But I Thought That WAS Quality Time!!??

Over the years, I have visited with many depressed teens and tweens in my office who felt disconnected from their families.  Interestingly, almost universally, they desired more connectedness.  Sometimes the youth were skeptical that things could change... but typically they wanted them to change.

I visited with a young man whose father was a hunting enthusiast and spent most of his free time on the weekends at the deer lease. The brother had a good relationship with dad because the brother liked hunting.  This child who was a bit more sensitive felt very distant from his father.  Unfortunately, the father had made no effort to find out what the child liked.  “We are just different,” the father had told himself.  He used this as an excuse to not nurture a relationship with his son.  The son began to feel inadequate and depressed.

A teenage girl was feeling left out that grandparents came to town to visit other family members but did not reach out to her. The mother relayed the information and then the grandparents invited her to attend a football game.  She declined the invitation because she hated football.  Her rationale?  She felt that if they wanted to spend time with her they would have selected an activity that all would enjoy, or chosen a way to engage in a meaningful way with her.  Rather than communicating her feelings, she retreated to her bedroom and cut her thighs with a craft knife blade to distract from her emotion.

Recently in my office, a high school student shared frustrations with his father’s lack of availability, and his mother was shocked.  “But he takes you to all of your lacrosse practices and sits in the stands, watches and waits for you” she said.  “But I am busy then,” the boy replied.  “’We never get to hang out or talk.”

A boy with ADHD enraged his father with off-task behavior, and the family was frequently in turmoil and conflict.  With a little probing I learned that the father and child were frequently in screaming matches.  “Are they having fun together?”  I wanted to know.   No.  The child did not like what the father liked.   A little problem solving revealed that everyone liked board games, however, the family rarely played them.

When a person is not doing well emotionally or behaviorally, a psychiatrist or therapist will often assess the key relationships in that person’s life.   Sometimes, emotional problems develop when there has been longstanding conflict and tension or lack of nurturing and support.  Changing family dynamics can be a powerful catalyst for healing.   Conversely, when someone has been struggling with depression, anxiety, addiction, stress, etc., family relationships often suffer and may need repair.

Certainly, when children are struggling, it can be helpful to think about the family system:  what strengths and supports are in place to help the child thrive, what support is missing or not working well, how are a child’s negative behaviors impacting caregivers’ and siblings’ ability to care for them?  How are parents’ behaviors, expectations, frustrations, and reactions impacting a child? When parents feel that family interactions and behaviors are problematic, in can be useful for them to evaluate their engagement with their children and critically consider if it is optimal.  Often, youth I meet with in my office share a concern that an important person in their life is not sharing meaningful time with them.  Sometimes, this is a distorted perception that can be addressed in therapy.  Often it is truth.  Fortunately, treatment can improve this scenario.

It’s realistic to expect that kids simply have to do things they don't like or things that are necessary for the family.  In fact, this is useful to help build frustration tolerance and ability to accept delayed gratification.  Sometimes, children benefit from exposure to experiences that they would not choose, but will advance learning and development.  Piano lessons, anyone?  However, children should ideally be afforded the time to engage with their parent in activities the CHILD likes.  Over and over again, I see parents failing to make an effort to engage with a child in a way the child prefers.

Certainly there will be times with teenagers that everything is boring, family members are annoying, and family members’ attempts to foster relationships are shunned.   Sometimes “I don’t care” from a teenager is the closest we get to “yes, I would love to!”  As youth gain maturity and a desire for independence, more time is naturally and appropriately spent with peers; however, most youth thrive when independence is tempered with boundaries, guidance, support, and love from their families.

Giving a teenager options on when and how to spend family time can help.  “I would like to take you out this weekend so we can catch up.  Would you prefer to go to lunch today or breakfast tomorrow?”   Asking a child for ideas on activities to do together can be productive but often overlooked. 

Children who feel alone and bored can find ways to fill this void.  There are peers who will introduce them to marijuana or alcohol, perhaps sex before they are ready.  Youth who are not engaged in meaningful activities within a family can create theories depicting themselves as inadequate or unimportant.  While it is key to focus on homework and tests, service hours, and chores, it is imperative that the value of the relationship is not sacrificed.  Often times, this realization is the most pivotal for families I see in crisis, looking for solutions.

In this busy era of practices, rehearsals, and large homework loads for kids and out-of-town travels, conference calls, and dinner meetings for parents, it can be a challenge to carve out time for leisure activity, let alone a sit-down family meal.  In the Portteus household with four young children, we deal with the daily struggle to manage tasks and support relationships in caring and meaningful ways.

If you are not feeling engaged with your child, it might be a good time to invite them to do something fun… and let them choose!  Families with conflict or disengaged relationships may also find it useful to evaluate and treat possible depression and address relational problems in therapy.

Andrew Portteus, MD, MPH

The Portteus Psychiatry Group is a family mental health practice that provides diagnostic evaluations and treatment with individual therapy, family therapy and medication management.   To learn more about us, read Dr. Portteus’ blog, or schedule a consultation, visit www.drportteus.com or call 214-550-3367.

Selecting A Mental Health Provider

When someone begins to identify a problem and wants to seek the help of a mental health professional, they are often left wondering “Who do I see?”, “Where do I go?” “What kind of practitioner would be best?”, “And what is the difference between a psychiatrist and a psychologist?”… 

To determine the right fit, it is useful to understand the specialized education and training different providers have obtained, where their skill sets overlap and where they diverge.

 A psychiatrist is a medical doctor (M.D.) who has attended four years of medical school after college and then completed a four year residency training program in psychiatry. A child and adolescent psychiatrist has completed a two year fellowship in child psychiatry in addition to the residency. This training involves taking classes and working with supervisors in psychiatric hospitals, outpatient mental health clinics, schools, and therapy clinics. A psychiatrist is trained to evaluate and diagnose behavioral and mental health problems, determine whether or not a medical problem could be causing the symptoms, and to develop a comprehensive treatment plan with behavior modification, therapy, and/or medication.

 Psychiatrists have training both in psychotherapy and in using medications to treat mental health problems. A psychiatrist is a good bet if you need a comprehensive assessment to figure out what is wrong and determine a diagnosis, if you need someone to talk to about private or sensitive problems, or if you or your child have a condition that will respond well to medications such as: depression, anxiety or panic attacks, obsessive-compulsive disorder (OCD), attention deficit hyperactivity disorder (ADHD/ADD), bipolar disorder, schizophrenia, tic disorders (Tourette’s), sleep problems, etc.

 In my practice as a psychiatrist, I work with both adults and youth. When working with a child, I visit with children and parents, review school reports, inquire about medical histories, observe behaviors, and sometimes play and draw to understand what is happening with a child. I look at mood and behaviors, thoughts, sleep and appetite patterns, school and work performance to develop an understanding. I have some patients who come to see me for psychotherapy to improve their mood or behavior, some who were referred by their therapist for me to evaluate and prescribe medications, and others who come for both therapy and medication treatment at my office. As a child, adolescent, and adult psychiatrist I often work with families, too. I frequently collaborate with primary medical doctors, psychologists and diagnosticians, language and occupational therapists, school personnel, and individual and family therapists when it is helpful to have a team approach.

A psychologist completed a graduate (Ph.D.) program in human behavior. Psychologists have specialized training in administering and scoring educational and psychological tests such as IQ and achievement tests, personality tests, etc. They have training in diagnosing mental health problems, developing treatment plans, and providing psychotherapy. Some psychologists primarily conduct testing for learning and personality problems, some primarily conduct psychotherapy and behavioral training, and many do both. If a parent is concerned about a learning disability such as dyslexia, they may seek testing from a psychologist to evaluate the problem. Psychologists will refer clients to a psychiatrist if they believe medication would help with focus problems, mood problems, behavior problems, or anxiety. Psychiatrists often will refer their patient to a psychologist if they suspect a learning problem needs to be evaluated or to receive psychotherapy. 

Educational diagnosticians are also helpful in conducting testing for school and learning problems. Speech and language therapists are helpful in diagnosing and treating language processing problems. 

A therapist (or psychotherapist) may be a psychiatrist or a psychologist, or a therapist may have completed a master’s degree program in social work or counseling and have completed training with a supervisor. A licensed therapist has completed licensure requirements such as a LPC (licensed professional counselor), LMFT (licensed marriage and family therapist), or LCSW (licensed clinical social worker). Because anyone can call themselves a “therapist”, it is important to review their credentials and inquire about their areas of specialty. Therapists can be helpful when a person needs someone to talk to about life adjustments, grief, or promoting positive changes in the future, when one has developed negative or worrisome thought patterns that need to be corrected, when they need help with communication problems or family dynamics, or when they need help with parenting or behavior management. 

To find a provider it can be helpful to get recommendations from friends, school counselors, pediatricians and primary medical doctors, clergy, the internet, etc. For more information about mental health topics or my practice, see additional information on my website at www.drportteus.com

Andrew M. Portteus, MD, MPH, PA

Promoting Emotional Development In Young Children

When asked about helping young children regulate their emotions, I recalled an event from our own family experience a few years ago. My wife and I were grilling some meat on the stove and the kitchen began to get smoky as the marinade caramelized.  Then the smoke alarm sounded-- it was a shrill, piercing, high-pitched squeal.  My wife turned up the fan on the vent-a-hood while I made a mad dash to hallway to yank the smoke detector from the ceiling and remove the batteries.  I was not quick enough.

Our twin boys, two-years old at that time, began to cry. They stood paralyzed.  They needed to be held.   "What Happened?" was asked and answered repeatedly for the next half-hour. We reassured them, and the boys parroted back "we're OK" and "it’s OK".   We explained and discussed the benefits of the smoke alarm.  "What happened to the alarm?" played in stereo like a broken record between sniffs and sobs and verbalizations that everyone and everything was doing well. 

"That alarm startled me" I said, finally.  "It startled me, too." one of the boys shared.  That alarm was too loud, it scared me." I said next.  "Alarm was too loud" and "it scared me too." I heard repeated from different directions.  Then, things seemed to calm.

Dr. Portteus and his twin boys

This experience reminded me of the importance and benefit of helping young children put words to ideas and the feelings that go with them. 

My wife and I try to help verbalize feelings when we see a meltdown starting.  “It’s frustrating when you cannot get the blocks to stand up like you want to…” or “I understand that you want to watch Elmo and are disappointed that we can’t do that now.  We can look forward to watching Elmo after lunch…”

It seems rare to find books for young children with engaging characters and storylines that are also helpful for emotional development.  We were very pleased, recently, to find some books with fun stories and colorful drawings that help children process fears, frustrations and anxiety, so I wanted to share the recommendations:

Author Anna Dewdney has written poetically about the experiences and emotions of Llama Llama.  Llama Llama Misses Mama addresses separation anxiety and adjustment.  Llama Llama Mad at Mama deals with frustration management, delayed gratification, and seeing the positive side of a difficult situation.  Llama Llama Red Pajama addresses fear of being alone, patience, and not jumping to fearful conclusions.  All these stories promote secure attachment and confidence.  One of my little llamas asks to read one of these books every night.  Hopefully the little llamas you know will like them too (and learn about emotional regulation in the process).

To learn more about the Llama Llama book series, visit www.annadewdney.com.

To learn more about the Portteus Psychiatry Group and my practice as a child, adolescent, and adult psychiatrist, read more on my website, www.drportteus.com.

Andrew M. Portteus, MD, MPH, PA

As Mean As A Rattlesnake!!!

Not long ago, a mother was sharing with me her frustrations about her teenage daughter’s behavior.  The girl was rude.  She was disrespectful.  She was argumentative.  As the mother talked, she became louder and more animated until eventually she screamed out “She’s as mean as a rattlesnake!!!” 

When I visited with the daughter, I discovered that she had been feeling bad for some time.  She wept in my office about many concerns and frustrations.  She was stressed.  She has not been sleeping well lately.  And she had been feeling very irritable.  Little things were making her annoyed and she was over-reacting.  She had been feeling like nothing would work out for her and she was starting to think about suicide. 

Fortunately, this girl presented for treatment and we were able to provide her some brief psychotherapy and start and antidepressant medication which drastically improved her mood and behavior.

We often think of Depression as feeling sad or blue and crying more.  But depression does not always present this way.  Often, irritability can be a presenting feature of Major Depression. 

When working with families, I sometimes meet with a father who is short tempered and reactive.  Family members walk on egg-shells to avoid a conflict.  He may be a workaholic.  He sees himself as task oriented, but coworkers find him difficult and overbearing.  He looks tired from poor sleep.  He is depressed and does not know it.  Sometimes I meet a mom who is “flying off the handle” and “snapping” easily.  She reports mood swings and decreased enjoyment from her life. 

I often see children who have stopped enjoying activities they have usually liked, have given up friends, and tell me they get easily annoyed by little things.  Often as we explore more we discover an untreated depression.  A while back I met with a kindergartner who had always been sweet and loving.  The parents knew something was wrong when he erupted in class after a little girl came over to compliment his painting.  He took his paintbrush and destroyed his work and hers.   He had become angry and irritable and cried easily.  He told me he felt like a bad boy and wished he were dead.  He had gone out in the road and sat down, wishing a car would hit him, but he hadn't told anyone.

Depression is a biochemical, metabolic change in the brain that can present with sadness or irritability.  It often can cause loss energy, lack of enjoyment in activity, and decrease in concentration.  There may be sleep or appetite disturbance.   Stress or anxiety may be present.  Depression often runs in families.

If an individual suspects that they or a family member are depressed, they should meet with a mental health professional or their primary physician to explore the diagnosis further.   Antidepressant medication can often be effective and well tolerated.  Cognitive behavioral therapy can also be helpful.  Exercise, a healthy diet, and good sleep hygiene can also help improve mood.  Some studies have suggested that Omega 3 fatty acid supplements (fish oil) may help promote a good mood, too.

To learn more about features of depression and treatment options, visit my website www.drportteus.com.  To schedule an appointment you may call my office at 214-550-3367.

Adult ADHD, Wait Is That Me?

When parents are discussing their child’s school difficulties and problems with inattention and distractibility and we review ADHD criteria for their child, a parent will often say “wait a minute…  that sounds a lot like me!”  As ADHD was not as well understood and less commonly treated a generation ago, many adults were never diagnosed or treated for ADHD as children.  They may have been called “spirited” or “ a chatterbox” or “a daredevil” if they had hyperactive traits, and may have been said to “not be working up to their potential” or be “daydreaming too much” or “not complete assignments” if they had inattentive traits.  Since ADHD tends to run in families, it is not unusual to find ADHD traits in a parent or grandparent of an ADHD child.

Many adults with ADHD have learned to adapt to ADHD traits and have found a niche where ADHD may even be an advantage professionally or socially.  Adults with ADHD are often fun and spontaneous, and do well with creative ideas and shifting task frequently.  Yet for some, disorganization, trouble listening in meetings, procrastinating, getting sidetracked, forgetting appointments, making careless mistakes or letting things slip through the cracks can have serious social implications or prevent advancement at work.

“One of the most rewarding parts of my career has been working with adults with ADHD, helping them become more focused, organized and productive and then watching the transformations as they gain confidence and satisfaction and success in their relationships and professional endeavors.”

— Andrew M. Portteus, MD, MPH, PA

Not long ago I met with a very likable and intelligent young father who was struggling with his marriage and facing divorce.  His wife had gotten frustrated with his not finishing school, bouncing from job to job, and not completing projects around the house.  Although he was well read, well spoken, and highly intelligent, he felt like a loser.  Nothing ever seemed to work out or go his way.   We were able to identify and treat ADHD with dramatic results.  He was then able to see tasks through to completion and began to thrive professionally.  Later, he wept that this had not been pointed out years sooner, as he felt earlier treatment would have saved a lot of stress in his marriage.

I have met several stay-at-home moms who were frustrated that they never seemed to be able to get caught up.  Somehow the laundry never got done, maybe started but not put away.  The bills would frequently seem to be paid late.  They would order and address the Christmas cards, but never get them mailed.  They would leave church services and ask themselves “what did they just talk about?”  They felt like they were always misplacing their car keys or cell phones, and running late or forgetting meetings.  Several moms who were evaluated and diagnosed and started medication have reported that “things seem to just run a lot smoother”  and  “I get things done now.”

I have worked with several professionals who reported doing pretty well, but noticing they struggled with sitting through meetings.  They couldn't keep up with e-mails.  They had a hard time organizing several projects and making deadlines.  They put off the boring parts of their jobs and found that they made careless mistakes entering data.  They reported feeling like their minds were someplace else if they have to do a lot of technical reading.   Graduate students with ADHD often find that they are able to study and pay attention and their grades improve when diagnosed and treated with medication.

Adults who feel like they have difficulty staying focused, who get sidetracked and distracted easily, who struggle with staying organized, who feel forgetful, or find that they lose belongings frequently may want to explore the possibility of inattentive type ADHD (Previously called ADD).  If the difficulties are causing problems with work or school or family functioning, it may be useful to seek an evaluation or treatment.    A psychiatrist who is experienced with ADHD can evaluate symptoms and recommend treatment options.  Organizational strategies and medications often help reduce problems associated with ADHD.  For more information about adult ADHD and treatment or to schedule an evaluation, you may visit the Portteus Psychiatry Group website www.drportteus.com.

Andrew M. Portteus, MD, MPH, PA

The Importance of Setting Boundaries & Limits

Right now, with our two-and-a-half year old twins, my wife and I are helping them explore their environment to learn new things and to have fun with play.  To create happy and secure children, we are also teaching limits and boundaries.  A lot of time has been spent sharing our expectations and enforcing consequences for good and bad choices:

"You can't pull your brothers hair or bite, or you will have a time out and need to say sorry" (And if you reply "I'm not ready to say sorry", your time out continues.)

"You can watch a DVD in the car on a long road trip if you don't put your feet on the screen or pull the wires, if you do, daddy will turn it off."

"You need to tell us what you want with words.  We will help you as soon as you stop screaming and let us know what you want."

Milk stays in the cup.  Food stays on the plate.  We sleep in our own beds at night...

As children grow and develop more skills, some things get easier.  But parents of tweens and teens point out how new challenges quickly replace old ones.  As children mature, their needs for boundaries change, but continue.

It is helpful for children to know clearly what is expected of them.  It is hard to win the game if we don't know the rules.  It is hard to reach a destination if we don't have a map.  Family rules should be established and discussed. 

When parents are rigid, unreasonable, and unyielding, they may be met with defiance and hostility.  But when parents are vague, wishy-washy, and inconsistent, they may find their children floundering.  Parents must own the responsibility to set the clear path for their children. 

Throughout my career, I have been interested to learn that numerous teenagers want to be shown the way and the road by their parents.  Many adolescents tell me privately that they want limits from their parents, and that it lets them know that their parents love them (even if they protest in their parents presence.)  Teens will often push for new freedoms, and they should.  This is how they grow in independence and responsibility.  But, this push should be met with negotiation and parental guidance.

Recently, a young adult who was struggling in college and searching for direction asked his father to impose a curfew and help him establish structure in his life.  He determined that his lack of self-discipline and follow-through stemmed from a lifestyle of permissiveness and absent parenting that started with his parents divorce in his teen years and continued throughout his adolescence. 

It is best when rules are developed from a place of love and respect, and when limits are fair and reasonable.  Any adult who has worked for a boss who was arbitrary, hostile, and controlling will tell you that the experience was demeaning and did not nurture their best work.  Similarly, children will respond best to a boss who is loving, compassionate, forgiving, and fair.  Sometimes, the hard part of parenting is giving your children what they need when it is not what they want.  Being a loving parent does not mean giving in or sacrificing parental limits to become your child's best friend.  It does mean working in the best interest of your child. 

Psychologists and psychiatrists believe an important part of establishing boundaries is recognizing that your child has a choice of whether or not to follow the rules.  It is hard to exert our will on another.  Children have the freedom to follow rules or not.  But there should be consequences for their choices.

Consequences should be proportional to the mistake.  They should quickly follow the offense and they should be finite in duration.  To have an impact, they should be enforced.  Consistency is essential.  Ideally, consequences should matter and be tailored to motivate an individual child.  When possible, consequences should be determined and discussed in advance, hopefully as a deterrent to pushing the boundary.

Children should be rewarded with praise, positive feedback, and privileges as the consequence for making good choices.  Similarly, children should face the negative consequence of a poor choice.  When consequences are used appropriately, parents don’t need to scream or lecture excessively to get their point across.  They can let the consequence do the work.

To help children develop character, it is useful to allow children to accept the natural consequences that result from their behavior at school, on sports teams, and at other activities.  Certainly, there are times when parents must advocate for their child when a child has been treated harshly or unfairly, but parents who bail their children out from all problems rob their child of the opportunity to learn the lessons of their actions.  They create entitlement and irresponsibility.

Finally, it is important for parents to set good examples and model appropriate behavior.  It is hard to expect a child to be honest if he sees a parent twisting the truth or taking unfair advantage.  It is hard to expect a child to be kind and respectful if he sees a parent belittling others or acting in an abusive way to a spouse or talking about people behind their backs.

“Based on my work with adolescent patients, I believe parents should set boundaries and expectations consistent with the core values and morals of the family. These typically include parameters around Homework and Chores, Relationships with Friends or Siblings, Bullying and Teasing, Lying and Cheating, Alcohol and Drug Use, Safe Driving, Sexual Behavior, and Accountability Measures related to Curfews, Check-Ins, and Performance Expectations when outside the home.

In addition to these long standing parenting challenges, the digital age has us all questioning norms and limits— whether as an adult or a child. Parents must be mindful of setting electronic limits with their children, from time spent on TV, Computers, Gaming, Social Media, Emailing or Texting. We know there can be public, embarrassing consequences associated with risky behavior in these areas, and I encourage parents to use such topics to engage in discussions with children or teens about what a certain behavior is worth to them, both in the short, or long term. Online safety should be a priority for all families.”

— Andrew M. Portteus, MD, MPH, PA

On a recent vacation, my wife overheard a group of twelve and fourteen year old girls by the pool discussing boys' penises, sexual activity they have engaged in, and their alcohol consumption.  A waiter reluctantly delivered two pina coladas that a girl accepted for her parents who had stepped away.  The girls consumed the drinks, and when the father returned, his daughter thanked him for ordering the drinks.  He nodded in acceptance.

Currently, alcohol and drug use among middle and high school students is astronomical.  One reason, I believe, is that parents are failing to set clear expectations and boundaries around illegal alcohol consumption.  Because some kids experiment, and perhaps because they, the parents did, many adults are now creating an environment of permissiveness and acceptance. 

The fact that kids may push boundaries is not an acceptable reason to not have boundaries in place.  It is the reason kids need them more than ever.

I encourage parents to discuss expectations, to set safe and supportive boundaries for their children, to reward good behavior, and to enforce consequences when needed.  Your kids will be better for it.

If you have concerns about your child's behavior or family functioning, or if you have a mental health need, you may visit the Portteus Psychiatry Group website www.drportteus.com or contact out office at 214-550-3367 to schedule an appointment.

Andrew M. Portteus, MD, MPH