Category: teenagers

What to know about psychiatric residential treatment

What to know about psychiatric residential treatment

residential centerHave you been searching for psychiatric residential treatment for your child?  Do all the programs sound wonderful?  Ads include quotes from happy parents, and lovely photos and fabulous-sounding activities.  But what’s behind the ads?  Residential treatment programs are diverse, but there are important elements they should all have.  Here’s how to avoid low quality residential treatment.

Psychiatric residential treatment is serious stuff–it’s difficult to do–especially when troubled children and teens are put together in one facility.

Should you ask other parents for their opinion of a program?  In my experience with a child in psychiatric residential care, and as a former employee of one, word-of-mouth is not a reliable way to assess quality or success rate.  There are too many variables: children’s disorders are different; acuity is different; parents’ attitudes and expectations are different; length of time in the facility is different; what happens once a child returns home is different…  It’s most helpful to ask questions of intake staff and doctors or psychologists on staff.  Quality psychiatric residential care facilities have important things in common.

What to ask about the staff:

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  • What is the training and licensure of staff?  Are there therapists with MSW degrees, registered nurses, psychiatrists and psychiatric nurse practitioners, and is a medical professional available on site 24/7?
  • There should be a high staff to patient ratio, and a physically comfortable environment with lots of emotional support.
  • Do the staff seem mature to you?  Do they support each other, are they a team? There is often heavy staff turnover at residential treatment centers because the work is emotionally draining, so staff cohesion is as important as the qualities of each individual.
  • Safety is paramount.  What are the safety and security plans in the facility?  Staff must be able to safely manage anything that can go wrong with troubled kids.  They should be trained in NCI (Nonviolent Crisis Intervention), “training that focuses on prevention and offers proven strategies for safely defusing anxious, hostile, or violent behavior at the earliest possible stage.”

What to ask about programs:

  • Does the program specifically identify parent/family involvement as part of treatment?  Does it emphasize parent partnership with staff?  Ask.  Whether you live close or far from the center, even out-of-state, you should be regularly included in conversations with staff about your child’s treatment.  You should also be included in a therapy session with your child periodically; some facilities can connect with you over Skype.  Your child’s success in psychiatric care depends on their family’s direct involvement.
  • The program should coach you in specific parenting approaches that work for child’s behavioral needs.  While your child is learning new things and working on their own changes, you must know what to establish back home when they return.
  • You should be informed why your child is getting the treatment or behavioral modifications he/she is receiving.
  • Last and most important: when your child leaves, there should be a discharge meeting and a discharge plan.  What this means:  all staff who worked with your child get together with you and discuss what treatment should continue once they go home.  Medication management and therapy is identified in advance, appropriate school accommodations are discussed, changes in the home environment are discussed if needed…  You should never leave without knowing what comes next in the months following care.

Body health is brain health, and vice versa.

  • residential programsMental health treatment will include medication and therapy, but must also include positive activities and an educational program.  The whole body needs care:  exercise, social activities, therapeutic activities (art, music, gardening), healthy food, restful sleep, etc.

Is your child emotionally safe as well as physically safe?

  • You should be able to visit the unit or cottage where your child will live, see their bedroom, and see how the other children interact with staff and how staff interact with each other.

What to ask about the business itself:

  • Can you take a tour ahead of time?  Can your child or teen visit too if appropriate?
  • Are emergency services nearby (hospital, law enforcement) that can arrive quickly?
  • Does the facility have a business license in their state?  Do they have grievance procedures?  Is the center accredited as a treatment facility, and by whom?  In the U.S., the main accreditation authority for healthcare facilities is The Joint Commission.

Psychiatric residential treatment works miracles, but it doesn’t work for all children.  Some need to go into treatment more than once to benefit. Some fall apart a few weeks or months after discharge.  These are common.  What’s important is that staff observations and advice help you and your child with insight and skills for managing his or her unique symptoms, and for communicating effectively.

Good luck.

 

What was your experience when your child was in residential care?  Please share your comment so others can learn.

How to help your troubled teen after they turn 18

How to help your troubled teen after they turn 18

Most young people aren’t ready for adulthood by 18 years of age, but your troubled teen is especially unprepared. By 18, their legal status instantly changes to “adult” and they are free to fail at life’s countless tests. Your hands are tied and you can’t keep your son or daughter safe from themselves any more.

Pace yourself for a marathon

Your job as parent is far from over.  Parenting an 18+ year-old will feel the same as when they were 17 years 11 months old.  They’ve been behind their peers for a long time–emotionally or socially or academically. You’ve done everything possible to get them ready for adulthood, but they simply aren’t!  For troubled teens, the teen years last into the mid-20’s or longer. And this is really scary; suicide rates across all age groups are highest for people aged 16-24.  It’s the period of greatest stress, whether the person is suicidal or not.

Many people with disorders aren’t able to take responsibility for themselves until about the age of 30.

Over the past 16 years, I’ve asked this question of people with mental health disorders and addictions, or I’ve asked their parents, siblings, children, or their friends:  “At what age did (you, your loved one, friend) make the conscious choice to take responsibility for treatment?  When did you/they get a stable job, or live on their own, associate with healthy people?  I asked dozens of people. Their answer? Every single one told me they or their loved one didn’t turn things around until they were between the ages of 30 – 33In my experience, you start to see signs of awareness that they need help in the late 20’s, with limited attempts to face their problem.

True story: a co-worker once shared about his bipolar disorder and years of substance abuse.  I would never had guessed that this stable, wise person had had a troubled past.  I asked when he turned his life around; it was 30.  I asked what motivated him.  He said, “I couldn’t avoid it anymore.  I ran out of excuses.  I just hit rock bottom too many times.”

Why does recovery take so long?

  1. Anosognosia “a deficit of self-awareness” caused by mental disorders.  They simply can’t tell they are different from anyone else, so they resist messages that they are.
  2. They get good at coping.  They squeak by, or use others, or depend on parents to rescue them.  They try to delay the inevitable scary thought that there really is something wrong with them.
  3. Their brain or emotional development is slower than normal people.  They may need an extra 10 years to go through the final maturation phase into the adult brain.

Because of their mental disability, a child over 18 needs better life management skills than their ‘normal’ peers because they have so much more to worry about.  Besides the usual adult responsibilities, they need self-discipline and self-monitoring for mental and emotional stability. They need to be continually alert to their states of mind–the same as someone who’s an insulin-dependent diabetic needs to continually check blood sugar.  They need to remember to take meds and stay in therapy.  They need to avoid or limit fun excesses their peers can get away with, e.g. parties with poor snacks and alcohol.  They must stick with a healthy diet, exercise, and investment in supportive friendships.  You know your child, all of this is hard for them!

How much to sacrifice and how much to let go?

Parents have a tendency to rescue their adult son or daughter when a crisis befalls because it’s so hard for the child to recover from set-backs.  But rescuing too much makes them more dependent on the parents (or adult siblings).  On the other hand, pressuring a troubled teen to be an “adult” when they are not ready push them to dependence on others who might make their life worse.  Pressure can motivate them to cope with drugs or alcohol, or take unnecessary risks, or give up.

True story:  I met a couple in their 70’s who’d rescued their troubled 34-year-old daughter her entire life, and faced cutting her off financially because they couldn’t afford it anymore. They were heartbroken to let her go, and painfully afraid she would become homeless or suicidal, and they deeply regretful they unwittingly undermined her capacity for independence.  Don’t let this happen to you.

You must transition away from “parent” to case manager, therapist, and mentor.

  • Case manager – This is the busy work.  You are the one to fill out forms, make appointments, provide transportation, ensure prescriptions are refilled and taken.  Follow-up on calls and emails regarding anything: banking, waivers, police reports, insurance, appointments, etc.
  • Therapist – This is actually easy if you can keep your thoughts to yourself.  You listen.  You acknowledge their feelings without rescuing them or smoothing over issues.  You ask probing questions so you can get data that will help you help them meet their needs.
  • Mentor – Start by building trust.  When they trust you they’ll listen, and when they listen you can teach them all the things they need to know to be independent (like the self-management skills in the paragraph above).  Mentoring also means setting boundaries and expecting better of them.

A major challenge is where they’ll live.

At home:  Can you bear the stress if they live with you? or if they leave your protection?  How do you help them move on?  If your troubled young adult child must live at home full or part-time, adjust your rules and expectations. Rules can include a requirement for ongoing mental health care. Your troubled child of 18 or more becomes your guest who stays at your invitation, or a renter who contributes to the household and follows the landlord’s rules.  On the other hand, you’ll need to step back and respect their privacy and acceptable choices and activities.  This may not be easy with someone 18–this means compromises and letting go of being the parent boss.

In an apartment on their own:  This is the preferred situation, but who will be ultimately responsible for rent and utilities?  Who can pay the deposit, usually the first and last month’s rent?  Should the manager/landlord know about their condition in case there are problems?  Problems include property damage, inappropriate visitors (drug users or sellers, couch-surfers, party animals), neighbor complaints.  In one parent’s case, both the local police and management company were notified and given both parents’ phone numbers.  It helped at first when there were complaints, but as the complaints and calls to the police continued, their child eventually evicted along with the others who camped out there.

With roommates or housemates:  I do not recommend this unless you are willing to move your child repeatedly.  Even if your child is not antagonistic–maybe withdrawn due to depression–it is very stressful for housemates.  Your frequent calls and visits for a check-in will also be stressful to them.  And what about these co-inhabitors?  Are they safe for your child to be around?  Will they victimize your child?

With a boyfriend or girlfriend: the same concerns apply as for housemates.  This living situation is only as stable as the partner.  Some couples stay in a parents’ basement.  This too is only as stable as the partner and the parents.  Consider that these living arrangements are temporary.  Good luck if they have shelter for a year.

In the eyes of the law, you are not responsible for them anymore.

You really aren’t.  In fact, you have the right to banish your 18 year-old from your home and change the locks on the doors.  Parents who do this are usually in fear for their physical and emotional safety–not because they don’t care.  If this describes you, it’s understandable and forgivable if you feel forced into this step.  But know this, things change.  Your adult child will change.  Banishment need not be forever.

At the age of 18, broad institutional supports kick in. (don’t you wish that were sooner?)

  • Once they turn 18, people with mental health problems are protected from discrimination in their job/housing/education by laws that protect all disabled.
  • Insurers are required to provide mental health care on par with all other treatments and services.
  • Adults over 18 are better supported by mental health organizations that offer support groups, referrals to safe housing or job opportunities, social connections with accepting peers, and legal and legislative advocacy.
  • Educational institutions have special departments solely for supporting students with disabilities, and that includes troubled young adults.

This 4 things are what your troubled teen needs to function after 18. They are based on long-term monitoring of 1000’s of others in their 40’s and 50’s with mental health challenges who did well in life:

  1. Ongoing support from family, friends, and institutions

  2. A job or continuing education

  3. Ongoing mental health care

  4. A safe living situation


Adjust your expectations for how quickly they’ll progress.

Parents of any ‘normal’ 18 year old also revise their relationship with them, becoming a mentor and peer rather than a parent.  What’s going to be tricky for you is avoiding a default role as ‘parent’–watch out for this!  What young adult wants their parents telling them how to live their lives (even if you’re right)?  If you want their trust–which you do–dial back your ‘parenting’ and remove the power differential it implies.

Keep up regular communications with your child even if they resist.  Do everything you can to build a and maintain a relationship even if it’s difficult.  If not with you, than with another mature adult who can mentor them.

–Margaret

Please comment.  Your thoughts and experiences help others who read this article.


If you would like to get ongoing updates on the latest news and research in child & adolescent mental health, follow my Facebook Page.

Is my teen ‘normal’ crazy or seriously troubled?

Is my teen ‘normal’ crazy or seriously troubled?

girl in rear view mirrorA high percentage of teenagers go through a rebellious or ‘crazy’ phase that is normal for their age and brain development. The difference between normal teen-crazy and truly troubled behavior is when the teenager falls behind his or her peers in critical areas.  At a bare minimum, a normal teen will be able to do the following:

  • Attend school and do most school work if they want to;
  • Have and keep a friend or friends their own age who also attend school;
  • Develop a maturity level roughly the same as his or her peers;
  • Exercise self-control when he or she wants to;
  • Demonstrate basic survival instincts and avoid doing serious harm to themselves, others, or property.
  • Enjoy activities that interest them.

boy in baseball capIt is normal for many teens to be inconsistent, irrational, insensitive to others, self-centered, and childish.  Screaming or swearing is normal–regard this the same as a toddler temper tantrum.  Outlandish imagination and ideas are normal in the adolescent phase too. These are behaviors that crazy teens grow out of unless something else is holding them back.  What you’d call troubled behavior, the kind that necessitates mental health treatment, is a matter of degree.

This is your challenge:  How do you tell the difference?  Troubled teens with mental disorders have the same challenging behaviors as ‘normal’ crazy teens… How do you know if they need serious mental health treatment?  Look for pervasive patterns of social and behavioral problems that stand out against their peers, patterns which persist or occur in different settings Look back at how long these patterns have been occuring.  Are the patterns repeating themselves, or are behaviors increasingly worse? Do you You your troubled teen is slipping behind and won’t grow out of it.

screaming boySigns of abnormal behavior

A sudden change in behavior.

  • An abrupt change in friends and interests, and loss of interest in things your teenager used to enjoy.  This might indicate the onset of a serious mental illness or drug use or both.
  • Unusual ideas, or obsessive beliefs, or unrealistic plans, see:  “Unsettling: what psychosis looks like in children and young people.”
  • Others think there is something abnormal about your child.  (e.g., your child’s friend comes forward, their teacher calls, other parents keep their children from your child, or someone checks to see if you’re aware of the nature of his or her behaviors).


Unsafe behaviors
 (“Unsafe” means there’s a danger of harm to themselves or others, property loss or damage, running away, seeking experiences with significant risk (or easily lured into them), abusing substances, and physical or emotional abuse of others.)

  • If a troubled teenager does something unsafe to themselves or others, it is not an accident, but something impulsive, intentional, and planned.
  • They have a history of intentional unsafe activities.
  • They have or seek the means to do unsafe activities.
  • They talk about or threaten unsafe behavior.


How psychologists measure the severity of a child’s behavior 

“Normal” is defined with textual descriptions of behaviors, and these are placed on a spectrum from normal to abnormal (or “severe emotional disturbance” – SED).  Below are a few examples of a range of behaviors in different settings.  These descriptions are generalizations and should not be used to predict your child’s treatment needs, but they do offer insight into severity and the need for mental health treatment.

School behaviors

Not serious – This child has occasional problems with a teacher or classmate that are eventually worked out, and usually don’t happen again.

Mildly serious – This child often disobeys school rules but doesn’t harm anyone or property.  Compared to their classmates, they are troublesome or concerning, but not unusually badly behaved. They are intelligent, but don’t work hard enough or focus enough to have better grades. They could use help from a school counselor, teachers, and possibly a therapist for themselves or the family.

Serious – This child disobeys rules repeatedly, or skips school, or is known to disobey rules outside of school.  They stand out in the crowd as having chronic behavior problems compared to other students and their grades are poor even if they’re very intelligent.  This child needs mental health or substance abuse treatment.

Very serious – This child cannot be in school or they are dangerous in school.  They cannot follow rules or function, even in a special classroom, or they may threaten or hurt others or damage property.  It is feared they will have a difficult future, perhaps ending up in jail or having lifetime problems.  If they cooperate, this child requires intensive mental health and or substance abuse treatment.

Home behaviors

boy looking right

Not serious – This child is well-behaved most of the time but has occasional problems, which are usually worked out.

Mildly serious – This child has to be watched and reminded often, and needs pushing to follow rules or do chores or homework.  They don’t seem to learn their lessons and are endlessly frustrating.  They can be defiant or manipulative, but their actions aren’t serious enough to merit intensive treatment, though a school counselor or private counselor would be very beneficial.

Serious – This child cannot follow rules, even reasonable ones.  They can’t explain or take no responsibility for their behavior, which can include damage to the home or property, or harm to themselves or others.  They need mental health treatment or substance abuse treatment.

Very serious – The stress caused by this child means the family cannot manage normally at home even if they work together.  Running away, damaging property, threats of suicide or violence to others, and other behaviors require daily sacrifices from all.  Police are commonly called.  This child needs intense psychiatric treatment and/or substance abuse treatment, and likely residential treatment.

Relationship behaviors

somber boyNot serious – The child has and keeps friends their own age, and has healthy friendships with people of different ages, such as with a grandparent or younger neighbor.

Mildly serious – This child may seem extra immature.  They will argue, tease, bully or harass others, and most schoolmates avoid them. They are quick to have temper tantrums and childish responses to stress that always require extra attention from parents and caregivers.

Serious – The child has no friends their age, or risky friends, and can be manipulative or threatening. They can have violent tendencies, poor judgment, and take dangerous risks with themselves and others.  They don’t care about others’ feelings, or may readily harm others physically or emotionally.  This child needs therapy and psychiatric mental health treatment or substance abuse treatment.

Very serious – The child’s behavior is so aggressive verbally or physically that they are almost always overwhelming to be around.  The behaviors are repeated and deliberate, and can lead to verbal or physical violence against others or themselves.  This child needs intensive psychiatric and/or substance abuse treatment.

Pay attention to your gut feelings.

If you’ve been searching for answers and selected this article to read, your suspicions are probably true.  Trust your intuition. Most parents have good insight into their child.  If you’re looking for ways to “fix” or change your child, there just aren’t any easy methods or medications or therapies to do this except over time.  Treatment means multiple life changes in addition to medication and therapy, and these can include help for insomnia, a change in diet, treatment for digestive system problems, and household changes to reduce stress.

Mental illness is serious and recovery is a long slow process.  It is  understandable if you want them to recover quickly–your stress can be intolerable.  Avoid pushing for recovery because it will only stress your child and lead you to disappointment.  Instead, cooperate with professionals (teachers, treatment providers), and prepare yourself for a parenting marathon.  What’s the best way to prepare?  Work hard on your own mental health and wellbeing.  Lower your expectations for steady progress.  This advice and wisdom from other parents may help you face this daunting task.

boy in plaid shirtEarly treatment, while your troubled teenager is young, can prevent a lifetime of problems.  Find a professional who will take time to get to know your child and you and the situation, and who will listen to what you have to say–a teacher, doctor, therapist, psychiatrist or other mental health practitioner.

–Margaret

Your comments are encouraged.  Your story helps others who read this article.


If you would like to get ongoing updates on the latest news and research in child & adolescent mental health, follow my Facebook Page.

“You’re under arrest!”: Crime and Troubled Teens

“You’re under arrest!”: Crime and Troubled Teens

You’ve tried everything. Now you watch helplessly as your troubled teenager starts down a path leading to jail, and you wait for that call from the police. There’s been a crime. It finally happened like you thought it would.  But this bad news can be good news. This may be the point when things start to turn around.

“Experts estimate that from 40 percent to 70 percent of youth in the juvenile justice system suffer from some form of mental health disorder or an illness – anything from ADHD to full-blown psychosis. About 15 percent to 25 percent have mental illnesses “severe enough to significantly impair their ability to function.”” (see “Mentally ill minors put in juvenile hall” at end of this post)

Juvenile crime is considered as serious as adult crime, and juvenile “detention” is just like jail for adults. Yet there is one critical distinction between teenage and adult justice: teens are given a second chance for a clean record and an education.  If your jurisdiction is enlightened, they will get treatment for mental illness or addictions. An adult criminal record is forever a barrier and an embarrassment. It comes up when a former convict applies for a job, a loan, a college degree, military service, a rental, or even a volunteer opportunity.

The juvenile justice system is only partially punitive because society recognizes that the teenage brain is the problem that causes much crime, whether or not they have a mental disorder or addiction.  Enlightened juvenile court judges want their rulings to be “rehabilitative” or “restorative” justice. Enlightened agency directors understand the need for additional support services for learning disabilities, addiction, mental illness, and vocational training.

In the system, teen criminals (“adjudicated youth”) are required to participate in consequences and treatment; it’s a “carrot and stick” approach.

  • The carrot:  The teens attend school and receive training for vocations such as car repair or catering.  They participate in positive character-building activities such as training dogs for adoption, building and maintaining hiking trails, or constructing homes for Habitat for Humanity.
  • The stick: Teens have a complete lack of freedom, whether in detention or out on probation, intensive monitoring (including random urinalysis), immediate consequences for behavior violations, and physical labor to pay back victims (community work programs).

When a police officer calls to say your son or daughter has been arrested, use this as an opportunity to help your kid. It’s a perfect teachable moment. Not only do you have their attention, you can hand the problem over to the Law to enforce their behavior and treat their disorders or addictions. Your son or daughter cannot refuse—when held or convicted on criminal charges, your child has no rights to anything except humane treatment and an appearance before a judge. You are off the hook. You can step back and relax… and be the Good Guy for once.

How to work with the juvenile justice system:

  • Be an active partner with the court. Cooperate fully with the judge, court counselor or therapist, and any attorney, case worker, or probation officer involved.
  • Show up for everything:  visitation, family therapy, court hearings, and parenting classes even if you don’t think you need them.
  • Stand shoulder-to-shoulder with staff.  If your teen has a probation officer, do what they tell you, even if it means tattling on your kid.
  • Be cooperative with staff, and they will work harder for you and your son or daughter. Support the programs required for your teen, and support your teen when they struggle. Your involvement will someday impress on your child that you’re on their side and care.
  • Change your ways.  If you’ve been too harsh with your teen in the past, go easy on them now and let him or her see your good side. If you’ve been too easy on them or too protective, demonstrate backbone. Show you know what’s best for them and that you will remain in charge once they are released.
  • Stick with your child.  If your teenager becomes a Frequent Flyer in the system, it doesn’t mean they are lost.  Remember, they have that uncontrollable teenaged brain and need more time and lessons for it to reach maturity.

Once they come home on probation you need to set strict limits on their activities, and work with the probation officer or social worker to enforce them. These are harsh at first, but should be negotiated later when behavior improves, with consultation with the juvenile justice staff.

Remove risks:

  • Don’t allow them to stay out late ever. Set an early curfew, and report them to their probation officer if they are late.  When they get angry about this, explain that you are bound by the law and that they should discuss their concerns with the officer.
  • Not negotiable: ban drugs and alcohol, especially marijuana. (“Marijuana is uniquely dangerous for troubled teens”.)  Hide prescription drugs and alcohol if you use them. You have the right to search their room and belongings.  If pertinent, hide weapons, matches, or other means of harm to themselves or others.
  • Stop or limit contact with risky friends. This may mean monitoring visits, monitoring cell phone use and internet access, or blocking access entirely if used for crime.
  • Limit access to money to prevent drug/alcohol purchases or escape plans. Get receipts if necessary.
  • Reduce free time. Busy them with as many activities as you can–a job is the ideal.
  • Build your own network of other concerned parents to track your kid… in other words, to spy on them.  Besides other parents, I even contacted businesses where my teen was known to hang out, such as a mall and cafe.  See  “Gang up on your kids: Parent networks for tracking at-risk children.”

Three Goals:
     1)   stay at home
     2)  stay in school
3)  stay out of trouble

Three House Rules:
     1)  continue mental health treatment
     2)  no violence when upset
     3)  clean body, clean clothes

Build their esteem as you would for any troubled child. Guide them to their strengths. Give your teenager something to do that they good at, and allow them ample opportunity to shine. More at  The good things about bad kids.

Extreme measures. I know of three cases where parents took drastic steps to help their son or daughter stay out of trouble, and these worked!

True story – a single father was worried about his son’s gang involvement, especially since the son was still on probation for a crime, and additional charges would draw lengthy prison time. Dad sold the family home and bought another one in a neighborhood ‘run’ by an opposing gang. The son was terrified to leave the house except for his new school, a long way from his gang brothers. This son graduated high school and left the area for college… alive, uninjured, and with a clean record.

True story – After a couple of years trying to keep their daughter out of trouble, parents started looking for work in a smaller town.  They wanted to find a safer place with fewer risks and more eyes. After she completed her mandated one year probation, the family moved.  She was upset to leave her friends, but they were the problem friends. Her crime sprees ended.

True story – a single mother was on the edge of sanity and financial ruin trying to manage the world her son created.  While visiting a juvenile justice counselor with her son, the counselor made an off-hand comment about handing him over to foster care so that she could get her job back and sleep at night.  With a heavy heart, she went forward and obtained a “voluntary placement” for him (temporary state custody), and he went to a foster home.  After two years, he was ready to come home and she was ready and empowered to support him.

A note of caution:  You may have seen ads for outdoor programs or “boot camps” for at-risk teens. Some of these programs are extremely inappropriate for troubled youth, even traumatizing. Or some may not allow teens with a criminal history. Get advice about therapeutic programs for your at-risk teenager from a counselor or social worker, not just from the program itself.  Your teen’s providers often know which ones are appropriate.

The people in the Juvenile Justice System

In my personal experience, 99% of employees in juvenile justice are there because they care about teens, they like teens and “get it” about them, and they believe in the power of what they do. My co-workers have many success stories among their cases. Some former delinquents come back to work for the juvenile justice system and use their hard-won experience to help the next generation.  Ironically, it’s the one job where a criminal record helps!

If you are concerned about what your child will experience in the juvenile justice system, just call and ask.  You may be surprised.

Challenges, risks, and potentially serious problems

  • A troubled young person in detention or incarceration is exposed to others with criminal behavior. They may bully or be bullied or both.  They may meet fellow inmates to sell drugs to when they get out, or learn who can supply them with drugs. Depression is common, and presents as anger or self-destructive behavior, such as getting in trouble on purpose.
  • Not all juvenile departments provide mental health treatment, or treatment is inadequate.  And sadly, there are still places where staff and citizens don’t believe in the mental health “excuse” for bad behavior.  You may need to be an assertive advocate for treatment.  Work with your child’s public defender, who is provided by the court, and give them evidence of mental health problems in  medical records.  Your child will need to sign a waiver for the attorney to have the records.
  • Some states have Mandatory Minimums–pray it’s not yours. Certain crimes lead to long prison sentences regardless of the circumstances of the crime or the mental illness of your child. My state of Oregon will incarcerate anyone over age 15 for seven years if they commit one of these crimes. This made sense to the voters who put it into law, but the reality is a worst-case scenario for how NOT to rehabilitate youth.  No one I’ve ever met in our state, from judges to prosecuting attorneys to sheriffs to probation officers, thinks it’s a good idea–the outcomes have been horrible for reasons too lengthy to go into here.
  • Each county and state has a different culture and attitude towards juvenile delinquents. Some are exceptionally harsh, or they neglect the kids’ legitimate needs; some are reluctant to treat kids like individuals with different needs and strengths; some get that right balance of punishment and rehabilitation. It depends on the judges, the county, and the state. Each is different.

Is your child at risk from criminal involvement or charged in a crime?  Please comment so other parents who read it can learn from your experience.  Thank you.

How am I doing?  Please rate this article above, thank you.

–Margaret


Mentally ill minors put in juvenile hall (excerpt)
Daily Bulletin, Mediha Fejzagic DiMartino, June 12, 2010

“Juvenile halls have become catch-all basins for severely mentally ill youth.  Designed as secure holding facilities for minors who are going through the court system, juvenile detention centers now double as a default placement option for youth diagnosed with schizophrenia, bipolar disorder or major depression.   “There is no place for them in [our system],” said a county juvenile court judge in California.  “We can’t just arrest our way out of the problem. Juvenile hall is not a place to house mentally ill.”

Find The Humor in Your Crazy Child

Find The Humor in Your Crazy Child

Note of caution: it’s never appropriate to make fun of a child.  The purpose of this article is to help a parents’ ease stress by finding humor in their situation, private humor–never to be shared with the child or anyone else who will share it with the child.

I don’t suffer from insanity, I enjoy every minute of it.

Things can only go downhill so far until you lose it.  Troubles build, going from bad to horrible, and then your child says something so bizarre or silly, and even though it may be politically incorrect, and even though it may seem sick or hurtful or embarrassing, there is absolutely nothing left to do but laugh (not in front of the child).

“That boy gave me so much trouble, then one day he said to me, “Mom, why is it always about you?” !
–Mother of an 18-year-old son with mild schizophrenia

“Normal,” a setting on a washing machine.

For parents like you, humor is necessary, even “gallows humor.”  Laughter is a legitimate strategy for relieving stress, and brain scans prove that laughter reduces stress signals.  An emergency room nurse once told me that ER staff joke among themselves about patients in order to help them cope with the intensity of their job. They talk about some patients as “too stupid to live,” or when a motorcycle accident victim is brought in the door (who wasn’t wearing a helmet), they refer to them as “organ donors.”  With each other, some police use the term “knucklehead” instead of “person.”  A sex-offender therapist told me her team tells sex-offender jokes!

“… as high as 94 percent of people deem lightheartedness as a necessary factor in dealing with difficulties associated with stressful life events.”
–David Rosen, Professor of Psychiatry and Behavioral Science, Texas A & M University

We child-proofed our home, but they still got in.

You have permission to laugh at all the crazy, zany, exasperating, nonsensical, and nutball things your child does or says, just never in their presence… or in anyone’s presence who doesn’t understand. It doesn’t mean you don’t love or care your child, but humor really helps your own mental health. In the support groups I facilitate, a parent will occasionally share a funny story about their troubled child and the room roars with laughter.

True story – A 15-year-old girl had professed suicidal thoughts for so long that no one could remember a time when tragedy wasn’t looming. They had locked up every potentially dangerous item, but the terrified parents were never certain they could keep her safe from herself.  Removing the knives and rope was obvious.  But household cleaners?  What weapon of self-harm would be next? Daily life became a quest to guess what else she could use to kill herself, then to hide it.  But her mother realized one day that her picky daughter would never ingest chemicals; they tasted too bad.

You can’t scare me, I have teenagers!

True story – At health class in high school, students saw a film about emotional trauma.  Upon returning home, a 14-year-old son exploded with fury, berated his mother, then charged off to his room and slammed the door, once, twice, three times.  The mother was accustomed to this behavior and went to his room and attempted to calm him down.  He screamed, “I finally found out why I’m having so many problems!  I learned in health class that I am a “feral child” because you abandoned me when I was a baby!”

True story – The 20-year-old schizophrenic son angrily obsessed that his mother spoke with his school counselor when he was 11.  He railed that this invasion of privacy was wrong, immoral, hurtful, illegal, unethical, and stupid, and every other sin he could think of. Mom had long learned to just let him vent, but one day she became exasperated and said, “That was nine years ago! I apologized a hundred times. What more do you want?” The son stopped for a moment, confused, and said, “I don’t believe you. Did you erase my memory again?”

True story – The 16-year-old daughter had ADHD and bipolar disorder. She had grandiose plans to become a famous person and lead an “epic” life.  She was immensely proud of having an ‘exciting’ disorder that gave her ‘permission’ to be crazy.  Once she made an unsuccessful attempt to lose weight, explaining, “I tried anorexia but didn’t have the discipline.”

The main purpose of holding children’s parties is to remind yourself that there are children more awful than your own… or maybe not.

True story – The mother of a violent 10-year-old daughter said “I just bought a gallon of spackle on sale, which is great.  Spackle is my friend!”  Another mother with a violent 16-year-old son agreed.  She said she’d become skilled at repairing and texturing dry wall after all the damage he’d done.  Both moms brainstormed starting a company to repair homes battered by troubled children. “It would help the parents, and we could offer support too… and not judge!”

True story – Several parents at a support group were sharing their frustration from hearing friends talk proudly about their wonderful children, and the fun things they did together.  Each parent had similar experiences, and each felt embarrassed, ashamed, left out.  One mom finally blurted, “Those stupid happy families, I hate them!”

Do you have a funny story or quote to share about your child?  Please add it in the comments section–you’ll lift another parent’s day.

 

–Margaret

Planning for Your Troubled Child from Birth to 18 – What to Expect and Do

Planning for Your Troubled Child from Birth to 18 – What to Expect and Do

Parents face daily challenges with a troubled child or teen, and easily overlook the future.  I know I did.  What’s going to happen as they grow and change?  What does one plan for?  It helped me to hear from parents who had already traveled this path.  Based on their experiences, these are some things you can expect–and do–before your child reaches the pivotal age of 18.

Your child may not be ready for adulthood by age 18, but be OK with this.  Collective experience indicates your son or daughter  will continue to need your support and health care management into their mid-20’s.

If he or she reaches young adulthood with the capacity to maintain well-being on their own, you’ve done a good job.

From birth to age ~5

YouConsider yourself lucky if he or she has an identifiable behavior problem early!  You have ample time to understand your parenting needs and prepare, and use the many “special needs” services for young children.  Start a file and keep absolutely every medical and school record and contacts for people and services.  You are about to become a case manager.

Your family

  • Talk with siblings frankly.  Explain that sister or brother has a different brain and will be treated differently.  Inform them you will be distracted by their sibling’s need for appointments and other issues, and that it may feel unfair.  Ask for their patience.  Reassure them you love them very much.
  • Talk with your partner or spouse about revising expectations for your child, and accepting that your life may be harder than you planned .  Discuss how you will work together and share responsibilities, and work through disagreements about parenting the child in the future.

Everyone – Keep friends, activities, and plans the same.  Keep hobbies and interests alive.  Be as inclusive as possible of your special needs child but don’t sacrifice your family’s needs.  It’s a tricky balance.

Ages ~6-11  – young children

If your child’s behavior problems started at this age, read the above.  It still applies, except you may find fewer services, and sadly, more blame.  Seek professional help now.  Early intervention is the key to future mental health.

What to teach your family:

    • Our lives will be different from other families, but this is normal for families like ours.
    • We will support your sister or brother, but we will take care of ourselves and each other, we will have each other’s back.

What you should do:

  1. Make safety a high priority in your home, emotional safety as well as physical safety.
  2. Focus on schedules and planned time for activities every day.  Maintain this structure consistently, including weekends and holidays.
  3. Teach your child skills for managing behavior–they may not be able to stop it completely.
  4. Modify your home to reduce stress: Less noise or over-stimulation.  Better diet. A separate time-out  space.  Lock up valuables or dangerous items.  Consider a therapy pet.  Create a  tradition of whole-family activities:  Wii, playing cards, board games, exercise games, art or crafts, movie night…
  5. Take frequent “mental health breaks.”  Be generous with yourself without guilt.  Let other family members have breaks too.

Managing resistance: tips and advice

Practical ways to calm yourself, your child, your family

From ~12-18 – ‘tweens and teens

If your child started having problems at this age, most information above still applies, but this may be the most difficult period!

Two things happen in the teen years:

  1. They enter a normal phase of development where they seek their own identity, and want freedom and a social life separate from the family.  But they take more risks, and expose themselves to more risks.
  2. Some mental disorders start at this phase, or get much worse and become quite serious:  major depression, bipolar disorder, schizophrenia and schizoaffective disorder, anorexia, borderline personality disorder… Risks include school failure, criminal activity, substance abuse, suicide, and assault.

Priorities

Safety – You may need to take unusually strong measures to ensure physical and emotional safety. Many need to lock up all knives, or allow siblings to lock themselves in their own room for protection, or search their teen’s room, or take away the cell phone and internet access.

Your well-being and that of other family members – Assertively seek outside support for your family, such as a support network of friends and family, or a religious community or support group, or mental health treatment for yourself, or all of the above.

Education – This is critical, even if it’s only for one or two classes per day.  If your teen cannot complete high school in time with their peers, it’s not a disaster. They may not graduate now, but they can finish their education eventually.  It’s never too late.

Positive peers and adult mentors – Keep your son or daughter from risky youth or adults.  Encourage activities with anyone they like and trust whom you approve of.

Ongoing mental health treatment –  your child may not believe (or accept) they have a mental health problem but they can at least comply with treatment.

By age 18

mature at 25

25 years???  Yes, hang in there.  Pace yourself.  You can do this.  At a minimum, this is what your child needs–fundamental criteria for a functional adult life:

  • A steady job and income, or a meaningful activity (volunteering, school)
  • Healthy, stable relationships
  • Maintenance of health and hygiene
  • Decent housing, maintenance of housing and belongings
  • Maintenance of financial stability

Additional information about young adults in here:  “How to Help Your Troubled Child After They Turn 18


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ARE YOU OVERREACTING?

ARE YOU OVERREACTING?

Your child’s incessant problems and scares can literally give you symptoms of PTSD and anxiety disorder that you can’t control.

Like many parents, you might go to extremes to control situations so they won’t get out of hand. You don’t intend overreacting, but so much frustration has built up that any little irritation sets you off like rocket.  You’re battling to make things stop now.

Overreactions are emergency alarms without the emergency.

You can’t see it coming, but then it happens.  In an instant you are on an unstoppable mission to fix, contain, punish, or halt anything that upsets your sense of well-being, imagined or not. Overreacting is a sure sign of stress and that you need a break!  Overreactions may also come from the anger of losing the day you planned, or the life you planned and came to expect.

Dad, project strength on the outside, even when you don’t feel it on the inside. Relieve your tension later, away from the family or co-workers, by doing something physical, for example.

If you are overreacting to gain control, you are actually losing control.  Your parenting choices need considered, thoughtful decisions instead of an automatic 911 call. When your blood boils, you’re not aware how your behavior creates a toxic environment around you and the rest of your family… nor how it worsens a troubled kid’s behavior.

  • Do you worry even when things are fine?  Do you find things to worry about that aren’t problems?
  • Are you so stressed and traumatized that you just can’t stand it anymore and want the behavior to stop immediately, yesterday?
  • Is every little minor thing a reason to pull out the heavy artillery?
  • Do you overwhelm difficult situations with your own anxieties or explosions?

It’s common for parents with really difficult kids to get stuck this way, so forgive yourself if you overreact, and stop and look at what this does to your relationships and interactions with your troubled child.

  • Do you stop eating, or start drinking, when your stress is just an overreaction to a situation you’ve already handled?
  • If you’ll do anything to make your child stop a challenging behavior, might you go too far with little things? Will you call the police because they slammed the door?
  • When others hear you constantly complaining, might they consider that the problem is you?
  • Do you mirror your child’s bad behavior to show them what it looks like? Are they interpreting this the way you hope, or are you lowering yourself?
Mom, you know this helps no one. You have every reason to “lose it” but find a safer way to relieve tension. Get away occasionally, or distract your worries with friends or an activity you enjoy.

Overreactions sabotage opportunities for improvement. They terrify everyone , and your family starts to hide things from you, or downplay things, just so you won’t overreact or worry yourself to death. When family members feel a need to keep secrets, the isolation feeds your worry. Members will smooth over problems or distract you with lightness to counterbalance your fearful or explosive state of mind. Now you are less in control and receive less of the support you need for your own well-being.

If you feel paralyzed by worry or lash out as a way of coping, you are disabling yourself stress and/or depression. Before you completely lose control and your self-respect and parental authority, take care of yourself and get help for both your physical and emotional exhaustion. Check in with others and ask them if you are thinking clearly or realistically.

You must be emotionally centered and healthy or you will never be able to help your child become healthy.

Remember, your child and family need you to be 100% together.  Let some things go for the greater peace.  Center yourself so you can notice when your child is doing well and offer praise.  When centered, you are flexible, patient, compassionate, and forgiving.   This draws people towards you, to look after you and care for you.  Go ahead, aim for sainthood.  Just starting down that path would relieve everyone else’s stress over you.

–Margaret

Animals that make good therapy pets

Animals that make good therapy pets

An amazing variety of creatures make good therapy animals:  dogs, cats, “pocket pets” like ferrets, birds, and reptiles are therapeutic for children who struggle with any disability:  physical, behavioral, and developmental. A calm smiling dog, an affectionate cat, or a small pet a child can hold is a great therapist. The right therapy animal offers unconditional love and affection, and the ideal animal makes your child feel special.  Measurable benefits have been seen with many creatures “ranging from dogs, cats, birds, and fish to goats and snakes.”

If you are considering therapy pet, strategically pick the right animal.

When identifying a pet, monitor your child’s interactions when they are first introduced to the creature. Be honest with yourself, the therapy animal you think is best may not be the best for your child. Hyperactive and barking dogs, aloof or mean cats, fearful hamsters, and noisy birds don’t work and can be outright stressful. Pay attention—people are often unaware how much stress a fussy pet causes with distractions and chaos.

What is the right animal?

  • The animal’s natural manner fits your child’s emotional needs.
    • Quiet–if your child easily experiences sensory overload;
    • Soft, active, or affectionate–traits that help a withdrawn or anxious child;
    • Interactive–if your child needs to maintain interest or needs attention: a bird that speaks, or a dog that follows instructions;
  • The animal likes to be with your child for long periods. The animal has a preference for your child.
  • Your child is able to treat the pet humanely. (Animals can be abused consciously or unconsciously by troubled children.)
  • You appreciate the animal too and aren’t concerned about mess, smell, hair, or feathers in your home. You should consider yourself the one responsible for its care. This pet is a therapist first, and not a lesson in responsibility. Your child can learn responsibility another way.
  • The child’s pet should still be welcome and cared for if it doesn’t work out for your child. If it’s not wanted, consider a rescue shelter or humane society that can find a caring owner.

Dogs

Most people are familiar with therapy dogs. Their natural affinity with humans is the reason why dogs are the most popular of pets.  And research shows dogs reduce depression and anxiety.  If you are interested in getting a puppy to train as a therapy animal, you can find instructions on how to train certified therapy dogs, and pick up tips for training your dog to fit your home.  (Real certified dogs need significantly more training so they can trusted in nursing homes, hospitals, and schools.) “How to train a therapy dog”

Birds

The parrots and parrot-like or hooked beak birds are smart and can have marvelous personalities.  They will affectionately bond with their owner for life. These colorful birds can be trained to perch on a finger or shoulder and spend time with people, other birds, even dogs and cats! The best low-cost option is a parakeet, a low maintenance, happy chirpy creature, easily tamed, and easily trained to talk.

“Patients hold and stroke cockatiels so tame that they often fall asleep in a human lap.” Maureen Horton, the founder of “On a Wing and a Prayer” tells of “non-responsive patients in wheelchairs who suddenly begin speaking again while petting a cockatiel as their relatives weep at the transformation.” She described bringing her birds to visit a group of violent teenage delinquents who clamored to touch a cockatoo named Bela. “For a few minutes,” Horton says, “these hardened criminals became children again.”
— “On a Wing and a Prayer,” a pet-assisted therapy program, uses birds to visit patients.” Connie Cronley, Tulsapeople.com

Fish

Fish can’t be held, but few things beat the visual delight and serenity of a beautiful aquarium.  Fish have personalities and form interactive communities in a tank, which are fun to watch, and individuals are fun to name. There is a reason aquariums are common in waiting rooms and clinics, lobbies, and hospitals.  They help people relax and calmly pass the time.

“Pocket pets”

Little mammals that like to be cuddled and carried around, often in pockets, are good therapy:  ferrets, mice, rats, gerbils, hamsters, guinea pigs, and very small dogs. It is best to select a young animal that is calm and won’t bite, and handle it gently and often so that it becomes accustomed to being held. Challenges with many pocket pets include running away or escaping their enclosures, urine smell, and unwanted breeding. As the main caretaker, you will want to be comfortable with their needs.

Reptiles

Snakes and lizards are also excellent pets and demand little attention, and they are readily accepted by children. My bearded dragon, Spike, comes with me to my support groups. Dragons are a very docile species–safe with young children and popular with teens and parents. Other good species are iguanas, and geckos.

“I’d have to say my Leopard Gecko Mindy is very much therapy for me. She really is my therapy lizard, she wants to sit with me when I’m upset and tolerates me, which even my two dogs and cat won’t. She’ll just find a place on me and curl up and be like “I’m here, I won’t leave you.””
–User name “Midori”, Herp Center Network

Horses

Properly trained horses are extraordinarily healing. certified horse therapy programs are considered medically effective treatment and often covered by health insurance. Horses benefit disabled children and teens across the board: those with physical disabilities such as paralysis and loss of limbs, mental/cognitive disabilities such as development disabilities and retardation, and children with mental and behavioral disorders. The horses are selected for their demeanor and trained to reliably respond appropriately to children who may misbehave. Therapists are specially trained also to collaborate with the horse as a team. Horses have a “large” serenity and a lack of concern with the child’s behavior. They are also intelligent and interactive like dogs, provide a warm soft hide to lean on, and they empower their riders. A child on a horse will connect with the animal’s rhythmic bodily movement, which stimulates the physical senses and keeps the child physically and mentally balanced. According to parents and children in these programs, horses change lives.  New research proves horses are genuinely effective:  Study Suggests That Equine Therapy is Effective.

–Margaret

How has your child’s pet improved mental health?
Your comments help others who read this article.


The science behind animal therapy

Are dogs man’s best therapist?
Psychiatric Times. H. Steven Moffic, MD. February 29, 2012

Note: this is an excellent article by a psychiatrist who moved from disbelief to belief that dogs have a genuine therapeutic value, healing some of the most psychiatrically challenging children. http://www.psychiatrictimes.com/blog/moffic/content/article/10168/2040421


Children’s best friend, dogs help autistic children adapt (summary)
Journal: Psychoneuroendocrinology, 2011, Universite de Montreal

Dogs may not only be man’s best friend, they may also have a special role in the lives of children with special needs. According to a new study, specifically trained service dogs can help reduce the anxiety and enhance the socialization skills of children with Autism Syndrome Disorders (ASDs). The findings may lead to a relatively simple solution to help affected children and their families cope with these challenging disorders.

“Our findings showed that the dogs had a clear impact on the children’s stress hormone levels,” says Sonia Lupien, senior researcher and a professor at the Université de Montréal Department of Psychiatry and Director of the Centre for Studies on Human Stress at Louis-H. Lafontaine Hospital, “I have not seen such a dramatic effect before.”


Pet therapy: how animals and humans heal each other. (summary)
by Julie Rovner, March 5, 2012, National Public Radio

“A growing body of scientific research is showing that our pets can make us healthy, or healthier. “That helps explain the increasing use of animals — dogs and cats mostly, but also birds, fish and even horses — in settings ranging from hospitals and nursing homes to schools, jails and mental institutions.”

“In the late 1970s that researchers started to uncover the scientific underpinnings animal therapy. One of the earliest studies, published in 1980, found that heart attack patients who owned pets lived longer than those who didn’t. Another early study found that petting one’s own dog could reduce blood pressure.

“More recently, says Rebecca Johnson, a nurse who heads the Research Center for Human/Animal Interaction at the University of Missouri College of Veterinary Medicine, studies have been focusing on the fact that interacting with animals can increase people’s level of the hormone oxytocin. “That is very beneficial for us,” says Johnson. “Oxytocin helps us feel happy and trusting.” Which, Johnson says, may be one of the ways that humans bond with their animals over time.”


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Your rights as the parent of a teen with a mental disorder

Your rights as the parent of a teen with a mental disorder

Parents have more rights than they think.

In a previous blog article on the subject of parents rights, I described how parents can be shocked to learn that their troubled teenager has the right to refuse treatment, Balancing teen rights with parent rights when the teen has a mental disorder.

What if your teen refuses treatment?  They get worse. Over months and years, if your child experiences serious symptoms of the disorder, such as schizophrenia, depression, or bipolar disorder, their brain loses cognitive function just as in Alzheimer’s disease.  Breaks in treatment means loss of brain function, and they become more vulnerable to multiple hospitalizations.  A troubled teenager can refuse treatment for any reason, and explaining the mental health risks to a person clouded by anxiety, depression, mania, or paranoia goes nowhere.

If a teenager had any other illness besides a behavioral disorder, refusing or withholding treatment would be considered child abuse and grounds for removing the child from the home.

Laws in many countries err on the side of protecting a person’s civil rights, but a teenager is not ready to take the responsibility that goes with these rights.(An excellent website on pertaining to Special Education Law is Wrightslaw. Click on “Topics from A to Z.”)

What if you’re teen becomes involved in crime?

  • For safety and health reasons, you have the right to search your teen’s room and remove or lock-up risky items like drugs, weapons, razors, pornography, or anything negatively affecting health. Be careful: this can destroy trust if done inappropriately. Inform your teen only if you find and remove unsafe items but otherwise leave everything else alone!
  • You can set any curfew time you think appropriate, and you do not have to adhere to curfew times used by law enforcement. Suggestion: compare with other parents’ curfews. Your teen will more likely follow rules that his or her peers follow.
  • You can monitor everything in your home, and on your computer and phone. You can limit cell phone services, and get GPS tracking on the phone and in the car. Prevention is more effective if your teen is informed about this, and it prevents others from taking advantage of your child, too.
  • You can report your concerns to anyone: teachers, other parents, and the local police precinct.
  • You can search for your child by calling other parents or businesses, or visiting their friends’ homes, or searching public places where your child might be.
  • You can and should call the police if your child runs away, or if your child is being harbored by someone who wants to ‘protect’ them. It is illegal to harbor runaways and those who do are subject to criminal charges.
  • You can and should notify anyone who encourages your teen to run away or who takes your teen with them without your permission, that this is custodial interference and subject to criminal charges.

What if your child’s mental health provider doesn’t share information you should know as the parent?

“Communication between providers and family members needs to be recognized as a clinical best practice.”*

  • You have the right to contact any mental health professional directly, and provide information relevant to your child, your family (e.g. marital conflict), and your family’s needs (e.g. bullied siblings). The professional can legally receive and document this information, but may not be able to discuss it with you.
  • You have the right to communicate freely and openly with a practitioner or teacher about anything you both already know—no confidentiality exists.
  • You have the right to schedule your own appointment with a professional without your teenager, and ask for information about how to get help for yourself and your family, and what kinds of help you may need.
  • You have the right to information about your child’s diagnosis and behavioral expectations, the course of your child’s treatment, and how you should interact with your child at home.
  • You have the right to a second opinion. And you have the right to change treatment or refuse treatment based on that second opinion.
  • You have to right to participate fully in medical decisions about your child. For example, you have the right to ask a doctor to stop or change medication or treatment that is creating behavior problems or side effects, which harm your ability to manage your teen.
  • You have the right to “information about the treatment plan, the safety plan, and progress toward goals of treatment.” *

What if your child’s provider claims they must keep all information confidential to protect patient privacy?

“While confidentiality is a fundamental component of a therapeutic relationship, it is not an absolute.”*

“Medical professionals can talk freely to family and friends, unless the patient objects after being notified of the intended communication. No signed authorization is necessary.”

–Susan McAndrew, Deputy Director of Health Information Privacy, U.S. Department of Health and Human Services

Teachers and mental health professionals have leeway with confidentiality.  Professionals often misunderstand the Health Information Privacy and Accountability Act (HIPAA), which defines what must be kept confidential. Many also misunderstand the Family Educational Rights and Privacy Act (FERPA) and state laws that govern confidentiality, so they tend to err on the side of confidentiality. However, the American Psychiatric Association states:

“Disclosures can sometimes be justified on the grounds that they are necessary to protect the patient. For instance, it is generally acceptable for a psychiatrist to warn a patient’s family or roommate when the patient is very depressed and has voiced suicidal thoughts”* or plans to harm others.

Professionals should provide explicit information about safety concerns: such as the warning signs of suicide; the need to adhere to medication and other treatment; an explanation of how your teen’s disorder can impair judgment; an explanation of reasons the teen must avoid substances like alcohol and drugs (including some over-the-counter drugs); and the need to remove the means for suicide, especially firearms, sharp objects, matches, chemicals, etc.

How doctors and therapists manage confidentiality

Their basic philosophy is to do what is in the best interest of their patient. For example, if the teen is in an abusive family situation or seeking care only on the condition of confidentiality, their privacy will be protected. “The default position is to maintain confidentiality unless the patient gives consent… However, [family members or friends] may need to be contacted to furnish historical information…” If the practitioner determines that the teen is (or is likely to become) harmful to himself or herself or to others, and will not consent, then they are… “justified in breaking confidentiality to the extent needed to address the safety of the patient and others.
–The American Medical Association, 2001, “The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry.”

A good professional will be honest with your teen, and tell them that they will communicate with parents based on what they already know. They will also tell your child that suicide or violence risk will always be communicated to you and/or an emergency medical service. From everyone’s perspective “It is always better to defend an inappropriate disclosure than to defend a failure to disclose with bad outcome (e.g. injury or death).”

Giving a teenager with behavioral problems the rights to make critical medical decisions is too risky!

I hope that families and mental health advocates can someday agree on how to maintain civil rights without letting a person control their future when they are not in their right mind. Until then, work with the system as best you can. I find that teachers and practitioners do their best to help families despite the restrictive civil rights and confidentiality mandates.  Good luck.

 

* Reference“The Clinician Should Maintain a Confidential Relationship With the Child or Adolescent While Developing Collaborative Relationships With Parents, Medical Providers, Other Mental Health Professionals, and Appropriate School Personnel,” developed by Jerry Gabay JD and Stewart S. Newman MD. The authors would like to acknowledge the support of the Oregon Council of Child and Adolescent Psychiatry for their support of this effort.

Solid Wisdom for Parents of Troubled Children and Teens

Solid Wisdom for Parents of Troubled Children and Teens

 

Other parents have gone before you and faced the challenges that come with a very troubled child.  Get a jump on your task and learn from other’s experience. Wisdom is out there.  You can avoid common mistakes and the stress they cause everyone.

First things first:

You are not alone. All families experience the same fears no matter what the child’s challenges: guilt, anger, frustration, failure, and mental and physical exhaustion.

There is a way. The steps to finding peace in the home are the same for all families and all children regardless of diagnosis

You can start now. You can improve behavior without having a diagnosis, and the techniques work for the majority of difficult children.

There is reason for HOPE. Your child has the capacity to do well . With your support and treatment, difficult children improve.

Have realistic expectations: They may need extra support into their 20’s… but that’s OK. There’s time to catch up with their peers on education and life skills.

Plan ahead for a crisis, brainstorm options for an effective response and create a checklist. You can’t think clearly in a crisis that you didn’t see coming.

What helps your child in the long-term

Pay attention to his or her STRENGTHS not weaknesses. Always find something great about them.

Guide them to their gifts. Give them ample opportunity to do what they are already good at.  They may not be able to be well-rounded, so don’t force them.

What helps you day by day

  • Be your own cheerleader. Silently think, “I can handle this;” “I’m the one in control.”
  • Regularly talk through your feelings with others who understand and won’t judge.
  • Get a life, maintain personal interests, and occasionally set thoughts of the child aside without guilt.
  • Commit to doing the best you can, and accept that this enough – plan to let go someday.

You’ll know you’ve done a good job when your child is able to take responsibility for their own care. This is a monumental personal achievement!

How to calm down a tense situation 

In a neutral patient voice, give directions or requests. You will need to repeat yourself, calmly, several times. Your voice should not communicate strong emotions. Tone of voice, not words or volume, is what creates a bad response.

Don’t rush calm. Give the child plenty of time to unwind and settle. Calm is more important than quick.

Ensure there’s a calm place to go – a time-out space, even for you.

Bring in help – a therapy animal or another person who can calm your child if you are not able to calm down.

Reduce sensory chaos in your home:  noise, disorder, family upheavals, the intrusive stimulation of phones and excessive screen time.

Ideas for managing resistance or defiance

You want your child to be resistant to the negative things they’ll face in life. It represents willpower, and is a strength to cultivate… but only certain defiance.

Be quiet and LISTEN. If you respond, address how they feel underneath, not what they say.

Use reverse psychology–ask them to do something you don’t want them to do, so they can defy you and do the opposite.

Choose your battles. Let them think they’ve won on occasion.

For an ODD child, give multiple instructions at once, including things they do and don’t want to do. It becomes too much work to sort out what to defy and your child may do as told.

Actively ignore – for a child who demands inappropriate attention, stay in the vicinity but don’t respond, look away, act like you can’t hear. They can eventually give up. Works best for ages 2 – 12.

Mix it up – Be unpredictable. Give a reward sometimes but not all the time. Try new ways to use incentives or set boundaries and structure.

9 common parenting mistakes

If you’ve done any of these, don’t worry.  Forgive yourself.

1. Treat your household like a democracy. Your child should  have an equal say in decisions.

2. Find fault with them and tell them about it repeatedly. If they do something positive, it’s not good enough.

3. Pretend your child has no reason for their behavior. Ignore his or her needs or challenges. Are they being bullied? Are they having a hard time sleeping? Is your home too chaotic?

4. Make rules and only enforce them once in a while, or have consequence come later.

5. Treat your child like a rational mature adult.  Make long explanations to a 3-year-old about your reasoning. Assume a teen wants to be just like you.

6. Expect common sense from children who are too young (5), or from young adults with a long history of not showing common sense.

7. Keep trying the same things that still don’t work. Repeat yourself, scream, show how frustrated you are with them.

8. Jump to conclusions that demonize your child. “You are manipulative and deceitful,” “You don’t listen to me on purpose,” “I’m tired of your selfishness…”

9. Make your child responsible for your feelings. If you lose your cool, insist they apologize.

Not problem children, but problem symptoms 

When you observe these behaviors, remember that many of them are normal for children from early adolescence into adulthood. For troubled children in particular, expect these and don’t be frustrated by them.  What you focus on instead are things pertaining to their safety, education, and physical and emotional health.  If these are going along OK, you can work through the other problems with immaturity later.

Problem symptoms

Does not show common sense and is not influenced by reason and logic (irrational because are thinking is driven by: chemistry, neurological issues, past trauma…)

Has no instincts for self-preservation, and poor personal boundaries (brain disorders delay or limit their capacity for social learning and awareness)

Has no well-adjusted friends, or has friends who lead them in risky directions (they’re being bullied? good friends leave because of their behavior? risky friends share and understand their problems? risky friend are using them?)

Doesn’t respond to rewards and consequences (rational thinking competes with mental noise in their head: paranoia, anxiety, panic, fear, depression. ADD, ADHD)

Has limited character strengths of honesty, tolerance, respect for others, self-control (social learning is delayed or nonexistent)

Seems lazy or apathetic or lacking in willpower (clinical depression, marijuana use, or the result of taking their phone to bed)

Does not make plans they can realistically achieve, hangs on to fantasies (“magical thinking”, mania or hypomania, anxiety, ADHD…)

Acts younger than their peers, they will not be ready for adulthood by 18  (common to many normal children, your child may grow out of it or improve with treatment)

Lives in the here and now; doesn’t think about the past or future (also common to many children, they may grow out of it or improve with treatment) 

Does not notice or care about their effect on others.  (self-absorption is normal to some degree, but not in excess, instead it could be from:  depression, schizophrenia or psychosis, autism spectrum disorders, narcissism, or many other disorders)

Make these your priorities, in order

1. You and your primary relationship(s)

2. Basic needs and responsibilities: housing, clothing, food, income, health

3. Your challenging child or teen.

Ineffective:  This is often how parents end up spending their time when a child has a mental illness. Make the slices equal in size–not too much for one, not too little for others.

 

Good:  The really important foundations in your family need adequate time.  Don’t let your child dominate.  Everyone will do better when your household is stable.

Lean in.  One day at a time.  Deep breath.  Hope is. 

 

–Margaret