Cute child feeding his pet dog

Keeping The Family Peace

What does Family Peace even mean? Are you thinking that sounds a bit too “Kumbayah”?

I do not think every minute of family time is going to go smoothly. I am talking about “mostly kind, mostly peaceful”. Trust me. I am a Mother as well as a Doctor. We have teens and a kindergartner. So, with this context let’s go for it!

I want to make sure that you know that parents need to be on the same page in raising your child a “majority” of the time. I also believe that if you are a single parent reading this you need an amazing support system (family, friends, coaches) to support you in raising your child. We all need support and the right kind of help.

I believe the core ingredients to family peace are: respecting each other, having fun together, setting clear expectations, setting clear boundaries and being consistent in your parenting style. This includes letting any relatives, childcare, coaches, and teachers know of your child’s “style” of relating to the world in the best way possible.

If you want your child to respect you, you need to spend time with them having fun too.

I mean it. If your kids are laughing with you combined with obeying family expectations you are “nailing it”.

 

Most kids respond amazing to praise.

If you like a behavior and want to see more of it you can praise the process of the action they are taking. “I like the way you fed the dog without me asking. Strong Initiative!” “You were really focused when you were doing your homework”. “Thank you for listening to me today. Your behavior was amazing”.

When I was in training as a Child Psychiatry Fellow at UCLA, we all praised and praised and praised the good behavior. I roll pretty positive yet even for me it felt like an “over the top” Hallmark card greeting of joy. Guess what? It works. This method of praise combined with “ignore” described below have been the gold standard recommended of parent training techniques.

 

Ignore the behavior you don’t want to see.

Do not make eye contact, look away, face another direction. If they keep doing it you can redirect them with: “I really liked the behavior you were having earlier today. I want you to continue to earn your allowance (your screen time, your gaming time); let’s turn it around”.

 

In Summary:

 

Step 1: Sort Quality of Behavior

Behavior you like = Praise It

Examples: Feeding the dog. Doing Homework. Saying thank you. Sharing a toy.

Behavior you dislike= Ignore It.

Examples: Whining. Stalling on chores. Fighting with sister. Rolling their eyes at you.

Behavior you find Unacceptable. Set firm consequences.

Examples: Hitting a sibling. Leaving house without permission.

 

Step 2: Praise Effectively=Better Behavior

Tips on Praising:

Praise the behavior not the child.

Praise immediately.

Make eye contact.

Get on the same level as your child.

Hug or give a pat on the back.

Have a smile on your face.

Use a loving tone of voice.

Create meaningful praise to your child.

 

Step 3: Ignore Effectively.

Tips on Ignoring:

Ignore IMMEDIATELY!

Make no eye contact.

Turn away from your child.

Focus on something else (counting to 10, breathing).

Have a neutral, blank face.

Give no verbal or nonverbal message.

Stay calm and emotionally detached.

 

Praise when the behavior stops or one you like starts.

If your child is wearing you down and there is another parent around (or adult figure) I recommend tapping or whispering “tag team” to your support and to take a break from your child if you are semi “losing it” (aka about to drop the f-bomb or yell at the top of your lungs). Quickly transition with “Your Father is going to talk with you now and I will check in with you in a little while”.

I am a firm believer in “date nights” or “alone time” away from your children so you can be a more effective parent.

Do not spend the entire date talking or thinking about your child. You need to play/relax too.

Be consistent. Be loving. Be concise. Set developmentally appropriate rewards.

I have to “walk the walk” at my house just like you. I find mindfulness and twenty minutes of meditation my “secret peace weapons”. Really. I actually tell myself: “Be kind. Be loving”, all throughout the day.

 

You can do this!

 

Dr. Denise

Medication and Child Psychiatry

I am personally grateful that I went to medical school and became an Adult and Child Psychiatrist. Why? Because mental health is the most important part of a person’s well-being. Happy individuals with healthy thoughts create a society in which we can all thrive. We need to think of our children and our future. We need to get rid of the stigma of mental health and focus on mental wellness.

Did you know there is a shortage of Child Psychiatrists in the U.S.A.?

According to the American Academy of Adult and Child Psychiatry, there are approximately 8,300 practicing child and adolescent psychiatrists in the United States — and over 15 million youths in need of one.

I just attended an amazing MasterPsych conference presented by the American Physician Institute in Laguna, California last October. Guess what discussion I engaged my “kindred spirit” child psychiatry colleagues in during our lunch breaks?

Integrative mental wellness and collaborative care.

Using the least amount of medications.

Spending time with our patients.

We talked about the importance of tools such as solution oriented therapy, cognitive behavioral therapy (CBT), nutrition, exercise, yoga, meditation, parent training, and psychoeducation.   As doctors, we know how and when to prescribe medication and value all of the clinical trials that have been done to support the treatment when needed.

I believe that a Child Psychiatrist is the best person to decide if a child would benefit from being placed on a medication for behavioral issues. The dilemma we have is that there are not enough of us. We need to solve the problem of shortage of well-trained child psychiatrists and be a part of the solution for our children getting the proper treatment.

WE NEED A PARADIGM SHIFT. NOW.

Step one is getting rid of the stigma of mental health in our society. Doctors of all specialties and subspecialties need to respect and hold mental health in high regard. In medical school I excelled in many rotations as a third year medical student, even surgery. When I declared psychiatry as my residency choice there was a definite stigma from my colleagues. I moved forward with passion and strong conviction that psychiatry was the right fit for me. I believe that mental health is the foundation of all health and wellness. It should be integrated into all health care.

As Child Psychiatrists we need to be open to being part of the solution of attracting more medical students into our profession. We need to be thought leaders in supervising pediatricians on mental health diagnosis’. If we have a proper system in place then I believe the children will get the right treatment and be put on the least amount of medication.

Dr. Denise

 

The Dr. Denise Way

My approach is to meet my clients where they are at – to understand their world view and their perspective on medicine and wellness. I want people to embrace their mental health. Your strengths can be your weaknesses. My golden rule is to be loving and be kind and be the best version of yourself. What does your best look like for you to thrive, not just exist? Create your own golden rule – something that keeps you grounded and mindful throughout the day.

Depression

If you’re not having the true joy each day that you are familiar with in the past, there could be a good chance that you’re suffering from low grade depression. Most people who come to see me have just had a traumatic event and they are pre-disposed to having a larger depression and now they are having hopelessness and the inability to get out of bed. You don’t have to wait until a traumatic event happens and you start feeling hopeless and not be able to get out of bed. Go see someone before your low grade depression turns into a major depression. You can have a lot more joy in your life. If you don’t have enough energy or enough joy, even if you are successful you might want to get assessed or let your doctor know you are feeling this way. You can experience a much more joyful life. 

Obsessive Compulsive Disorder and Anxiety

Did you know that Obsessive Compulsive Disorder  (OCD) affects 2-4% of adolescents and that 80% of people who have OCD experience symptoms before age 18?

It is important to point out that most mental health challenges start in childhood.

I value science and the need for a uniform way of discussing mental health, yet feel the term “disorder” (when discussing mental health) really puts a distance to someone embracing their “neurostyle”. We need to identify children who need extra mental health support and integrate wellness thinking and acceptance of neurodiversity in our society. Let’s discuss OCD now.

Did you know that the World Health Organization (WHO) ranks OCD as one of the ten most disabling diseases?

The OCD cycle usually starts with an environmental trigger that leads to an obsession described as intrusive, repetitive, negative images, thoughts or impulses. This causes distress as manifested by anxiety, fear, disgust or shame, followed by compulsive behavior as represented by repetitive thoughts, images, or actions.

The OCD cycle

(Trigger >>Obsession >>Distress>>Compulsions >>Negative Reinforcement)

It is a myth that OCD is an Adult disorder.

The two common onset peaks for OCD include earlier for boys that have the triad of OCD, ADHD and Tic disorder, and early puberty for girls.

In child psychiatry it is common for children to present with more than one behavioral disorder. OCD exists in combination with one other behavioral problem ¾ of the time and with multiple problems 1/3 of the time.

How do we identify and begin to treat OCD?

A diagnostic interview is done which includes parent and child interviews, a review of rating scales, report cards and if OCD is present a clinician scores the severity of OCD with the Yale-Brown Obsessive Compulsive Scale (YBOCS). The 10-item (each item rated from 0 (no symptoms) to 4 (extreme symptoms) Y-BOCS scale evaluates the severity of obsessions and compulsions separately and is the standard scale used in treatment outcome studies of obsessive compulsive disorder (OCD).  The severity of OCD is based on total core: 0-7,is subclinical; 8-15 is mild; 16-23 is moderate;24-31 is severe; 32-40 is extreme.

Do you want to know the good news? Pediatric OCD is usually responsive to treatment with the goal of a score of <8 on YBOCS .

“Exposure therapy is the secret sauce in treating OCD,” UCLA Scientist and Professor James McCracken M.D. would say during our child psychiatry clinic. Exposure therapy is a behavior therapy that involves the exposure of the patient to the feared object or context without any danger in order to overcome their anxiety. An example would be an individual with fear of contamination. The exposure would be putting their hands in dirt and not allowing them to wash their hands for a period of time.  The patient ranks their fear level before and after the exposure and realizes that the fear reduces over time after exposure.

The first line treatment for OCD is Cognitive Behavioral Therapy with  Exposure and Response Prevention (ERP).Children who lack insight, have ADHD or depression, have a family history of OCD, or high family conflict tend to have challenges with response to behavioral therapy alone. From a medication standpoint the Selective Serotonin Reuptake Inhibitors are the first line of treatment, the four FDA approved SSRI”s are Clomipramine, Fluoxetine, Sertraline and Fluvoxomine.

The well known POTS study (Pediatric OCD TREATMENT STUDY JAMA 2004:292(16) reveals that  combination treatment was consistent with a 53.6% remission rate and CBT alone 39.3%, Zoloft alone 21.4%. It was also noted that those with family history of OCD had more than a 6 fold decrease in response to CBT alone.

Combination therapy yields the best results for moderate to severe OCD.

Let me give you a clinical example of a sixteen-year-old girl, Christina (pseudonym) who I worked with whose trigger to her obsessions was watching television and witnessing motor vehicle accidents, or driving over speed bumps. Her obsession was that she had fatally harmed someone as her obsessive image and thought. Her compulsive behavior was getting in the car and retracing her route to make sure she had not actually injured someone.  She would call hospitals to make sure no one had been hurt.  She came to see me for help with her OCD.

Her YBOCS score was in the extreme range (>32). She did not respond initially to CBT-ERP alone. A combination of Prozac and exposure therapy yielded great success for Christina! Her YBOCS was less than 8 within a year of treatment. She and I drove in her car and we would ride over bumps and not go back to the site to see if anyone was ok or call hospitals to make sure no one was in the emergency room. Christina is now in her mid twenties successfully working and is not on any medication for OCD! She utilizes her tools from therapy, exercises regularly, eats healthy and meditates routinely. This is a great thrive story-right? This is why I love what I do.

Dr. Denise