child and adolescent psychiatry

ENABLING IS TOXIC.

People typically seek therapy for themselves or their children to find relief for emotional distress or improve behavior or habits. Therapy can be useful for personal and family insight, growth, and empowerment. However if therapy becomes a place for a person or family to simply confide and vent without any actual relief or improvement, then it may not be helpful.

In my work with patients, I advocate that one of the goals of therapy can and should be to not need it anymore. And this means that the therapeutic work by nature should involve understanding of thoughts and feelings as well as behavior change. One of my jobs is to listen to patients in a non-judgemental way, but if I do not use therapeutic techniques to point out how patients may be perpetuating patterns or not allowing themselves to make emotional gains, than I would be allowing them to stay in the sick role. This is called enabling. It is something I will not do. And by being aware of this potential therapeutic hazard and drawing firm boundaries against it, I can give patients and families opportunities to seek true improvement though it is difficult.


Enabling is toxic. The enabler (the person—a health professional, partner, family, or friend—trying to help) usually has good intentions but without expectations for the enabled (the person in need of help who is likely stuck in a cycle of poor decisions and distress) to make behavior change, he or she is only allowing or fostering the dysfunction to continue. The enabler thinks they are helping but the truth is they are scared and trying to control the situation that the enabled is not yet willing to fully address.

As long as the enabler keeps enabling, the enabled will never get a chance to make positive change. And this is what differentiates enabling from healthy, appropriate help. The healthy, appropriate helping approach allows for the control and decision making to be put in the correct, albeit unpracticed, hands.


FOOD EXTREMISM CAN BE DANGEROUS

There are no solid medical studies (randomized placebo controlled trials) to prove that any type of dietary restriction (plant-based diets, veganism, vegetarianism, gluten-free, sugar-free, cleanses, etc.)  has definitive long-term benefits on growing children and teens (or adults, for that matter). Yet, many parents and youth are seduced by the lure of dietary extremism. As a physician who provides psychotherapy to kids and teens with depression, anxiety, eating disorders, PTSD, adjustment issues, etc., I need to express my deep concern about this. There are multiple levels of physical and emotional damage that can occur as a result of engaging in restrictive food behavior. And no matter how mature youth may seem, their abstract thinking is still in development and they may not fully comprehend that "cutting out carbs" may not just be "cutting out carbs." It may be a way to feel more in control of their chaotic lives. It may be a way to lose weight because they think that'll make them feel better about themselves. It may be a subtle holier-than-thou attitude they pick up from grown-ups in their lives. The list goes on.

Today’s food restriction culture is dangerous, especially for our youth. Even if well-meaning parents, adults, documentaries, and magazines don’t say the following exactly, many teens tell me that the underlying nutrition lessons are: “deny yourself and you’re better,” “restricting is not an option,” “if you don’t eat organic, you might as well eat fast food.” These smart youth describe first world food restriction as "privileged" and "elitist"  but they nevertheless feel compelled to subscribe to it. They feel alienated from their parents and peers who follow extreme diets but can't help but to follow suit. And then...oh the dark, dark places they reveal their vulnerable, developing minds go…

Bottom line: unless a youth has a serious, diagnosed medical condition that requires dietary restriction or is being raised in a family with longstanding religious dietary guidelines, it's worthwhile to take a step back from all the food hoopla and consider the potential harm in unfounded claims of miracle, cure-all, one-size-fits-all food plans and diets. 

I advise parents of my patients to keep it simple. Eat well-balanced, nutritious, and home-cooked meals with your kids as often as possible. Briefly express gratitude to the cook or comment on the deliciousness of the food, but avoid negative or black-and-white food judgments or opinions that aren't backed by science  (like “bread is crap,” “the piece of fat on the steak is so gross,” “sugar is horrible,” etc.). Kids will learn to choose good, nutritious, varied foods in appropriate portions if it’s role modeled at family meals.

Food is fuel. Meals and snacks bring people together and teach social skills and reinforce positive self-worth. Beyond that, thinking, controlling, and restricting food isn’t necessary and can be harmful.

Here are some “food for thought” articles about the pitfalls of food extremism:

https://www.vox.com/science-and-health/2017/7/25/16018658/what-the-health-documentary-review-vegan-diet

https://www.jad-journal.com/article/S0165-0327(16)32391-6/pdf

https://www.self.com/story/i-used-to-be-a-wellness-influencer


 

My Own Hero

It took decades to escape the prison

Of Indian & American patriarchy and I’m newly arisen

Sober from the narcosis of Bollywood heroin: to be a heroine-

long-haired, buxom woman in need of a male “good samaritan”

To save her. To validate her worthiness.

Not so anymore. These days I am my own hero, impervious

To misogynistic fog, walking tall in my Timberlands

Stomping over narrow-minded hoopla, ready to withstand

The negativity that keeps coming when I’m brave & use my well-intentioned voice

To help others discover their truth and choices.

Free from the shackles of giving a fuck what you think

Cuz you haven’t lived in my skin or been on my brink.

Anxiety Sucks, but Trump Could Use Some.

I don’t normally wish a psychiatric disorder on anyone, but I wish Trump had Generalized Anxiety Disorder (GAD). See then he’d overthink everything instead of being so brazen. Then he’d get stuck on thinking and thinking and thinking about how other people viewed him. His anxious brain would force him to attend to other people’s feelings before his own. I’m convinced that a Trump with GAD would be a toned down more empathetic human being.

But, for most people afflicted with any of the anxiety disorders, especially kids and teens, life is extra challenging.

A major component of anxiety disorders is overthinking. So when presented with a situation, a youth with anxiety disorder will automatically and effortlessly come up with every possible cause and effect of said situation. If the situation is dangerous, than this overthinking is a good thing. A biologic, rewired brain, protective thing (Anxiety disorders like PTSD can develop after or during exposure to adverse experiences such as abuse). But when the situation is no longer dangerous and it’s just plain old life, the overthinking is detrimental. It prevents the youth from being in the moment, developing their complete identity & positive self-worth, and making good decisions. They end up trapped in an endless loop of negative automatic thoughts, feelings, and behaviors based on what they perceive will keep others happy even if they harm themselves or someone else. Here’s a common example of overthinking that teen girls tell me about in the office: “I was at a party, the parents were out of town. And the guy I was kind of dating wasn’t there. This popular boy started talking to me. I used to like him so I was all giddy inside. Anyway, he gave me a beer and I didn’t really want to drink it but I did. He started touching me and it was cool at first. But then I wasn’t sure. I tried to move his hand away, but he was like, ‘Come on, I’ll be gentle. Don’t give me blue balls.’ I told him I had a boyfriend but he said ‘he doesn’t have to know.’ I knew that was wrong but he kept trying to convince me. I’d never had sex before and I didn’t want to but I couldn’t say no. If I said no he would get mad. He’d tell everyone I was a loser. He’d hate me and then everyone would hate me. So I let him. Hey, I’d rather deal with it than risk having him mad at me.”

Woah, right? But that is how powerful anxiety is. It makes youth do things their rational selves wouldn’t do.

In addition to overthinking, anxiety disorders can also make youth hold the opinions of others as definitively true. They have difficulty creating thought and feeling boundaries and are often unable to cling to rational thoughts of themselves. And this can have tragic effects. A common example of poor thought and feeling boundaries that teens tell me about: “The kids at school teased me about being fat ever since I was in second grade. It was so bad. I didn’t tell anyone. No one helped me. I even started making fun of myself. I hated what they said but I hated myself more. I started skipping meals. Exercising in my room at night. By the time I got to high school, I was binging and throwing up everyday. I still got teased. Nothing I did made me lose weight. I couldn’t stop thinking about what a worthless piece of shit I was. Am. I wanted to die. I tried to kill myself a couple of times…”

In med school and residency, I’ve gotten top notch training on how to help kids and teens with anxiety disorders. But more than that, I have an anxiety disorder and I’ve come to understand how it almost destroyed my life—this has made me passionate about helping anxious youth find their way through the quagmire of overthinking. And I practice what I preach. I practice being mindful and in the moment. I practice doing cognitive behavioral therapy on my automatic negative thoughts. I get enough sleep. I eat regularly. I exercise regularly. I don’t partake in social media. I try to work on expressing my true thoughts and feelings in the moment even though it takes everything inside of me to do so sometimes.

My latest battle is not internalizing the harsh negative online reviews people have posted about me as a psychiatrist. Things like, "I didn't like her at all" or I'm "unprofessional." My personal favorite, I'm "the worst psychiatrist." Luckily, these days I can fight off the anxious overthinking that tries to make me ignore all the evidence that points to the opposite of their disapproving opinions—that there are more positive reviews online than negative, that reviews shouldn’t really matter at all because I know in my heart that I give my all to my patients in every session (even if that means pointing out things that they don’t want to hear since I know this will give them a better chance of truly healing), that I don’t just do fifteen minute medication checks, that I will not prescribe medication unless it is medically necessary, that I insist on family therapy if indicated because youth don’t exist in a vacuum, that I do intensive talk therapy with youth with the goal of making them assertive, self-confident, and able to utilize a myriad of coping strategies to recover from—and/or live with at a manageable level—whatever psychiatric disorder(s) that plague them. All that and I’m not Trump.

Three Simple Rules That Can Have a Life-changing Impact on Kids and Teens

My teenager looked over my shoulder as I finished typing the first draft of this blog post. She proceeded to roll her eyes and mutter, “Ugh. This is our household.”

I smiled a satisfied smile to myself because, yes, this is our household.

Outside of my household, I’m a child and adolescent psychiatrist and I have the privilege of guiding young people through individual talk therapy to help them overcome mental health issues such as anxiety, depression, eating disorders, post-traumatic stress disorder, reactive attachment disorder, etc. Sometimes there are also complex family dynamics at play that require specific family interventions such as parent education or family therapy.

Over the years of doing individual child and adolescent talk therapy and family therapy, I’ve found that without a certain baseline, non-negotiable structure at home, therapy isn’t as effective or lasting. Because without this basic structure, it is that much more challenging to navigate the muddy waters of mental illness and that much more challenging to even begin to negotiate normal social, emotional, physical, and/or intellectual developmental tasks. Without limits and rules at home they may become even more entrenched in their mental illness. And a lack of boundaries doesn’t just affect youth with mental illness. It can negatively impact any young person.

So what is this baseline, non-negotiable structure I recommend? It’s three simple rules for children and adolescents that parents can enforce.

  1. Social media and screen time - 2 hours a day maximum, but less is better.

  2. Uninterrupted sleep time - 9-10 hours each night.

  3. Family meals - eat together as often as possible.

I apply these rules to my own tween and teen. I recommend the rules for all youth in general, as well as for the youth I treat. Let me give you a bit more detail on each rule.

Social Media and Screen Time

More studies are coming out about the detriment of social media and prolonged screen time. The bottom line is that excessive electronics isolates and prevents youth from learning about normal face-to-face interactions with people, which are an important part of development and happiness. The worst case scenario regarding isolation is that it is a risk factor for suicide. But being plugged in for two or more hours a day can also lead to a significant increase in suicide risk factors.

When youth have their heads buried in screens they are not self-reflecting or thinking independently. It’s not their fault that they want to stare at all the dazzling images and words on their screens. See youth do not have fully developed abstract thinking so they are more vulnerable than adults to being swayed by what flashes before their eyes. That’s also why they are more susceptible to peer pressure. So they see these fancy, filtered images and words and they may become convinced that they have to look and behave that way. They may think they have to get a certain amount of comments and likes to be worthy. They may engage in excessive texting or messaging that doesn’t allow them to learn the nuances of social communication (facial expressions, tones in voice, etc.). They may be vulnerable to online bullying. They may be constantly thinking they are missing out. They may live through their screens instead of in the moment. All of this can impair their ability to move through the normal stages of social, emotional, and intellectual development.

Incidentally, I quit social media. My tween and teen are not allowed to have social media. I figure I should practice what I preach, right?

Sleep

Poor sleep in youth can lead to negative outcomes such as struggles in school, car crashes, and/or depression. Numerous studies have shown that 9-10 hours of uninterrupted sleep is optimal for youth, especially teens because they are in an intense stage of physical, intellectual, and emotional growth.

It is helpful to remove all electronics from their bedroom at bedtime (except a good, old fashioned alarm clock) because teens will often surreptitiously use these devices in the middle of the night. They are not bad for doing this. Testing boundaries is part of normal teen development and it is up to parents to set and enforce the limits to help guide and teach them.

Most kids will not happily go to bed early, my kiddos included. They will most likely complain and fight it. They may also panic because they haven’t finished their homework. But in the long run, sleep is more important. Parents can rest assured that despite what their youth say, setting strict bedtimes helps with brain development and teaches youth to make more efficient use of their time. It may even bring up the issue of cutting back on extracurricular activities if there really isn’t enough time to get homework done. This raises another issue—that youth need time to be bored to help with their normal emotional and intellectual development. But that’s for another blog post.

Eating Meals As a Family

In this day and age of being overscheduled, I cannot overemphasize the importance of eating meals together as a family. I recommend decreasing youth activities if this will allow for more meals together. That’s how important it is. Eating meals together, especially dinners, teaches kids about face-to-face communication. It also can lead to better family relationships, improved nutrition and enjoyment of food, boosted grades and vocabulary, decreased depression and stress, increased ability to bounce back from bullying, improved overall mood, and fosters a positive outlook of the future.

As a side note, there is a trend in our society to eliminate more and more types of food from our diets. The science behind this “purer” eating is not crystal clear. There are many factors besides food that contribute to overall health and longevity.  Still, it is not uncommon for people who don’t have medical reasons for dietary restrictions to cut out all meat, gluten, dairy, sugar, etc. For adults, this is a personal choice and I’m not addressing that right now. But children and teens have different nutritional needs than adults and it can be dangerous for youth to be eating “pure,” “clean,” vegan, or some other restrictive diet unless they are properly monitored by a parent who can make sure they are getting enough calories, protein, vitamins, and minerals. Chronic lack of these nutrients can lead to medical problems and organ damage.

A typical example I see in my practice is the teen girl athlete who restricts her food intake and then doesn’t get enough calories to maintain her high activity level. She loses weight and stops having her period. Contrary to what some people think, it isn’t normal for a girl athlete to not have a regular menstrual cycle. Also parents need to be aware that restrictive diets can be a guise for eating disorders. In fact, "healthy," restrictive eating is the most common trigger for eating disorders in teens that present to my office. Eating disorders are complex and can have devastating consequences, including death.

If the family does not have long established exclusionary food preferences or practices (such as for religious or diagnosed medical reasons), I recommend that youth not be allowed to suddenly follow any restrictive diets. They can make up their own minds when they are eighteen but until then parents can protect them by normalizing inclusive, structured eating- regular meals and snacks, normal portions, preparing and offering a variety of foods, not making negative comments about certain foods, ingredients, or bodies. This makes it less likely that the youth will have disordered eating when they grow up. This makes it less likely that the youth will link food with control and self-worth. They will be more likely to grow up with the understanding that food is simply fuel and nourishment, not a means to happiness, and most certainly not who they are.