described as “whopping”).

• The average effect size was .8! Remember, this is across 36 studies and more than 3K kids.

∫• The largest effect sizes were found for treatments that took a behavioral approach (see the commentary section below).

• There is evidence that many treatments offered to youth with disruptive behavior problems are not the ones with the most evidence supporting their use; moreover, when these treatments are compared to evidence-based behavioral treatments there is a large difference in favor of the behavioral treatments. As the authors note “…widely used approaches rarely show support.”

• “Treatment effects were consistent across samples of varying compositions of racial/ethnic minorities.”

• “These findings provide robust quantitative support for consensus guidelines suggesting that psychosocial treatments alone should constitute first line treatment for early disruptive behavior problems. Against a backdrop of reduced reliance on psychosocial treatments in this age range, and increased reliance on pharmacological treatments in the absence of controlled safety and efficacy evaluations, the present findings also underscore the urgency of improving dissemination efforts for supported psychosocial treatment options, and removing systematic barriers to psychosocial care for affected youth.”

• “Roughly 50% of U.S. counties have no psychologist, psychiatrist or social worker.”

Comment

Readers of this blog will note how much this study is consistent with a primary point I’ve been trying to make (and quoting from my own previous entry):

“Psychological problems are akin to medical problems in so many ways: they are nearly universal by the time a kid reaches adulthood (about 90%), most of the time they are treatable in a short period of time, they are easier to treat the earlier they are caught and, if they are left unchecked, can cause very stressful and costly consequences. However, unlike medical problems, only about 20% of youth who need evidence-based mental health care get it.”

This is profound social injustice and it needs to stop!

What can you do to help?

• Ask your pediatrician if s/he screens all children for mental health problems in her/his practice on well visits. If not, ask him or her to reconsider. If s/he says that s/he doesn’t screen because s/he would have no one to refer such children to, make a counterpoint and a suggestion. The counterpoint: parents deserve to know if their child could benefit from a mental health evaluation. So, even if no help can be found, the problem has been upgraded. The suggestion: contact your state’s psychological association and ask if they can help to identify a provider to whom your pediatrician may refer; it is highly likely that that they will be passionate in their efforts to assist. Should you convince your pediatrician to grow in this way, a quickly administered pediatric mental health screening tool is available in the public domain (i.e., it’s free): Pediatric Symptom Checklist.

• If your child’s defiant or disruptive behavior is causing anyone distress, get him or her help for it today. Besides tapping your state’s psychological association, you may also try here .

• Ask the mental health professional you interview at least two questions:

√ “In what types of problems do you specialize?” (This is a better question than “do you specialize in working with children?”) If you hear kids listed, that’s good. If not, ask if s/he knows of someone who does. Of course you may live in a community where this person is your only choice. So, you can ask if s/he has had success treating this problem.

√ Once you identify a viable clinician, ask “You obviously can’t know if my child has Oppositional Defiant Disorder at this point, but what is your treatment approach when you have diagnosed a child with Oppositional Defiant Disorder(ODD) and that’s the only problem?” There are synonymous terms for a good answer: “behavior modification,” “parent training,” (an unfortunate term in my view but it’s used), “behaviorally oriented family therapy,” and “behavioral treatment.” The clinician might also name some specific treatment manuals/approaches such as “Parent-Child Interaction Therapy,” “Incredible Years,” “Helping the Noncompliant Child,” “The Triple P-Positive Parenting Program,” and “The Defiant Child Program.” I would be very concerned if the first line of approach were a different one, including the use of medication treatment.

Just to give you an idea of what you might be in for, when I have a child who has ODD, and that’s the only problem, the treatment phase of the work (i.e., not including the evaluation phase), takes 8 sessions. In my own practice this cures the problem over 90% of the time. And, the two most common reasons I’ve found it doesn’t work are (1) the parent(s) don’t apply the techniques, usually because of personal pain and limitations or (2) there was another or different problem interacting with the ODD (e.g, the child really was suffering from an emerging case of bipolar disorder, the child was privately sniffing glue on a regular basis, a parent was substance dependent but tried to hide that). If a child truly has just ODD, and the parent does the techniques, it works.

The truth I/m reviewing here still seems to be too much of a secret, at least from most parents, teachers and pediatricians I’ve known. This leaves kids, parents and families suffering needlessly. As Jerry Garcia once noted: :Somebody has to do something, and it’s just incredibly pathetic that it has to be us.”

In closing let me share that you can also find multiple behavioral strategies in my parenting book as well as suggestions for identifying, and affording, quality mental health care.

How do I get my kid to sleep in his or her own bed?!

First I should state that co-sleeping, or kids sleeping in the same bed as their parents, is a culture bound phenomenon that is inherently neither healthy or dysfunctional. So, if you’re from a culture where this is common, and none of the caveats I describe below are in play, no worries. However, there are instances when co-sleeping is symptomatic of an underlying problem. In my experience, the most common of these are marital disturbance, adult loneliness, anxiety–in the child and/or the parent(s)–or some combination of the three. The purpose of this post is to suggest strategies for dealing with situations when you wish for your child to sleep in his/her own room but s/he is freaked out about that (the other problems could be addressed in counseling; you may also find articles pertaining to those topics within this blog site).

Avoidance is rarely an effective strategy for coping with fears that your child has regarding developmentally appropriate activities or situations. As none of we engaged parents are happier than our least happy child, it’s natural for us to support avoiding those (developmentally appropriate activities or situations) that distress our child. But, avoidance is a jealous strategy; the more it is used the more it pulls to be used. Plus, avoidance doesn’t deal with the underlying problem. Keeping in mind that you may need professional and tailored consultation, here are some strategies to try on your own (some of these are merely strategies for promoting sleep hygiene).

• Set up an incentive program for sleeping alone. If your child is younger, or the problem is a mild one, a star chart may suffice (i.e., each successful night earns a star on a chart). Make it so that that your child earns something s/he desires after so many stars are on the chart. If your child is older, or the problem is more significant, it may be more effective to establish a daily incentive program (i.e., sleeping alone earns the privilege of watching TV the next day). There are multiple possible permutations of this that I review in Chapter Five of my parenting book. However, the bottom line idea is to make it in your child’s best interest, as s/he perceives such, to sleep alone.

• If your child is showing a lot of distress about this, you could use the technique of shaping. With your incentive program in place, let the first phase be a reward for something that is a small step forward from where you are at now (e.g., you lay with your child helping her/him to fall asleep in her/his bed, then leave, for a week; then progress to being in a chair in her room as s/he sleeps; then you are in the hallway, etc.).

• Install a nightlight if that comforts your child.

• Allow your child to fall asleep to soothing music or to an audio book of familiar material (you don’t want him/her trying to stay up to hear the next development in the plot line); just make sure it shuts off after a designated time. Alternatively, you could read your child a book. (You could also use shaping for both of these strategies).

• Your child may find a lavender aroma in the room to be soothing.

• A bath or shower before bed can be relaxing and prepare your child for sleep.

• Try to keep your child from consuming caffeinated beverages in the afternoon and evening. A balanced diet is also something that can make a positive contribution to most behavioral problems that kids display.

• Try to ritualize the hour before bedtime (i.e., usually the same procedures followed in the same order).

• Having had at least an hour a day of physical activity (i.e., sweating and breathing hard) can facilitate a good night’s sleep.

• Try to avoid intellectually demanding or exciting activities the hour before bedtime.

If these strategies don’t resolve the problem in a short period of time, and in consultation with your child’s pediatrician, it would usually be advisable to seek out the services of a qualified mental health professional. Click here for a referral.

Seven Myths about ADHD

There are three kinds of ADHD: a child has significant concentration problems but is not significantly hyperactive (ADHD, Predominantly Inattentive Type), vice versa (ADHD, Predominantly Hyperactive/Impulsive Type) and both (ADHD, Combined Type). About 75% of kids with ADHD have ADHD, Combined Type while the large majority of the rest have the inattentive type.  Below are seven common myths about ADHD. Following those I list core guidelines for evaluation and treatment.

Myth: ADHD is not a real disorder. This is akin to saying that diabetes isn’t a real disorder or asthma isn’t a real disorder. To my knowledge, no reputable scientist or professional organization subscribes to this position. About four to six percent of youth suffer from this biological disorder. Studies of the brain indicate that these youth show poor functioning in the parts of the brain responsible for impulse control and sustained attention to boring tasks.

Myth: ADHD, Combined Type can be caused by poor parenting or being raised in adverse circumstances. While significant attentional problems can be caused by an assortment of problems (e.g., trauma, depression, anxiety), the degree of sustained hyperactivity required to diagnose ADHD is usually not caused by environmental stresses (I say “generally” as even a broken clock is right twice a day, but I’ve never seen a case like this or read about a case like this). ADHD is a biological disorder caused by either genetic transmission (i.e., it runs in the family) or significant insult to the brain (e.g., mom smoking cigarettes during pregnancy).

Myth: ADHD is caused by what a child ingests. Certainly what a child eats could affect just about any condition. Moreover, correcting an unbalanced diet, or eliminating allergens or toxins, would be part of a helpful treatment plan for just about any disorder. However, nothing that youth put in their mouths has been established as a primary cause of ADHD.

Myth: A positive response to medication treatment proves that a child has ADHD. Many children will experience improved concentration on low doses of stimulant medication, whether they have ADHD or not. Our culture is replete with examples of people, who do not have ADHD, using stimulants to accomplish some desired effect (e.g., pilots during the Korean war took dexedrine in order to be able to focus better during long bombing runs).

Myth: Youth suffering from ADHD, who are treated with stimulant medication, are at higher risk to develop substance abuse problems as a function of taking the medication. Actually, the exact opposite seems to be more likely: having ADHD, and not receiving effective treatment for it, seems to double to triple the odds of substance abuse in adolescence. Moreover, the number one cause of death and serious injury among teens and young adults are accidents and youth with untreated ADHD are at a much higher risk to experience those.

Myth: ADHD can be treated effectively by enhancing a child’s motivation. As I wear corrective lenses I use the following analogy with my clients: “if I told people I wasn’t willing to wear glasses but was interested in other treatments, they might try to make the light brighter for me, cheer me on, or suggest that I get closer to things I’m reading. However, nothing is going to help nearly as quickly and effectively as my just putting on my glasses. And, my not putting on my glasses could eventually make me think that my problem with reading is a problem with my effort. And, if I go there in my thinking, I’m probably going to make myself very, very upset and sick.”

Myth: People outgrow their ADHD. It is true that a small percentage of youth with ADHD reach the point that their symptoms are not significantly impairing in adulthood (these are usually the milder cases with multiple protective factors at play). So, in that case this myth has some truth to it.  However, testing on those individuals will usually document the lingering presence of the disorder; it’s just not causing impairment anymore, secondary to the protective factors and brain maturation.

Evaluation guidelines

Keep in mind that in order to qualify for an ADHD diagnosis a child must show unusual and impairing inattention (usually to tasks that bore him or her) or hyperactivity/impulsivity at both school and home for a period of at least six months. The common standard for “unusual” is the 93^rd percentile (i.e, having the symptom worse than 92% of the youth’s peer group). Moreover, the onset of the first impairing symptom should be before the age of seven and no other viable theory can explain the symptoms that are being demonstrated (i.e., ADHD is a diagnosis by exclusion).

The methodology for determining the presence of the disorder is determined by a cost/benefit analysis. As I consider the myriad of factors at play, I’d suggest the following be the default standard for ADHD evaluations: a family interview, a child/teen interview, the completion of parent, teacher and child–if the child’s reading level is sufficient–behavior rating scales, a comprehensive review of school records and a review of any other relevant records. (The behavior rating scales should include broad-band measures that endeavor to assess for a spectrum of disorders as well as narrow-band measures that try to rule out ADHD specifically.) If one of these elements is missing, I’d worry about the increased odds of an inaccurate finding. If these sources of information leave the diagnosis in doubt, I’d suggest adding a computer based continuous performance test (e.g., the Test of the Variables of Attention). (There is a reasonable argument to be made for including a continuous performance test  in every evaluation for ADHD, so I wouldn’t differ with those clinicians who do.) In instances where a learning disability is suspected, additional cognitive and achievement testing would usually be in order.

Treatment guidelines

The large majority of children with ADHD have at least one other co-occurring condition (e.g., Oppositional Defiant Disorder). The configuration of the co-occurring problems would normally have a substantive impact on an evidence-based treatment plan. However, for ADHD itself, medication is the primary treatment of choice (i.e., the scientific evidence supporting its efficacy is overwhelming). It is also very common to need behavioral treatments, at both school and at home, to augment the primary treatment. As a primary treatment, the following would typically not be indicated: dietary manipulations, chiropractic treatments, play therapy, art therapy, music therapy or basically any interventions that does not have a sound scientific foundation to support its usage as a first line intervention.

For more science-based information on ADHD, consider any of the following websites designed for lay people:

www.chadd.org, www.add.org or www.help4adhd.org

Also, on 12/4/12, from 1 to 2 PM EST, there will be a Twitter chat on ADHD. (I will be one of the panelists.) This will be hosted by Dr. Richard Besser, Chief Medical Editor for ABC news. Just go to #abcDrBchat at that time.

What Can I Do If My Kid Freaks Out About Routine Dental or Pediatric Appointments?

Trips to the pediatrician and dentist are commonly feared by kids. This fear ranges from mild discomfort to debilitating anxiety. Let me offer six strategies to help:

#1: Avoid unhelpful reassurances. As I’ve written in other entries, a reassurance is a cue that danger is approaching. While parents don’t intend for their reassurance to be heard this way, kids often hear “okay, time to start freaking out.” Think about this for a second. If you were meeting with me in my office and I told you not to be worried about the ceiling collapsing on our heads, you, of course, would start to wonder about the security of my ceiling. Wait until your child shows distress before reassuring, and then keep them brief and proportionate. If they don’t work, as they often don’t, try the other strategies listed below.

#2: Prepare. Confronting fears is like swimming in a cold lake. At the end of the day, it is sustained exposure to the feared object that calms a person down (i.e., one gets used to it).  Some people know this intuitively and are inclined to cannon ball in. But, many prefer to go in slowly, getting used to the water as they go. This is what preparing your child for the appointment is akin to. If you go to Amazon and type in search terms like “kid, dentist” under books, you’ll get a myriad of choices that will allow you to discuss what the medical appointment might be like. You can also get books that generally help with anxiety. My favorite along those lines is the Scaredy Squirrel series by Melanie Watt. (I have the entire series in my office, including a Scaredy Squirrel puppet.) A related technique is to visit the office on a day when your child doesn’t have an appointment, spending time in the waiting area while doing the next strategy.

#3: Relax your child. A relaxed body and anxiety are like oil and water: they can’t mix. So, you can try to train your child to flush anxiety out of his or her body. The three elements to this are breath, muscles and mind. I tend to focus on the first two with kids. I ask kids to pretend that their lungs are in their lower belly, instead of their chest, and to breath deeply, but comfortably, in and out from there. I also ask them to try to make all of their muscles like a cooked, rather than an uncooked, piece of pasta as I walk them through their muscle groups in a soothing voice. There are also resources you can acquire to facilitate your child’s training along these lines. One of my favorites is the relaxation CD that my friend Dr. Mary Alvord and her colleagues have created. Also, and if the cost benefit ration seems worth it, you can acquire a small, portable biofeedback device that can help your child get into a relaxed state; I like the emWave2 for this purpose.

#4: Distract. Once in the office, try to distract your child with something interesting. I was on the sidelines of a baseball game recently when a young girl, who was barefoot, stepped on a wasp. She started crying in terror and pain. I broke out a couple of magic tricks (I keep them with me) and distracted her, reducing both her pain and her anxiety (and delighting her mother). There are an endless number of ways to do this: read a story, play an electronic game, discuss the details of a fun activity coming up that weekend, and so forth. If the medical procedure your child is going to receive allows for this, distract your child during it as well; if it doesn’t, ask if he or she can listen to a portable music player that you provide.

#5: Reward. I wouldn’t do this unless you know that your child is going to struggle. But, if you’re confident that’s the case, tell your child that if he or she is brave, and doesn’t put up a fight, that you will reward him or her afterwards, specifying what the reward will be. Try to keep the reward proportionate to the level of challenge your child is experiencing. So, the reward can be as small as going to ride swings at a local park or as big as a trip to a water park. Then reward, or don’t, based upon how cooperative your child was.

#6: Get help. If these techniques fail please consider consulting with a qualified child mental health professional. Often these kinds of problems can be remedied quickly with treatments that beat having a couple of adults restrain a terrified child. To get a referral near you click here.

Seven Tips for Coping with Homework Hell

So, you’re back-to-school. If you’re lucky your progeny completes his, her or their homework without a lot of fuss. However, if your kid(s) fight you on homework, do it carelessly or otherwise leave you feeling like you’re in homework hell, here are seven tips to help.

• Tip #1: incentivize effective homework completion. First define what effective homework completion means (e.g., a certain amount of time legitimately exerted without hassling anyone). Then establish what reward your child will earn by effectively completing the homework. The more problematic the behavior the bigger the incentive and the more it should follow immediately upon homework completion. For instance, if Aiden lives for his X-box, that might be earned by completing homework effectively each night. Be careful to put this as a reward, instead of a punishment. Xbox is earned, not taken away.

• Tip #2: Consider an excessive violation of the 10-minute guideline to be a symptom. Research suggests that there is often a diminishing academic return when students spend more than 10 minutes a night on homework X their grade in school (i.e., a 5^th grader spending 50 minutes, a 7^th grader, 70, and so forth). If your child is spending much more time than this consider tips #3 and #7.

• Tip #3: Consult with your child’s teachers when homework is problematic. For instance, your child’s teacher(s) may not realize that your child is spending an excessive amount of time completing homework, especially in the middle school years and onward (i.e., teachers may not be coordinating their expectations). For example, asking your child’s teacher(s) what he/she/they believe is a reasonable amount of time to spend on homework each night can begin a productive dialogue.

• Tip #4: Don’t get your shorts in a bunch about methods if the goal is being reached. Sometimes we parents try to over control how our child does his or her homework without considering whether or not he or she might get it done well using his or her preferred method(s). Some kids like music on, or to do homework on a bed, etc. As long as the cat gets skinned, who cares.

• Tip #5: If your child isn’t being truthful about what the homework is, add a communication system from school to home. This daily communication should include a behavior grade for any behaviors under concern, the grades that were returned that day (if any), the homework for the night and any long term assignments that are due. Compliance with this system should also be incentivized. (This can be a complicated system, so see my parenting book for a step-by-step break down of the how-tos.)

• Tip #6:If you can afford this, and your child needs it, consider hiring a tutor to help with homework (not to do the homework, but to help with it). In this economy, there are many trained educators looking to do such work.

Tip #7: If your child is working at it, but floundering, consult with a child psychologist. It may be that your child has a learning disability or a psychological obstacle (unknown to you) that is at play. A skilled child psychologist can get to the bottom of things and suggest an effective remedial plan. For a referral, click here.

 

Neurotic Parental Guilt

As a child psychologist, dad and friend of many parents, I’ve noted that neurotic guilt is common among we parents. Sometimes these feelings are mere flashes while at other times they are thematic. Of course there are situations in which experiences of guilt are not neurotic as they are helpful (e.g., situations where a parent is abusing or neglecting a child and the guilt feelings motivate change). But, here I’m thinking of instances when we engage excessive self-reproach for having human limitations or for having normative human experiences. In this entry I’ll first describe some common scenarios that evoke such quilt and then suggest seven strategies for coping with it.

The first common scenario is when there is a separation at hand:

• A child leaves for college, especially if the child leaving is the first born. (Many parents report feeling shocked at how quickly this day has arrived.)

• A parent departs for an extended period of time. This commonly happens when mom or dad serves in the military, but there are many examples of it in our run-and-gun culture (e.g., as a phase of relocating to another part of the country).

• A parent is on his or her death bed.

In these and other related situations we can be swept away with thoughts that we did not get the most out of our time with our child. We can mercilessly beat ourselves up with thoughts that we should have spent more one-on-one time, done more shared activities, communicated our love more effectively or just been a better parent. A famous quote by Kahil Gibran comes to mind “Ever has it been that love knows not its own depth until the hour of separation.”

The second common scenario is after some positively anticipated event or period of time is over such as:

• A vacation is finished.

• A holiday period is concluded.

• A weekend is over. (I wonder what percentage of neurotic parent guilt happens on Sunday nights.)

In these and related scenarios I might kick myself for moments of conflict, boredom or disengagement. I so much looked forward to having a joyful or meaningful experience with my child. And, when reality almost inevitably falls short of my high expectations–what I refer to as the “Clark Griswold Syndrome”–I kick myself with self-reproach and feelings of guilt.

I believe at the root of neurotic parental guilt is the overwhelming and gut wrenching love that we have for our kids. It is so encapsulating and powerful, that it makes us lunatics much of the time. So, my fellow lunatic, let me suggest some antidotes for this neurotic guilt:

Strategy #1: Use what we psychologists call “coping thoughts.” Coping thoughts are true thoughts that provide comfort. Wearing a pair of jeans that are so tight that they hurt serves no purpose. So, sane people swap them out. This type of neurotic guilt serves no purpose, so we do well to swap it out. Here are some coping thoughts to try on for size:

√ “Everyone has moments of stupidity, impatience and frailty. There is no escaping my humanity.”

√ “I love my kid more than my life. It isn’t possible to love someone more than that.”

√ “I do (have done) all kinds of things for my kid such as….”

√ “Conflict and disengagement are woven into the fabric of human interactions. There is no being together, for any extended period of time, without them.”

√ “Life is not a fairy tale, it’s better. But, that comes with mess for everyone.”

Strategy #2: Imagine you are in the future and your child is a parent. He or she is now coming to you for help with the exact same type of guilt you are now experiencing. What advice would you offer your future child? If your like most, this can lead you to a more wise and kind stance with yourself. (This is also one way to get in touch with what I have referred to as your “wells of wisdom.”)

Strategy #3: If your child is still living with you, or lives close to you. Try hard to do at least one hour of “special time” each week. If you do this exercise consistently you are taking a mighty step towards promoting an effective relationship with your child. (Special time is different from quality time. To learn more about how to do it see Chapter One in my parenting book, or download this article that I wrote.)

Strategy #4: Write a gratitude letter for your child. Click here for a blog entry on the specifics of this method. This can be a most profound human experience. (Be careful not to expect reciprocation though. It’s wonderful if a letter comes back at you later, but no one is served if you experience resentment secondary to a frustrated expectation.)

Strategy #5: Apologize for any real mistakes that you made and, if it’s a pattern, try to both understand the underlying cause(s) and take steps to either improve or resolve the situation. Steps for improving could include such things as spiritual direction, psychotherapy, improving health habits and enhancing your self-care (i.e., parenting from the cross is rarely effective), and I speak as someone who has taken abundant advantage of each of these self-improvement measures.

Strategy #6: A more elaborate version of the coping thought strategy would be to make a list of your parenting strengths and successes. This could be a one-and-done exercise or a weekly effort. It is a list of things you have done, or do, well as a parent. It can also include evidence of good outcomes that your child experiences or has experienced.

Strategy #7: Get helpful feedback. My personal criteria for such a consultant is that (a) he or she is wise about parenting (i.e., by experience, by training or both), (b) he or she cares about me and (c) he or she is as likely to agree as to disagree with me (i.e., someone who is only going to agree with me is of little use for this service).

In closing, and to beat one of my most treasured and favorite drums, if you think you could benefit from speaking with a good child psychologist, pick up the phone!

Video Games: Good or Evil?

There are many statements floating around out there about video games that suggest they should be either vilified or, less commonly, celebrated. “Video games are purported to…

…wreck your kid’s ability to pay attention.”

…make your kid violent.”

…take care of  your kids needs for physical activity, at least if he or she uses systems like Wii or Xbox Connect.”

“…promote addictive behaviors.”

“….offer a solution to social anxiety.”

In this column I’d like to make eight suggestions about video games that will respond to these and other concerns.

#1 Limit your kids total access to sedentary electronic pleasures to two hours a day. This is the sound counsel of authoritative bodies such as the American Academy of Pediatrics. If your kid is spending more time than this he or she is likely missing out on other important activities such as physical activity, doing homework and socializing face-to-face. Actually, if you are mostly hitting your stride as a family you may find that your kids don’t have more than two hours a day free anyway.

#2 Take the ratings seriously but also realize that they can, for any given game, not be a fit for your child. (I find some parents are surprised by just how graphic and adult-themed video games marketed for kids and teens can be.). If my kid is exposed to material that he or she is not developmentally ready for, symptoms can emerge (e.g., becoming aggressive, having a difficult time sleeping).  There are also parent advisory websites you can review content in the games. Click here for one such example.

#3 Watching your kid playing acceptable video games, and commenting on his or her skill as well as how much you enjoy spending time together, can be a useful way to spend special time. (Readers of this blog, and my parenting book, know about my recommendation to spend one hour a week, with each kid, one-on-one, doing special time.)

#4 If you’ve been reading this blog and/or my book, you know that another activity commonly recommended by authoritative bodies is for each child to sweat and breathe hard for 60 minutes a day. Video game playing activity counts towards this only if your child is actually sweating and breathing hard. If he or she can’t carry on a normal conversation and sweat is changing the color of his or her shirt, you’re good. Otherwise, it doesn’t count.

#5 Many gaming systems, and their attached games, provide online access. Imagine the following scenario. You sign your kid up for a martial arts class at your local Y, a class which encourages participants to interact and get to know each other. In the class are other kids like your kid. But there is also a 44 year old divorced man who is sexually frustrated and medicating his pain with alcohol, a 25 year-old man who is struggling to control his urges to sexually assault children and a woman who medicates her severe anxiety by chain smoking marijuana. How okay would that be? Point made? For an article on some specific suggestions to promote monitoring of your child’s or teen’s online life, click here.

#6 Keep an eye on how your kids’ video gaming impacts him or her. You are the world’s leading expert on your kid. Use that expertise to gauge how a given video game is affecting him or her, if at all. For instance, I once knew a kid in elementary school who started playing a couple hours of an E rated game each week. At the same time he started becoming aggressive at recess. His parents made the connection and took steps to resolve the situation (a straight-forward banning of the game wasn’t indicated. I describe this case in my parenting book in the chapter on monitoring).

#7 Many parents ask, “should I let my kid have a video game system in his or her bedroom?” Until I see a well-controlled research study that investigates this with a sample that is large enough to allow for broad generalizations, it’s hard for me to feel strongly either way. But, my intuition, is that if you follow all the other guidelines in this blog entry, and your kid is generally doing well in life, it’s probably okay. But, I wouldn’t hook up access to television programing as there are too many ways that could be problematic (e.g., becoming too withdrawn from family life, putting it on when he or she should be sleeping). Also, keep in mind that if having a video game system in the room proves to be problematic, it doesn’t take an act of congress to undue it

#8 What are the signs that the video gaming is becoming, or has become, problematic? The easiest sign is that your child is acting like he is crack dependent and the game playing is the crack. If this is the case, see this blog entry that breaks down how to deal with this kind of scenario. Otherwise, the gaming is problematic if it is interfering with any other important developmental tasks or if it is associated with symptoms. If in doubt, I’d recommend seeking out the services of a qualified mental health professional. For a referral click here.

Ten Tips for Expecting or New Parents

So, you’ve joined, or are about to join, the parenting club. Welcome! No matter where you go in the world you will find you have sisters and brothers who are willing to extend an abundance of empathy, wisdom, encouragement and assistance. Indeed, consider this blog one such resource. In this entry I’d like to offer 10 tips for this phase of your parenting life. (I will write this as if you are in a two parent household, but these tips can be easily adapted to other situations.)

#1 Establish your boundaries with in-laws and other well intended people. Some in-laws are wise and know not to offer unsolicited advice. But, others need help in understanding that you will reach out if and when you want advice. I’d suggest each of you speak with your own birth parents about this. This needn’t be unpleasant and can be done in a lighthearted way. Then, insist on these boundaries lest you want to live with no end to unsolicited advice.

#2 Don’t put the pressure on yourself to act like you know what’s coming. It doesn’t matter how intelligent and insightful you are. There is no way to reason to how much love, exhaustion and lunacy you will feel, and that’s totally okay. So, try to be at peace with that.

#3 Try to accept that there is no way to prepare fully for the chaos. Sure, it’s totally okay to nest and set things up. But, at some point the preparation can become like a soldier ironing his trousers before going into battle. Developing a certain comfort with chaos is very helpful to your mental health. (As a related matter, it’s always interesting to watch couples trying to determine the “perfect” time to have a child, as if a tornado could be put in a box.)

#4 Make an active plan for couple time. If you are not disciplined and proactive about this your romantic relationship will take a heavy hit. For a related blog entry click here.

#5 Agree to a childcare plan. Many parents wonder if it’s better for the child for the mom to stay at home or not. Bottom line: assuming the person(s) taking care of your child do a good job, it’s best to do the thing that will make you and your partner feel most satisfied. There is no one right choice. It’s a matter of personal preference.

#6 Agree to a nighttime feeding plan. Your new baby will sleep for only a few hours at a time until he or she gains enough weight to not need feedings throughout the night. So, have a discussion about who will do what when. There are so many permutations of this that I haven’t space to list them. It’s just important to talk it out lest the person doing all or most of the work builds up resentment.

#7 Make sure to take maintain a self-care protocol. Like many parents, you may be tempted to go on a cross for your child, but this is rarely in a child’s best interest. Just like the tip above regarding couples, it takes a proactive plan to stay at your best for your new baby.

#8 You are going to make lots and lots and lots and lots of mistakes and that’s okay. I still remember trying to lullaby my eldest Morgan to sleep, at around 3 AM, with the melody from Hush Little Baby but with made up NC-17 lyrics having to do with how much I needed her to get to sleep. As long as you keep trying to do well you’re probably doing at least well enough.

#9 You’re going to overdo things as a first time parent, and that’s okay. I remember having wipe warmers for Morgan and our grandmother neighbor finding that to be very funny. (I would now find it to be funny too but it’s semi-disrespectful to show such to a first time parent.) It’s normal to overdue for the first one, so don’t let anybody mock you for that. (By the way, by the time you might have a third child you end up carrying him or her around by the ankle.)

#10 Set up a college fund. Even if you put in a few bucks a month, that’s something. The expense can be overwhelming later, so this is an area where it’s better to err on the side of over preparing.

May God bless you!

Six Tips For When Your Child Has Experienced an Injustice

We parents do everything in our power to protect our children from experiencing injustice, including lobbying school personnel, coaches, other parents and law enforcement officials. However, it is inevitable that everyone experiences injustice, from the mild to the truly dreadful and horrifying. What follows are six tips for responding to these experiences after you’ve done all that you reasonably can or should to prevent the injustice or right the wrong.

#1: Let your child experience her pain. It hurts to experience an injustice. Empathic statements can help.  “You deserved that leadership position, what happened is wrong and it makes sense that you’re in pain over it.” “Being bullied is a shaming, awful experience and I understand how hurt you feel.” “Being arrested when you’re innocent is something no one should ever have to go through. You must feel more terrible than I can even imagine.”

#2: Let your child know that everyone goes through this and sometimes it happens because a person has displayed excellence. We all want to believe that we live in a just world where all wrongs can be righted and where virtuous, hard-working people do not have bad things happen to them. We all want to live in a world where others do not respond to our gifts and successes with jealousy, envy or resentment. But, in my experience, such perspectives are right up there with Disney’s “happily ever after” concept. Just as all bodies living in the world are exposed to germs and viruses, and need to learn to respond effectively to them to survive and thrive, our psyches need to learn to respond effectively to injustice when it inevitably comes our way.

#3: Teach the wisdom of the Serenity Prayer: “God grant me the serenity
to accept the things I cannot change; courage to change the things I can;
and wisdom to know the difference.” Regardless of one’s spirituality, the wisdom behind this psychological model is sound. Indeed, it is often used in helping people to recover from addictions because it can be the antidote to many kinds of madness that facilitate self-medication.

#4: Look for the opportunity imbued within all pain. The pain must be given its due for this to work well; this is not about being in denial about the injustice, or being pollyannaish about it. However, once the pain has been given its due think of the injustice, as one poet put it, as a dragon guarding treasure. Resilient people think this way: they take the hit and expect to become better because of it. Teaching your child how to do this at a young age is a major gift. (To read more on this theme see my blog entry Failure: An Important Part of a Psychologically Healthy Childhood.)

#5: Timing is everything here, but let your child know about injustices you’ve experienced, including your thoughts about what you did in response that was effective, ineffective or some combination of both. (Of course, you’re going to want to consider what material is developmentally appropriate for your child. For a discussion that highlights similar issues see my blog post Helping Children Cope with Scary News.)

#6: Teach unilateral forgiveness. In my judgment unilateral forgiveness is the psychological equivalent of an ironman triathlon. Yes, bilateral forgiveness (when the other person has acknowledged fault and has asked for forgiveness) can be, especially when the wrong has been mighty, a marathon unto itself. But, forgiving when the other person has not asked for it, or even feels justified in the injustice they’ve perpetrated, puts a person on one of the highest psychological roads a human can traverse. This is not the same thing as denying the injustice. This is not the same thing as tolerating the injustice or not protecting oneself from future manifestations of it. It is to say that bitterness, revenge and products of their sort are like poisons that hurt the victim most of all while forgiveness promotes healing and the capacity to not become owned by the injustice. Just as the case with training for an ironman triathlon, it takes lots of time and practice–often for many years and with many stumbles along the way. And, it can’t be forced. But, it’s a journey worth any effort we can offer it, both for ourselves and for our children. (To read a great self-help book on forgiveness see Forgiveness is a Choice.)

In closing, let me suggest that you may need to take additional steps if your child has been traumatized by the injustice. For a discussion on these issues see my blog post Ten Steps to Take if Your Child is Exposed to a Traumatic Event or click here to find a psychologist in your area.

What Should I Do When My Kid Throws a Fit?

Temper tantrums in childhood are nearly as common as the flu, though no one has developed a vaccine for them. What follows are the four most common problems that I’ve found are at the root of tantrums followed by four guidelines for how to respond.

Problem #1: Your child needs more positive one-on-one time with you

Possible Fix #1: One hour a week of special time

Just as plants grow their branches around obstacles to get light, kids grow their behavior towards that which gets them attention; neither process is conscious. In run-and-gun households–and aren’t we all this way these days–it’s easy to be quietly grateful when our kids are behaving and to give them passionate attention when they screw up. Sure, this kind of attention is like eating an unwashed radish, but if you haven’t eaten in days that can be a pretty delicious food. Moreover, our relationship with our child is like any other relationship in our life: speed bumps are more likely to cause crashes when the relationship hasn’t gotten enough positive attention.

My prescription would be to spend at least one hour a week one-on-one doing nothing but paying attention to your child, expressing positive thoughts and feelings about him and proportionately complimenting anything that he is doing or saying that is praiseworthy. This technique is called special time, which is different from quality time (i.e., in quality time something else is usually getting my attention in addition to my child). My space here is too limited to describe the technique, but I’ve elaborated upon it in the first chapter of my book Working Parents, Thriving Families, and a few days ago I did interview with USA Today that describes it more.

Problem #2: Someone is experiencing a significant stress

Possible Fix #2: Try to either eliminate/reduce the stress and/or increase resources

All of us break when our stress/resources ratio tips too heavily to the stress side. Resources are enhanced when we do things to rejuvenate ourselves, child and adult alike (e.g., socializing with friends, seeing an enjoyable movie). When we break we tend to break in the direction of our vulnerabilities. Adults may drink more, yell more, withdraw from others and so forth. Kids may tantrum. So, ask yourself whether there has been a recent increase in stress in your child’s life or in the life of someone else in the family. If yes, a starting point might be to see if such can be eliminated or reduced. If not, then I would try to be patient and try to increase everyone’s care.

Possible Problem #3: Your child doesn’t feel like doing something

Possible Fix #3: Incentivize future occurrences of the something

 One of the most important tasks we parents have is to grow our child’s capacity to do things when she doesn’t feel like it. No psychological muscle better predicts success in both vocational and interpersonal pursuits. So, if my child is freaking out just because she doesn’t care for a rule or restriction that is developmentally appropriate, I would set up an incentive for future occurrences. Lets say she’s freaking out because you’ve told her to clean her room. Perhaps you might decide that, going forward, access to TV is earned each day by having cleaned the room appropriately (i.e., to spec and without freaking out). You are not taking TV away in these instances. Your child is either deciding to earn or not earn TV based on her behavior. No matter what you’re going to insist on the room being cleaned, less you create a training program for throwing fits, but whether it results in the TV being earned or not is dependent upon your child’s choices.

I have a much more detailed description of setting up a range of behavioral programs in my parenting book. You can also find additional guidelines at this blog post: Seven Tips for When Your Child Refuses to Do a Chore.

Possible Problem #4: Your child is showing the expression of a diagnosable psychological problem

Possible Fix #4: Seek our the services of a mean-lean-healing machine

 Tantrums are like fevers. You know there’s a problem but it could be many different things. Like a fever, you try treating it yourself first if it’s mild. However, if it persists, or if it’s serious (e.g., the tantrums are violent), then it’s good to do as you would do with a medical problem: seek out the services of a clinician well trained to diagnose and to treat the problem(s). To find possible candidates, click here. Here are some related blog posts:

Signs That a Kid Needs Mental Health Services

Seven Common Myths About Counseling

Affording Mental Health Care

Ok, here are some things to try at the point of the fit, keeping in mind that these may not work or be appropriate for your child.

Guideline #1: Don’t reward the bad behavior

Caving in to your child’s demands often creates a training program for the bad behavior. Your child gets the idea, often not even consciously, that throwing fits gets him his way. Moreover, I wouldn’t increase your positive attention during the fit, which leads to the next guideline.

Guideline #2: Extinguish the flame

Your attention can act as oxygen for the flame. For example, lets say your child throws herself down on the ground in a fit of anger. I would, if she won’t hurt herself and others or damage property, and if it’s possible for you given other demands on your time, leave her alone as she calms down. You might say as you leave: “What you’re doing is inappropriate. Let me know when you’re ready to clean your room.”

Guideline #3: Use timeout

Timeout can be done in ways that are not effective. But, if you’ve gotten some good counsel on how to do it, this can be a good time to use it (again with the parenting book?!…sorry, its just that there is just so much relevant information that I can’t cram in here and I don’t want to leave you hanging).

Guideline #4: Do a psychological autopsy

Once everyone is calmed down, which might be after the fit, later that day or sometime after that, I would sit down with your child and deconstruct what happened. We all lose IQ points when we’re upset. We do well to wait until everyone’s brain is fully back online before doing this work. Some of the best teaching can be delivered through questions: “What happened yesterday when I asked you to clean your room?” “What do you think about how you acted?” “What would be a good way for you to make up for what you said and did?”

If you have two adults parenting in your household it might be good for the parent who was not involved in the conflict to do this autopsy. If the transgression was slight, a heartfelt apology may be sufficient. If not, simply apologizing is not good for your child’s character development. Therefore, I would look for a proportionate reparation he could make, for his sake (e.g., using his own allowance to replace a magazine he ripped up, writing out an apology, offering to rub mom’s feet .

Dealing with this issue can be a true pain in the neck, and make one wonder what exactly are the criteria for arranging for an adoption out of the home, but it’s very important work. And, you are to be saluted for taking it on!