There is a growing trend in kids enticing other kids to kill themselves. In previous generations, we only had to worry about who our kids were hanging out with in person, now we also have to worry about who our kids are hanging out with via the internet.  While the internet can be a great support system for children and adults alike, it can also be dangerous.

How can we prevent our kids from falling victim?
Transparency is key! Often times parents are afraid of talking about something for fear that it will happen. However, the opposite holds true. The more we talk about suicide as something that is happening to kids/teens the less likely it is to happen. The same thing is true for social media. The more we talk about the dangers of social media to our children, the more they are aware of what can happen.

Have a dialogue and be accessible for your kids.
Let them know that if they see something scary on social media to let you know and that they won’t get in trouble. At an early age, praise your kids for labeling their emotions and for sharing with you. The goal is that if someone is pressuring your child to do something, you want to know about it. If your child is saying things like “I want to die” or “I can’t do this anymore” don’t be afraid to ask for clarification. 99.9% of the time, they really don’t have an intent to kill themselves, but it can’t hurt to ask. If you do know someone that committed suicide, whether personally or through the internet, talk about it with your child. Let them know that suicide is final and that there is no coming back from that. Talk about ways the child could have sought help and could have found alternative strategies to cope.

Know the risk factors: These risk factors can’t cause or predict a suicide attempt, but they are important to be aware of.  Some of the risk factors include, but are not limited to; children who lack social support, change in mood, loss of pleasure from activities that they used to find pleasure in, have impulsive and/or aggressive tendencies or go through a hard life event. It is important to remember, that kids don’t have the coping skills that many adults have. We expect our kids to be able to problem-solve the same way we do, but their brains are not fully developed yet. As I mentioned before, if your child mentions ending their life, don’t be afraid to ask about it. Often times kids may be trying to get your attention, but sometimes it may be a real thought. 

Why are kids killing themselves at the urging of others?
Peer pressure has always been a thing, now there are just more ways to access it. The use of online chat rooms or virtual bulletin boards and forums can provide a platform for children to share their feelings with other children feeling the same way. This is often easier than talking about it in person and may present the risk of encouraging each other to commit suicide. The internet and social media can normalize and reinforce suicide. Many children write suicide notes or take videos that become viral online. These videos, notes and various other platforms glorify those who committed suicide and turn them into individuals who are now idolized by others. Sometimes kids don’t actually realize that suicide IS final. BE IN THE KNOW. It is important to keep up with the current “internet’ trends. 

How is social media a culprit?
Besides giving children a platform to discuss their suicidal ideations, social media can reinforce depression and anxiety. As we all know, people only post their happy pictures and pictures of their best selves. Social media leaves children (and us) comparing ourselves to others. Limit your child’s time on social media, monitor what they are posting, and let them know that social media is only showing a snapshot of people’s lives. Everyone has bad days, they are just not on display for others to see. Monitor who your child is following on social media. Make sure to occasionally glance at your child’s phone and see what they are looking at.  

What tools can we use to help? The more we learn about the potential dangers of social media, the more tools we have to help. USE THEM!  You will be able to see what sites they are using, who they are talking to and some even allow you to read their messages. Again, transparency is key! Let your child know that you have access to it and explain the reasons why.

Be there for your kids. Whenever your child comes to you with a problem, take the time to listen. Praise them for coming to you and help them problem solve. Kids want attention from their parents. Spend 10 minutes a day with your child doing what they want to do. Avoid asking questions about school and just comment on the activity they love. Kids are being told what to do all day every day, it feels great for kids (even teenagers!) to have their parent do what they want to do and be totally present. Whether it is watching the Kardashians or sitting with them while they play Roblox. The more approachable you are to your child, the more likely they will confide in you. If you think your child is suffering, look for help and advice. While the internet has many disadvantages, it also has many advantages. There are countless support groups and hotlines that are there to help you. Don’t be afraid to ask for help! More likely than not, other people are going through the same thing and can be your support system. 

Resources used for this blog:

https://suicidepreventionlifeline.org/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3477910/

Suicide is a growing concern among adolescents and young adults. It is currently the second leading cause of death of individuals between the ages of 15-24 years-old in the United States. Additionally, the rate of hospitalizations for suicidal ideation or attempts has nearly doubled between the years of 2008-2015, and this increase has been highest for individuals who are between the ages of 12-17 years-old.

Why do some individuals think about suicide?

According to the interpersonal theory of suicide described by Dr. Thomas Joiner (2005) thoughts about suicide, or suicidal ideation, are related to two areas of social functioning.

• The first area includes the feeling of not belonging or being accepted by others. This perception may be related to a real sense of exclusion by others or through a perceived sense of not belonging. This can be seen through higher rates of suicidal ideation and behaviors among those who have a history of peer victimization, or bullying. Higher rates of suicidal ideation are also found for individuals from historically marginalized groups, such as those in the LGBT community, and this has been related to challenges with feeling accepted by those around them. As noted above, this perception may also be present without any clear indicators of exclusion or lack of acceptance from others. This sense of exclusion may therefore be related to the negative cognitions that accompany depression and other psychological concerns.
• The second area of interpersonal functioning includes the feeling as though one’s life is a burden to others. This perception is defined by the belief by the individual that his or her death is of more worth more than his or her life. Again, this perception may be associated with depressive cognitions and interpretations of situations in one’s environment and may or may not be an actual message that is being sent to the individual by others.

What are risk factors for suicide?

Suicidal ideation is most commonly associated with a diagnosis of a psychiatric disorder, especially depression. However, thoughts about death and suicide are also seen in individuals who are not depressed. Additional risk factors for suicidal ideation and suicide attempts in teenagers include:

• A family history of suicide attempts
• A recent interpersonal loss, either through death or separation of a loved one
• Impulsivity
• Social exclusion or bullying
• A history of non-suicidal self-injury or self-harming behaviors
• A prior history of suicide attempts
• Access to weapons or other lethal means (e.g. pills or knives)

What are protective factors?

As described above, individuals who experience thoughts about suicide often feel disconnected and not accepted by others. Protective factors therefore include strong social and support networks. This includes feeling accepted by parents, teachers, peers and individuals in one’s environment. Protective factors also include strong communication and interpersonal problem-solving skills and an ability to seek help. The ability to identify reasons to live is also seen as a protective factor.

What are some warning signs that my child may be having thoughts about suicide?

• Emotional changes. Parents should look for changes in mood, which could manifest through a decreased interest in usual activities, increased agitation, and increased social withdrawal.
• Behavioral changes. In addition to increased isolation from others, parents should also be attentive to changes in sleep patterns, increased patterns of missing school or other related activities, increased physical complaints, or increased reckless behavior. Parents should also look out for statements related to suicidal ideation, notes about these thoughts, and patterns of giving his or her belongings away.

What can I do if I have concerns that my child may be having thoughts about suicide?

Many parents of adolescents who are experiencing thoughts about death or suicide are not aware that their child is experiencing these thoughts. People often feel uncomfortable talking about suicidal thoughts and behaviors due to concerns that these conversations will put ideas into their child’s mind. In contrast, you should feel comfortable addressing this topic directly with your child if you do have concerns, as you can then provide a source of support around these issues. Additionally, some statements made by youth surrounding death and suicide are not taken seriously by parents and other adults, due to the perceived function of these statements. Even if these statements are made in a moment of frustration from a teen, you should always follow up on these statements. Some questions that you can ask your children include:

• Have you been feeling sad or depressed?
• Have you been having any thoughts about hurting yourself, about death, or about killing yourself?
• Have you ever thought about killing yourself?
• Have you ever done anything to hurt yourself on purpose?

What should I do if my child is having suicidal thoughts or if I’m worried that he or she is not disclosing these thoughts?

You should always err on the side of caution and bring your child in for a psychological evaluation by a trained professional if you have any concerns.

• If you have immediate concerns about your child’s safety:
  1. You should bring your child to the emergency room or call 911 if you are worried that your child is at risk of hurting himself or herself.
  2. You should remove all dangerous objects from the immediate environment. These include medications, razors, knives, and weapons. This will prevent your child from hurting himself or herself in a moment of distress or impulsivity.
  3. You should closely monitor your child until he or she can be evaluated by a professional.
• If you are worried about your child’s emotional health but are not concerned about your child hurting themselves in the immediate sense:
  1. You should schedule an appointment with a trained professional, such as a psychologist or psychiatrist, to have him or her evaluated as soon as possible.
  2. You should continue to have open conversations with your child about his or her social and emotional functioning, including thoughts about suicide, and continue to take any statements made by your child seriously.

Numerous resources exist for individuals who may be having thoughts about suicide. Some places where you can find more support include the following websites and hotlines:

• American Academy of Child & Adolescent Psychiatry Suicide Resource Center: https://www.aacap.org/aacap/Families_and_Youth/Resource_Centers/Suicide_Resource_Center/Home.aspx
• American Psychiatric Association (APA): https://www.apa.org/topics/suicide/signs
• Teen Lifeline, 602-248-8336 (TEEN) or 1-800-248-8336 (TEEN)
• National Suicide Prevention Lifeline, 1-800-273-8255

Additional References:

Plemmons, Gregory, Hall, Matthew, Doupnik, Stephanie, Gay, James, Brown, Charlotte, Browning, Whitney, . . . Williams, Derek. (2018). Hospitalization for Suicide Ideation or Attempt: 2008-2015. Pediatrics, 141(6).

Joiner T. Why people die by suicide. Cambridge, MA, US: Harvard University Press; 2005.

 

According to the Encyclopedia of Children’s Health, “personality is what makes a person a unique person, and it is recognizable soon after birth. A child’s personality has several components: temperament, environment, and character.”  Although personality is speculated to continue to develop throughout several stages from infancy to adolescence, research has identified three personality types that may be displayed very early in life – as young as preschool – and persist throughout adulthood.  In addition, some speculate that these different personality types lead to different outcomes in various areas such as school, socialization, behavior, and self-esteem.

What are these three personality types?  And which one might describe my child?

The three personality types with their associated traits are as follows:

Resilient:

• Extraverted
• Conscientious
• Good at modulating emotions
• Bounce back from adversity
• Self-confident
• Positive orientation towards others

Overcontrolled:

• Shy
• Self-conscious
• Uncomfortable around strangers
• Low receptivity and openness to try new things and constructive feedback from others
• Low flexibility
• Inhibited emotional expression and low emotional awareness
• Low connectedness with others
• Perfectionistic

Undercontrolled:

• Disagreeable
• Lack self-control
• Low conscientiousness
• Low impulse control
• Emotionally dysregulated
• Aggressive

What are the outcomes seen in children with these different personality types?

	Resilient	Overcontrolled	Undercontrolled
Intelligence	High	Medium	Low
Academic performance	High	Medium	Low
Positive school behavior	High	High	Low
Internalizing problems	Low	High	Medium
Externalizing problems	Low	Low	High
Loneliness	Low	High	Low
Delinquency	Low	Low	High

In addition to these outcomes, additional research by Jaap Dennissen, a professor of psychology at Humboldt University in Berlin, Germany, found that both undercontrollers and overcontrollers took longer to move into adult roles, such as leaving home, developing a romantic relationship, and starting a career.  This was believed to be due to a social adeptness that is required to accomplish these things, which under- and overcontrollers may take longer to develop.

If my child seems to be an under- or overcontroller is there anything that can be done to help?

According to Daniel Hart, a professor of psychology and director of the Center for Children and Childhood Studies at Rutgers University, “Parents should understand that just because kids start out over- or undercontrolling doesn’t mean they can’t succeed in life.”

For overcontrollers, additional supports can focus on the following:

• Developing age-appropriate social skills
• Identifying and expressing feelings instead of internalizing them
• Becoming more flexible in trying new things and being open to feedback
• Tolerating mistakes
• Increasing self-confidence

For undercontrollers, additional supports can focus on:

• Increasing emotional and behavioral regulation through the use of learning more appropriate ways to express feelings
• Helping supportive adults develop good strategies in dealing with both positive and negative behaviors.
• Increasing perspective taking abilities and empathy for others.
• Teaching conflict resolution skills

Who can help my child these things?

The aforementioned supports can be provided by a variety of people such as parents and teachers, but if you become concerned that your child is not making progress in these areas, he or she may benefit from individual, family and/or group therapy services provided by a trained clinician.  Social workers and psychologists have received specific training in different strategies that help children work on these things and they can also guide you in how to best support your child at home and in the community.

Resources used for this blog:

https://www.nbcnews.com/id/22554554/ns/health-childrens_health/t/personality-may-be-set-preschool/#.XH_5EsBKiUl

https://www.researchgate.net/publication/264730913_Resilient_Overcontrolled_and_Undercontrolled_Personality_Types_Issues_and_Controversies

https://www.healthofchildren.com/P/Personality-Development.html

https://www.psychologytoday.com/us/blog/pieces-mind/201801/working-toward-psychological-health

Written by Sudha Ramaswamy, PhD, BCBA-D, LBA

Vacation, for many of us, means tossing structure and consistency aside.   It means spontaneity, and trying new things. It may also mean staying with new people or in challenging settings. Instead of the comforts of home and school, your child is therefore, suddenly expected to manage a world of changes, with expectations that may be beyond the abilities of a child who may have behavioral, language, sensory, or physical needs.  Here are some tips for travelling with your child who has special needs:

1. Keep it simple. Consider visiting just one place rather than visiting a few different places.  Also be sure to stick to one activity per day.  Too many varied activities could potentially be problematic.  Many children with special needs, especially those with autism, have difficulty making sense of everyday movements, sounds, and actions. Routine creates order in their lives. Thus, children gradually learn what to expect and when to expect it. Routine creates a safe and secure environment in which events are predictable (even on vacation!).
2. Always have a Plan B. Your child with special needs may have a wonderful time participating in a planned activity, or she or he may fall apart completely and have a meltdown.  A flexible attitude is the key to having fun when taking all children on vacation, not just children with special needs. Weather, sickness, or problem behaviors can alter plans at a moment’s notice, so make sure you have considered alternative activities you can do instead.
3. Maintain a home-like atmosphere. Many families love to vacation together. While that can be enjoyable with a child who has special needs, it can also become stressful for you if family members or friends begin to weigh in with parenting advice. An alternative may be to agree to vacation together, but not necessarily stay in the same hotel or rooms.  That way, if your child needs a break or you want to create a more familiar home-like structure, you can do so under your own terms and not feel the pressures of outside influences.

4. Plan at least a few activities that you know your child will enjoy.  Given that the activities are preferred will make it much more likely that problem behaviors/meltdowns will not occur.  You can even alternate preferred and less preferred activities on a schedule for your child so that having access to the more-preferred activity is contingent upon completing the less-preferred activity. Having those activities that you know your children will enjoy, will take the stress off those more difficult times of the vacation.
5. Bring along reinforcers. If you know your child will struggle without his or her favorite television show and you are not sure about what kind of television you will have access to, bring an iPad along for the trip. If your child needs specific toys, blanket, pillows, foods, or lovie, bring them along. Using positive reinforcement to let your child know they are doing the right thing is a great way to increase prosocial behavior and you can make use of what you know are reinforcers for your child to help push through potentially difficult moments on the vacation.

6. Prepare your co-travelers. If you’re vacationing with friends or relatives who do not know your child well, teach them about what to expect, what they can do to make life easier for you and your child, how to engage your child, and even better-what to do if a problem arises.
7. Research ahead of time. When you are booking a hotel, you can inquire about the types of accommodations that can be made for your child. For example, if you would like to avoid crowds, is there a quieter time of the day that tends to occur for check in? If there are buffets during mealtimes, what type of options are available? Is there a room available in a particularly quiet part of the hotel? Are there high locks on the doors (if your child has a risk for leaving the room)? You can also research accommodations that tourist sites such as amusement parks may make. For example, at all of the Disney Parks, you can reserve “Fast-Passes” many months in advance for reduced wait times on rides.
8. Prepare your child with special needs.  Your child with special needs will almost certainly be better able to relax and enjoy the vacation with you if he or she is prepared.

• Create a “social story” for your trip. Social Stories provide a visual preview, typically including a picture and caption of what to expect prior to a new experience. A social story is really an aid to help children with special needs prepare for what to expect as well as what to do or how they might feel in an event or unfamiliar situation.
• Speak about your plans with your child, sharing and emphasizing concrete details. You should try to keep your wording as simple (not vague) as possible. For example, “when we get to the beach you’ll get to build a sand castle with me” rather than “when we get to the beach we’ll have so much fun together”.
• As mentioned above, bring reinforcers along and state clear expectations for behavior along with a reinforcement system for appropriate behavior. For example, if you are aware of what activities may be difficult for your child, you can present an “if-then” contingency: for example, “If you can sit with us at the restaurant until everyone is finished, you can watch an episode of your favorite show on your iPad”.
• Have a plan for each day, and review the plan in the morning prior to embarking on the day’s activities.  Visual schedules are a great way to build routine and inform children about the expectations for the day.  You can prepare visual schedules right to your Apple Device by downloading schedule apps such as Pictello.

Additional sources:

https://www.autismparentingmagazine.com/social-stories-for-autistic-children/

It’s the middle of the afternoon and Mary’s 16 month old son just won’t settle down.  No matter what she tries to do, he just continues to cry, fuss and reject her efforts to soothe him.  She knows that he’s not hungry or tired, but cannot figure out what he needs.  She’s getting frustrated and starts to wonder, “Is this just a phase?  Or is there something going on that I should be concerned about?”

Kevin and Lisa need to get to work, but every time they try handing their 22 month old daughter to the nanny so that they can leave, she arches her back, screams and clings to them.  Once they are able to leave the house, she continues crying and screaming at the door to the point that the nanny does not know what to do.  They go through this every morning, which is becoming exhausting and emotionally draining.  They start to wonder, “Is this just a phase?  Or is there something going on that we should be concerned about?”

Every time Julie tells her 24 month old son “no,” he starts kicking and hitting her.  It can take up to 30 minutes to calm him down and sometimes Julie is so exhausted from dealing with the tantrums that she ends up giving him what he wants.  She starts to wonder, “Is this just a phase?  Or is there something going on that I should be concerned about?”

Jaidyn and Reilly just adopted a 13 month old daughter.  They have read some parenting books, but are encountering some difficulties that they had not anticipated.  They find that when they try soothing their daughter, even if they follow the advice given in the books they’ve read, she often tends to reject them resulting in their having difficulty calming her down.  They start to wonder, “Is this just a phase?  Or is there something going on that we should be concerned about?”

Do any of these scenarios sound familiar to you?  If so, you are not alone, as many parents have encountered the same struggles due to their child’s temperament and/or attachment difficulties.  These parents have become confused, as they may have not encountered these difficulties with their other children or if this is their first child, simply do not know what to do.  Fortunately though, a new treatment modality, Parent-Child Interaction Therapy for Toddlers, has been developed to help parents who are encountering these exact challenges.

What is Parent-Child Interaction Therapy for Toddlers (PCIT-T)?

Parent-Child Interaction Therapy for Toddlers is an early intervention program that involves coaching parents while they interact with their 12 to 24 month old children.  It is an adaptation of the standard Parent-Child Interaction Therapy (PCIT) model that was originally developed for 2 to 7 year-old children with disruptive behaviors.  PCIT-T has modified the standard approaches of PCIT to make them developmentally appropriate for 12 to 24 month old children.  Its techniques are based on the understanding that difficult behaviors in toddlers (e.g., tantrumming, aggression, anger, fussiness) are due to difficulties with emotional regulation (i.e., “big emotions”) rather than deliberate defiance.

How is PCIT-T going to help me more than the parenting books that I’ve already read?

PCIT-T provides both teaching and live coaching of concrete skills that have been proven effective in helping increase emotional regulation and decrease problematic behaviors in toddlers.  It also can increase your toddler’s language skills and encourage him or her to follow directions.  The live coaching component provides the necessary piece that parenting books lack, as although techniques written about may make sense in theory, they can be difficult to implement without the direct guidance of a professional.  In addition, PCIT-T also focuses on helping parents learn relaxation and positive self-talk strategies to use during stressful parenting situations. Learning about these skills and then being coached in using them in the moment that your toddler is experiencing a “big emotion” leads to better learning of the skill and an overall decrease in parental stress.

Could this just be a phase that my toddler is going through?

In short, yes, it could just be a phase, but difficulties with emotional regulation during the toddler years can also be a warning sign of more difficult behaviors to come.  For this reason, early intervention is the best strategy in setting up your toddler for success, as more change and progress in a shorter amount of time can be accomplished during this developmental stage due to negative emotional and behavioral patterns not yet having become overly reinforced and ingrained in nature.  PCIT-T is a short-term treatment modality with an average duration of 8-12 sessions.  This is shorter in comparison to both the standard PCIT modal for older children, which averages 15 to 16 weeks, as well as other parenting programs and behavioral treatments.   Therefore, intervening early on can prevent the need for more intensive and longer treatments down the road.

What types of children can benefit from PCIT-T?

Toddlers with the following behaviors are great candidates for PCIT-T:

• Tantrums
• Aggression (e.g., hitting, biting, pinching)
• Fussiness (e.g., screaming, whining, crying)
• Anger, frustration, head-banging
• Attachment difficulties (e.g., rejection of parent, difficult to comfort)
• Separation anxiety or withdrawal from parent

Toddlers with language problems can benefit from PCIT-T, as the skills parents learn increase children’s language abilities.  In addition, fussiness, tantrumming, and aggression, along with other behavioral concerns, can sometimes stem from language delays, as the child becomes frustrated due to their inability to communicate with others and therefore resorts to other maladaptive means in order to get their needs met.

Toddlers on the autism spectrum also benefit from PCIT-T as it improves the following abilities that are typically impaired in children with the disorder:

• Eye contact
• Shared enjoyment
• Playing with toys in more appropriate/integrated/elaborate ways
• Nonverbal and verbal communication

Toddlers who are in foster care can benefit from PCIT-T, as it will lead to a more secure and healthy attachment/relationship between them and their caregivers.   Either a committed foster care parent or birth parent (when reunification is the goal) can benefit from participating in PCIT-T with their toddler.

Toddlers who are in the process of being adopted or who have been adopted can also benefit, as PCIT-T will lead to improved parenting skills in the adopted parent, which will lead to a more secure and healthy attachment/relationship.

Toddlers with a history of abuse and/or neglect can benefit from PCIT-T as these traumatic experiences often negatively impact a child’s ability to attach to a caregiver in a healthy way and can also lead to emotional dysregulation.

How can I get started or find more information?

For more information about PCIT-T you can visit its main website at www.pcit-toddlers.org or visit our practice’s info page at https://manhattanpsychologygroup.com/child-treatment-services/parent-child-interaction-therapy-toddlers-pcit-t-ages-1-2. Our webpage also provides info on how you can initiate PCIT-T services at our practice.

Resources used for this blog:

www.pcit-toddlers.org

How much sleep should I be receiving?
The National Sleep Foundation recommends that adults receive between seven and nine hours of sleep each night. Sleep becomes a concern when an adult receives less than six hours of sleep or more than ten hours of sleep each night. The number of hours of sleep recommended is higher in youth, with the National Sleep Foundation recommending that school aged children receive nine to eleven hours of sleep each night and teenagers receive eight to ten hours of sleep each night.

National Sleep Foundation Recommendations (hours each day):

• Newborns (0-3 months): 14-17 hours
• Infants (4-11 months): 12-15 hours
• Toddlers (1-2 years): 11-14 hours
• Preschoolers (3-5 years): 10-13 hours
• School-aged children (6-13 years): 9-11 hours
• Teenagers (14-17 years): 8-10 hours
• Adults (18-64 years): 7-9 hours
• Older adults (>64 years): 7-8 hours

How common are sleep difficulties?
Between seven and 19% of adults are not receiving the recommended amount of sleep according to the Centers for Disease Control and Prevention. There are more than 70 different types of sleep disorders in existence. Insomnia is one of the most common sleep disorders, with 50-70 million people in the United States experiencing this condition. Insomnia is defined as difficulty falling asleep or staying asleep, and can either be primary or secondary to another medical or psychological condition. Other common sleep disorders include obstructive sleep apnea, which consists of disordered breathing during sleep, narcolepsy, which consists of extreme sleepiness or falling asleep suddenly during the day, and restless legs syndrome.

Why is sleep important?
Lack of sleep is associated with various physical concerns. For example, lack of sleep increases one’s risk for obesity, diabetes, and cardiovascular illnesses, such as stroke and heart disease. Additionally, lack of sleep weakens the immune system, making one more vulnerability to illness. It also puts oneself and others at risk for injuries through driving related accidents. Given these risks, it is not surprising that multiple studies have found that chronic sleep deprivation negatively impacts overall longevity.

In addition to the impact that sleep has on one’s physical health, sleep is also essential for the proper functioning of the nervous system. Sleep disruption affects the levels of stress hormones and neurotransmitters in the brain and also affects the speed at which cerebrospinal fluid is pumped through the brain, slowing down the housekeeping functions in the brain. A lack of sleep is therefore associated with difficulty concentrating, impaired memory and difficulties with mood regulation. In this sense, it is not surprising that chronic sleep difficulties affect 50-80% of individuals with psychiatric conditions. In the past, clinicians have viewed sleep difficulties as simply a symptom of various mental health conditions. However, studies suggest that sleep difficulties may also heighten the risk for and contribute to the onset of various psychiatric concerns in both adults and youth.

What psychiatric disorders are associated with sleep difficulties?
Depression: The majority (65-90%) of both adults and youth who have a depressive disorder diagnosis experience some form of sleep difficulty. Both insomnia and hypersomnia (sleeping more than the recommended amount of time) are symptoms of depressive episodes. Therefore, it is usually assumed that sleep concerns are a result of this psychiatric condition. However, recent research has shown that sleep problems typically precede other depressive symptoms. While the relationship between sleep and depression is complex and still being examined, these results indicate that depressive symptoms may result from chronic sleep concerns in some individuals.

Additionally, sleep problems are associated with a poorer prognosis for individuals with depression. Individuals with depression who experience sleep difficulties are less likely to respond to treatment and are at greater risk for suicidal ideation and behavior than those who do not have sleep concerns.

Anxiety Disorders: Similar to the relationship between sleep and depression, there is a strong relationship between insomnia and anxiety. Half of adults diagnosed with generalized anxiety disorder have sleep difficulties. Sleep concerns are also common in individuals with posttraumatic stress disorder and may be present in individuals with panic disorder, phobias and obsessive compulsive disorder.

Recent research suggests that in some cases, sleep disturbance can precede anxiety concerns. However, stress and related worries typically are reported prior to notable sleep challenges. Lack of sleep can then contribute to ongoing anxiety and exacerbate anxiety symptoms. Similar to individuals with depression and co-morbid sleep concerns, individuals who have anxiety and sleep challenges can also have a poorer response to treatment than those without sleep concerns.

Attention Deficit Hyperactivity Disorder (ADHD): Sleep concerns are common in children with ADHD, with almost half of those with a diagnosis presenting with some form of sleep difficulty. Children with ADHD frequently have a hard time falling asleep, experience more restless sleep, and wake up more frequently than those without ADHD. Sleep-disordered breathing and movement disorders that affect sleep are also common in individuals with ADHD.

Bipolar Disorder: Sleep irregularity is an extremely common symptom of bipolar disorder, with studies suggesting up to 99% of patients experience a decreased need for sleep during manic episodes. Depressive episodes experienced by those with bipolar disorder are also frequently accompanied by hypersomnia. Longitudinal studies indicate that lack of sleep can trigger a manic episode and that sleep problems worsen before both manic and depressive episodes.

What can I do on my own to improve my sleep?
To address sleep difficulties, you can first make lifestyle changes that have been associated with improved sleep quality:

• Create and follow a regular bedtime and wake-up schedule.
• Exercise and engage in physical activity during the daytime.
• Use the bedroom only for sleep (not for work or television watching).
• Keep the bedroom dark and free of distractions (such as computers or television).
• Avoid stimulants (caffeine and nicotine) and alcohol, especially close to bedtime.
• Avoid watching television or using the computer close to bedtime.
• Engage in relaxation techniques, such as guided meditation, prior to going to sleep.

What treatments exist for insomnia?
Cognitive behavioral treatments (CBT) exist that target sleep challenges. CBT can help an individual change negative cognitions about sleep and disrupt the cycle of psychological challenges and sleep difficulties. It can also be helpful to speak with a physician about the benefits of melatonin supplements to help with sleep. A physician can also be consulted about the potential benefits of prescription medications to address sleep challenges. However, prescription medications are usually prescribed short term and used in combination with behavioral approaches and lifestyle changes.

Given the strong association between various mental health concerns and sleep challenges, addressing the comorbid psychiatric issue, through CBT or consultation with a psychiatrist, can also help improve any secondary sleep difficulties.

Sources:

National Sleep Foundation
American Sleep Association
Harvard Health Publishing

 

Cognitive behavioral therapy (CBT) has been proven to be a very effective treatment for mental health concerns such as anxiety and depression.  With the large variety of CBT self-help books and web-based programs available though, one may start to wonder if seeing a professional is necessary or if those self-help methods will do the trick.

The answer to this question though is not a clear-cut “yes” or “no.”  Although some studies do indicate that self-directed therapy can lead to a reduction in symptoms of anxiety and depression that is sustained over time, these results may not give the full picture.  Given this, there are many things that you should consider before heading down the path of self-help.

How effective is self-directed therapy?

Studies have shown that self-directed therapy tends to be moderately helpful, whereas CBT with a therapist is more effective in nature.

What are the advantages of CBT with a therapist?

• Accountability –Having someone that you need to be accountable to will increase the likelihood that you will follow through on using the strategies and techniques that you are learning.  For example, if an important step in making progress is a particular behavioral challenge (e.g., facing a fear), you are much more likely to follow through with doing it if you have a therapist who is going to ask you about it.
• Added insight – One core component of CBT is identifying those thoughts and core beliefs that are causing symptoms of anxiety and depression.  Although some of these thoughts and beliefs may be easy to recognize, some may be hidden a bit and in need of a therapist to bring them into your awareness.  In addition, some of your thoughts and beliefs may be difficult to face and therefore easier to avoid.  In these situations, it can be helpful to have the support of a therapist who will push you to confront those things that are difficult to acknowledge and recognize.
• Support – CBT strategies are not always easy to implement and at times may make you feel uncomfortable.  In addition, the main reason why self-directed therapy ends up being ineffective is because it is easy to give up on. Having a therapist by your side to encourage you through the process and help you stay motivated can be an added benefit of in-person treatment.  When you are ready to give up, your therapist will be there to process with you why that is and help you realize the benefits of staying committed.

How significant are my symptoms?

Individuals who benefit from self-directed therapy tend to be those with mild to moderate symptoms of anxiety or depression that do not interfere with their ability to function on a daily basis.  Those individuals who have more significant symptoms (e.g., so depressed that they cannot get out of bed, so socially anxious that they avoid going places where they may need to socialize) are not good candidates for self-directed therapy and would benefit more from seeing a therapist.

How feasible is it for me to regularly meet with a therapist and can I afford it?

Various factors such as your work schedule, the area that you live in, the type of insurance that you have, and your financial means can impact your ability to find a CBT therapist that you can meet with on a regular basis and afford.  If you are unable to find a provider who you can afford, that is easy to get to, and that can meet with you at a time that is convenient for you, self-directed therapy may be the next best option.  If you are able though to find a provider who meets these criteria, in person therapy will likely be more effective that doing it on your own.

Are my only options self-directed or weekly individual therapy sessions with a CBT therapist?

No.  Another option to consider is combining self-directed therapy with brief weekly phone calls with a CBT therapist.  This way you still benefit from some of things that a therapist can provide such as added input and insight, accountability and encouragement.

I have decided that a self-directed approach would be helpful.  What do I do next?

If after considering the above questions you decide that a self-directed approach would be best, the Association for Behavioral and Cognitive Therapies maintains a list of books (http://www.abct.org/SHBooks/) that they have given their “seal of approval.”

In addition, Seth J. Gillihan, PhD, a licensed psychologist and Clinical Assistant Professor of Psychology in the Psychiatry Department at the University of Pennsylvania who specializes in CBT, suggests the following guidelines in pursuing a self-directed approach:

1. Find a book that resonates with you. People are drawn to different approaches, tones, level of detail, etc. If a book feels like a good fit, there’s a better chance you’ll stay engaged with it.
2. Choose a book that is based on solid research. Self-help therapy takes considerable time and effort, so it’s worth directing your energy toward a program that has a solid grounding.
3. Make room in your schedule to focus on the program. While there’s a good chance you’ll always have competing activities, it’s better to avoid periods in your life when you’re truly overextended and the therapy is likely to get pushed to the side.
4. Follow the program as closely as possible. It’s easy to want to skip parts of a program we’re already familiar with or we think won’t work. One of the dangers with that is if we find a program doesn’t help, we won’t know if it’s because it wasn’t right for us or because we only did part of it. Sticking to the instructions gives us the best chance of benefiting.

I have decided that a self-directed approach will not be the most effective.  What should I do next?

Since CBT has been proven to be one of the most effective treatments for depression and anxiety, you should start by searching specifically for CBT therapists.  Once you have identified a few options, reach out to them to get a sense of whether they are the right fit.  Even though CBT follows some basic principles and steps, each therapist might be slightly different leading to your “clicking” with one better than the other.  Consider how well you feel that your therapist can relate to you, how helpful they are, and how available they are during the times that work well for you to meet.

Resources used for this blog:

https://www.quora.com/Cognitive-Behavioral-Therapy-Is-there-an-effective-way-to-teach-yourself-CBT-or-do-you-need-to-do-CBT-with-a-trained-practioner

https://www.psychologytoday.com/us/blog/think-act-be/201609/therapy-without-therapist

https://www.nami.org/Blogs/NAMI-Blog/November-2016/Discovering-New-Options-Self-Help-Cognitive-Behav

What is the Montessori Method?

The Montessori Method was developed in 1907 by Dr. Maria Montessori. According to the American Montessori Society, the Montessori approach is recognizable by several hallmarks.

The first hallmark involves multi-age groupings. The idea behind multi-age groupings is that younger children will benefit by having the opportunity to learn from watching older children.  Older children will also benefit because the skills they learned previously will be reinforced by observing the younger children developing those skills they had already acquired. It is also thought to be a more accurate reflection of the real world where people of different ages interact consistently across settings.

Next, the Montessori method offers uninterrupted blocks of “work” time.  Dr. Montessori considered “work” to be what most adults consider play, as she felt that was how children learned; and described play as work out of respect to children. Children attending a Montessori program can decide what they want to play with from a selection of materials provided by their teachers.

Typically, Montessori classrooms have larger sizes and are less predictable and structured than classic classroom settings. Montessori classrooms involve specially selected materials, freedom within the limits of the classroom, and the opportunity for children to develop themselves within the constraints of the classroom with help from their teacher and peers.

The Montessori program provides a limited number of materials per day, and allows children the flexibility to engage with what most interests them. The idea behind this, that children learn best when they are motivated and interested in the subject matter, is crucial to the Montessori Method.

What do ASD children typically need in order to learn?

Autism is a spectrum disorder, meaning that symptoms can present very differently across children, and functioning can vary wildly. Therefore, children on the autism spectrum can have drastically different educational needs. Their level of functioning, personal preferences, and inherent proclivities can require a variety of teaching strategies to optimize potential. This means that if you are considering a Montessori Program for your child, you need to look beyond their diagnosis and assess their individual skills and areas for growth.

That being said, most children on the spectrum benefit from highly structured and predictable classroom settings. These classrooms offer visual aids to help children stay on task and understand what their day will look like. They have visual schedules so children diagnosed with ASD, who usually struggle with transitions, will be better able to prepare for them. Given that a highly stimulating visual classroom can be distracting and potentially overwhelming in the intensity of input for sensitive ASD learners, they may not have as much decorations on the walls as a typical classroom.  Classroom sizes are smaller.  Depending on the age of the children, play areas will likely have a variety of toys, but be visually unobtrusive to encourage attention to whatever task is at hand, and have areas marked with photographic and textual labels to assist children in cleaning up for finding what they need. Ample adult support is prevalent in well-organized ASD classrooms, as well as individualized plans to address each child’s unique needs. 

When is the Montessori approach likely not right for a child on the spectrum?

Parents, you know your children best. When looking at the areas you want to see them grow and develop, ask yourselves, will the Montessori method lend itself to challenging or supporting my child in this area? Many people assume that the Montessori method lends itself to children with ASD since children with this diagnosis can have areas of hyper-focused interest and can find learning in other areas aversive. The Montessori method allows for this to some extent by letting children choose from an array of activities (though it is possible none of the activities offered by the teacher will appeal to a child with ASD with restricted interests). There are certainly some children falling on the autism spectrum who will likely benefit from this method and be successful with a Montessori Program. However, there are several components to this method that could be harmful to a child falling on the autism spectrum.

One challenge for many learners with autism is that they cannot learn from their natural environment.  Being exposed to children of different ages and having the opportunity to choose from a variety of activities will not help a child who cannot learn from their environment—that type of child requires a structured learning program that is tailored to their individual needs and motivations. They will also likely require one to one support and a predictable daily schedule.

Another sign that your child may not benefit from a Montessori program is if they are rigid. The Montessori program allows for rigidities. In fact, it’s so open to children with rigidities, it fails to offer them enough opportunities to work past them. Children on the spectrum with rigidities will generally not learn flexibility without practice and conscious planning from their caregivers.  There will be times in a child’s life where these rigidities are not acceptable, and if they don’t have the opportunity to practice dealing with their preferences being unavailable, they will not learn how to cope with it. Those diagnosed with ASD generally need more learning opportunities, not less, to master skills and mature. If a child with ASD is not challenged to work outside of their rigidities, they will not be able to.

Montessori likely is not the right place if you have a child who is easily overstimulated.  A large unstructured classroom environment, like the Montessori method offers, will make learning and behavioral/emotional regulation even more difficult for those sensitive children. Children who become overstimulated by large rooms, crowds, or extra-busy environments will usually learn better in a smaller classroom with less children.  This type of settings allows them to focus on the skills at hand. They can be exposed gradually to larger more stimulating social settings as they learn to regulate.

When is the Montessori approach a good fit for a child on the spectrum? 

Parenting style and priorities come into play when assessing the suitability of a Montessori program for one’s child with an ASD diagnosis. It is possible that some parents will not want to challenge their ASD learners to explore things that they haven’t chosen themselves and just want them to be in an open and welcoming environment. If this is a parent’s preferences about their child’s school, then Montessori may a great option.

The Montessori method may also be a wise choice for a high functioning child whose main area for growth is in the social-emotional range. If a child is learning from their natural environment, does not get overstimulated by larger classroom settings, displays no rigidities but just seems “off” socially, then being around children of a variety of ages with multiple play options would provide valuable social learning opportunities.

1. Homework

• Why it can be a challenge: One of the earliest home battles related to school is often homework. When to do, how to do it, where to do it, how much to help, etc. While some schools do not introduce homework until later grades, it inevitably becomes part of the daily school routine at one point or another. Homework takes away from time that can otherwise be spent doing a preferred after school activity, socializing, or just relaxing. Students may struggle with homework for a variety of reasons including: learning differences, executive function deficits or stamina.
• What you can do: Research tells us that homework does not hold much added value in terms of learning. Parents should have a realistic conversation with their children’s teachers at the beginning of the year to ask a few key questions: 1. How much time can my child expect to spend on homework each night? 2. How does homework factor into their grades? Is there a consequence if they do not complete all the homework each evening? And 3. How much help and supervision should I be providing for my child? The answers to these questions can help you structure what homework time should look like in your house. For example, if the teacher explains that they want the students to work for 30 minutes each evening and parents should not be assisting their children, then homework time may look like a timer being put on for 30 minutes and you making sure your child is actively working rather than helping them. Having these answers will help to formulate expectations and allow you to further frame the role of homework for you child. Furthermore, you can work with your child’s teacher to identify if any of the challenges listed above (learning differences, executive functioning challenges, etc.) may be a factor, which can put you on the correct path in seeking an evaluation and professional treatment.

2. Friends

• Why it can be a challenge: All children experience ups and downs in friendships, as well as periods of loneliness. Establishing and maintaining friendships over time is difficult and can be compounded by different variables at school. While these sorts of challenges may be typical at all ages, bullying is never acceptable and should be addressed immediately. Bullying is different than teasing in that there is an imbalance in the peer relationship.
• What you can do: Talk to your child about how he or she is feeling. It is important to always encourage your child to talk to you or a trusted adult at school if they are being bullied or they feel excessively worried in social situations at school. If you notice continued sadness or anxiety, consultation and treatment with a licensed psychologist is recommend. Cognitive Behavioral Therapy is the gold standard in evidence-based treatment to address internalizing disorders.

3. Standardized Testing

• Why it can be a challenge: standardized testing is now part of the fabric of education. Curriculum is geared toward testing, and most schools will institute testing only focused work at one point in the school year. Additionally, there are outside tutors and programs designed to help students study for standardized tests. Many students struggle with various aspects of testing: academic pressure, testing environment, time constraints, method of testing, etc.
• What you can do: Talk to your child about the role of testing in their education. While testing is important, continue to prioritize other preferred activities and educational activities. This means it is important to not disrupt your child’s schedule for adding test prep, unless absolutely necessary. Work with your child to assess what is difficult about the testing. This may mean having a conversation with the teacher or a neuropsychological evaluation to determine if any testing accommodations may be necessary. Testing accommodations include: extra time, separate location with smaller amounts of kids, multiple day testing, etc.

4. Sleep

• Why it can be a challenge: Sleep is critical to all cognitive functioning. Lack of sleep or not getting enough sleep can mimic many psychological disorders, including ADHD, Anxiety and Depression. Additionally, many school days start very early, which can be especially problematic for older children in middle or high school. Many times students are also up late completing homework and staying connected via social media. The combination of these two factors can lead to lack of adequate sleep. It is also important to mention that sleep is not cumulative, meaning lack of sleep cannot be “made up for” on the weekend.
• What you can do: Stress the importance of good sleep hygiene in your home. This means setting a bedtime routine and sticking to it as consistently as possible. Screens should be avoided right before bedtime as well. If your child has to wake up very early for school, bedtime routines should start earlier. Keep in mind that is important that your child also have time to relax before bedtime. For older children with personal electronic devices, these can be stored outside their bedroom to ensure that bedtime really means bedtime. Remember the recommended amounts of sleep per age: school age children (9-11 hours), teenagers (8-10 hours) and young adults (7-9 hours).

5. Teachers

• Why it can be a challenge: Just like children have different styles of learning, all teachers have different styles of teaching. If your child’s teacher is not a great match, that can lead to daily difficulty in school. This can manifest in greater distractibility, behavioral concerns, academic struggles, as well as worry and sadness.
• What you can do: Talk to your child’s teacher. Assess the expectations of the classroom as well as your child’s ability to meet those expectations. Discuss accommodations with the teacher that may help your child become more successful. Examples include: movement breaks, alternate seating arrangements, classroom jobs, etc. If the situation does not improve, a trained psychologist or behavior therapist will be able to observe the classroom and make specific recommendations.

Among the adolescents I see in my office, some common topics of conversation include friends, family, school and stress. Most often, the stress is connected to school, with adolescents feeling that they have too much to do in too little time, and that the stakes-getting into a good college and setting themselves up for a successful future-are very high. Among some of them, pressure from parents along with a feeling that credit is only given for high grades instead of hard work is also a theme.

The stress that teenagers feel is very real and quite pervasive. According to a 2015 study conducted by researchers at NYU which surveyed juniors at private high schools, almost half reported feeling “a great deal of stress” on a daily basis and one third stated that they were “somewhat stressed” on a daily basis. The greatest sources of stress were grades, homework and preparing for college. In fact, according to a 2014 study looking at stress levels, teenagers had a higher overall stress level than adults (5.8 versus 5.1 on a ten-point scale).

When I speak with the parents of these teenagers, they often express their own feelings of stress and worry regarding the pressures their children are under, combined with a determination to push their child to always do his or her best work. This tension in families-between competing desires for success and a greater feeling of calm-can be difficult to navigate. Parents may feel pulled between wanting to tell their child that it’s ok not to sign up for an extracurricular activity and worrying that if they don’t sign up it will affect their chances of getting into the college of their choice, or that it will send the wrong message to their child about hard work and will lead down a slippery slope of decreased effort. Adolescence can be a wonderful time of great fun and personal growth. It can also bring about many challenges and difficulties, both for the teenager and the parent, high levels of stress being one of them.

The following are some recommendations for helping your teenager effectively manage and cope with their stress levels:

1. Prioritization and Time management: 

Help your child to figure out what is important and how much time they need to do it. You can support your child by helping them to plan out the night, week or month so that they have enough time set aside for nightly homework as well as longer term projects. This strategy is an important preventive step in making sure that work does not pile up and become overwhelming.

2. Self-Care:

First and foremost, this means making sure that your adolescent is getting sleep, since being chronically tired is (obviously!) not good for decreasing stress levels. But self-care is more than just sleep, it also means having enjoyable activities that your child is involved in and making sure that all of the tests and homework and school visits don’t crowd out the time set aside to read a magazine, play a game of pickup basketball, go to a yoga class or spend time with friends.

3. Physical Activity:

Being physically active is a great way to decrease stress since it increases endorphins, a “feel good” hormone, and can help regulate sleep. Exercise can come in many forms, from team sports to walking to school, so there are many options for your teenager to choose from in order to be physically active.

4. Putting things into perspective:

Despite our best efforts we all fail sometimes. This is not a bad thing and as a parent, it is an important lesson to teach your children. A bad test grade is disappointing and that feeling should be acknowledged, but it is not, as your teenager might believe, the end of the world. As parents, it is important to remind your teenagers of this fact and to even go one step further by helping them to reframe the failure as a learning opportunity. Doing this can be helpful in both figuring out where things went wrong and making changes for the future, as well as learning how to cope with the uncomfortable feelings that failure can bring about.

5. Focus on the process:

One source of pressure for teenagers comes from the weight of very high expectations to always succeed. This expectation can come from a variety of sources including family, internal pressure, peer pressure and cultural/societal pressures. Although it is both natural and healthy to want the best for our children and to have high expectations of them, focusing only on a test grade or the score of the game is a missed opportunity to also pay attention to the hard work that went into those results. Even more so, genuine praise for the effort, persistence and perseverance can be very powerful when the outcome is different from what was expected. Often, when we give praise to other people, it is outcome based, meaning that we praise the final product but not the effort that went into it. Effort based praise focuses on the process and can be given as your child is studying for the exam or practicing for the recital and is not contingent on the test grade or how the recital goes. Some examples are: “I’m really impressed with how much time you’re putting into this paper” or “I can see that you’re putting a lot of time and effort into practicing for your piano recital and I’m really proud of you for that.”

6. Model healthy coping habits:

One important source of information for children about how to cope with stress comes from their parents. As parents, you are always “on” because you are always modeling for your children. When it comes to stress management, this may mean taking a step back to look at your own coping skills and possibly making some changes so that you are modeling healthy strategies for your children.

7. Get outside help:

Sometimes, despite both you and your child’s best efforts, the strategies don’t seem to be working and the stress level doesn’t seem to be going down. In this case, it might be that there is something else going on, such as undiagnosed ADHD or learning issues or issues with mood or anxiety, that are getting in the way of decreasing stress levels and that need to be addressed for things to get better. In these situations, a psychologist can help to diagnose and treat the underlying issues so that everyone’s stress levels will decrease. Some treatment options include Executive Function Coaching for difficulties with planning and organization or Cognitive Behavioral Therapy for difficulties with mood or anxiety.