Parenting an Adolescent

Adolescence is a time of transition. Most parents find themselves bewildered by the changes in their previously affectionate and obedient children. Mood changes, withdrawal, monosyllabic answers and arguments find most parents asking, “What have we done wrong?”

Adolescence is marked by profound changes brought about by the hormonal surge at puberty. The physical changes are accompanied by emotional, behavioural and intellectual changes to which the child has to adapt rapidly.

“As their bodies, brains and worlds rearrange themselves, you (parents) will need to do your own reshuffling.”

Changing role of parenting adolescents

The need for autonomy, independence and a search for one’s own unique identity is an essential part of adolescence. Often, this is achieved by questioning and testing existing rules and norms. Make space for this quest. Handle an occasional error of judgement with explanations rather than with accusations and confrontation.

The essentials of parenting at this age are

1. Trust
2. Empathy
3. Respect
4. Support

Trust is important in all relationships. Trust your teen to do what is right. As far as possible, avoid correcting them and pointing out mistakes. Allow them to learn on their own.

Empathise. Your adolescent child is often plagued by self-doubts and insecurities. Remember you were an adolescent once, and do not trivialise their problems.

Respect their need to be away from you, alone or with friends. Listen to their opinions and try not to be dismissive of their views and values.

Support. Assure them of your love and support without being intrusive; this will encourage them to come to you in need.

Parenting styles

An authoritative parenting style provides the adolescent with opportunities to become self-reliant within a set of rules, limits and guidelines appropriate for his/her developmental age. The personality and temperament of the child may also influence your parenting style (a co-operative and responsible teen requiring much less supervision). The environment (e.g an unsafe neighbourhood) can also dictate your parenting style. Privileges and limits may be set with the active participation of the child. It helps to state your expectations without ambiguity (what is acceptable behaviour and what is not), set clear limits and enforce consequences (loss of privileges) when limits are not adhered to.

When parents differ in their parenting styles.

One parent (often a father who is away a great deal) may tend to be permissive in his parenting. Adolescents (and children!) are quick to take advantage of differences between parents. It is important for the parents to arrive at a consensus privately and present a united front when dealing with limits and consequences.

Autonomy vs Monitoring

There are no hard and fast rules. Monitoring does not mean constant surveillance. Safety concerns entail knowing about the whereabouts of the adolescent outside school hours, friends they are with and contact information. A schedule to return home should be worked out. Similar limits should be set for time spent on social media. Be honest in communicating your concerns and avoid doing things behind their backs. It only leads to lack of trust and a tendency to conceal things from you.

Do not seek to control. Often, clashes between parents and adolescent children are about who has control. Adolescents struggle for control over what they feel is their own life, while parents struggle to hold onto the control they had earlier.

Peers

Sometimes, you may be uncomfortable with the company your adolescent keeps. Do not rush into judgements and accusations. Observe for yourself if there is a genuine cause for concern. Teach your adolescents to say ‘no’ to what they feel uncomfortable about. Explain the harmful effects of risky behaviour (alcohol, drugs, sexual activity) at a young age.

When to seek help

Repetitive problem behaviours and high-risk behaviours require professional help and guidance. Aggressive and violent behaviour, progressive academic deterioration, school refusal or truancy, lying or cheating demand immediate attention. Increasing moodiness, lack of communication, inattention to personal hygiene are other warning signs of psychological distress.

Making the Cut—Self-cutting in Adolescents

Self-cutting in adolescents is the strongest predictor for subsequent suicide attempts. It is a clear signal of severe psychological pain being released physically by the act of self-cutting. However, relief is only temporary, and if ignored self-cutting can progress to suicide.

Self-cutting and Suicide

Repeated self-cutting in adolescents is the strongest predictor of attempted suicide. 70% of those who self-cut will attempt suicide at least once. The number of suicide attempts increases with the number of years engaged in self-cutting (Nock 2006). The risk of attempted suicide is higher than with any other psychiatric disorder including depression and borderline personality disorder. Self-cutting may be a uniquely important risk factor for suicide because its presence is associated with both increased desire and capability for suicide (Klonsky 2013).

Ms LM, 15 years old, was brought by her parents for counselling after a suicide attempt. She subsequently revealed repeated self-cutting over the upper, inner thighs after sexual abuse two years previously.

Self-cutting and Psychological Pain

The majority of people who self-cut do so to relieve intense psychological pain. It occurs independently of a diagnosis of borderline personality disorder, or history of sexual abuse in childhood (Klonsky 2014). Self-cutting has a calming effect. (Klonsky 2006). This is much the same way as applying a balm, the superficial irritation suppresses the underlying deep pain. Individuals who self-cut continue to do so because it decreases feelings of anxiety (Haines 1995). Some people self-cut to punish themselves. A small minority self-cut for attention seeking or to escape from responsibilities.

Ms RX, 24 years old: 'When I cut myself  I feel calm, I don't feel the pain'.

Self-cutting Scars

The scars of self-cutting can trigger distressing memories of a time of psychological pain. Seeing self-cutting scars on friends or hearing of self-cutting incidents can induce the urge to self-cut.

Ms KJ, 19 years old, had a history of self-cutting since middle school and was now coping well in a professional course while staying in hostel. She accidently saw self-cutting scars on her room mate. Since then she is anxious and fighting urges to self-cut.

An increasing number of self-cutting scars is associated with presence of suicide ideation and a history of suicide attempts (Taylor 2016). Visible scars on exposed parts of the body can restrict career and social choices. Skin grafting may be required in some cases (Todd 2012)

Mr JS, 21 years old, underwent training and qualified for an initial pilots license. During medical evaluation for a commercial pilots license self-cutting scars were noted on his chest. He was medically disqualified as a hazard to flight safety.

Why do some people self-cut and not others?

Biology may have an answer. A particular gene for serotonin regulation (5-HTTLPR) may be defective. Youths who face severe chronic interpersonal stress and have the defectives gene self-cut more than those with the fully functioning gene (Hankin 2014). Those who self-cut have reduced autonomic and stress responses to anticipation of pain making them less likely to avoid it. They also have increased responses after pain which reduces feelings of numbness and distress, and increases body awareness. This combination serves to reinforce self-cutting behaviour (Koenig 2017).

Self-cutting is a unique physical marker of severe psychiatric problems. Approach a mental-health professional for treatment.

References

1. Rebecca C. Brown and Paul L. Plener. Non-suicidal Self-Injury in Adolescence. Curr Psychiatry Rep. 2017; 19(3): 20. Published online 2017 Mar 17. doi: 10.1007/s11920-017-0767-9. Accessed 2018-09-14.
2. Haines J, Williams CL, Brain KL, Wilson GV. The psychophysiology of self-mutilation. J Abnorm Psychol. 1995 Aug;104(3):471-89.
3. Benjamin L. Hankin, Andrea L. Barrocas, Jami F. Young, Brett Haberstick, and Andrew Smolen. 5-HTTLPR x interpersonal stress interaction and nonsuicidal self-injury in general community sample of youth. Psychiatry Res. 2015 Feb 28; 225(3): 609–612. Published online 2014 Dec 3. doi: 10.1016/j.psychres.2014.11.037. Accessed 2018-09-13
4. Klonsky ED. The functions of deliberate self-injury: a review of the evidence. Clin Psychol Rev. 2007 Mar;27(2):226-39. Epub 2006 Oct 2. Accessed 2018-09-12.
   
5. Klonsky ED, May AM, Glenn CR. The relationship between nonsuicidal self-injury and attempted suicide: converging evidence from four samples. J Abnorm Psychol. 2013 Feb;122(1):231-237. doi: 10.1037/a0030278. Epub 2012 Oct 15. Accessed 2018-09-11
6. E David Klonsky, Sarah E Victor, and Boaz Y Saffer. Nonsuicidal Self-Injury: What We Know, and What We Need to Know. Can J Psychiatry. 2014 Nov; 59(11): 565–568. doi: 10.1177/070674371405901101. Accessed 2018-09-13
7. Julian Koenig, Lena Rinnewitz, Marco Warth,Thomas K. Hillecke, Romuald Brunner, Franz Resch, and Michael Kaess. Psychobiological response to pain in female adolescents with nonsuicidal self-injury. J Psychiatry Neurosci. 2017 May; 42(3): 189–199. Published online 2016 Nov 29. doi: 10.1503/jpn.160074. Accessed 2018-09-13
8. Nock MK, Joiner TE, Gordon KH, et al. Non-suicidal self-injury among adolescents: diagnostic correlates and relation to suicide attempts.  Psychiatry Res. 2006;144(1):65–72. Accessed 2018-09-08
9. Taylor A. Burke, Jessica L. Hamilton, Jonah N. Cohen, Jonathan P. Stange, and Lauren B. Alloy. Identifying a Physical Indicator of Suicide Risk: Non-Suicidal Self-Injury Scars Predict Suicidal Ideation and Suicide Attempts. Compr Psychiatry. 2016 Feb; 65: 79–87. Accessed 2018-09-11
10. Jodi Todd, Sara Ud-Din, and Ardeshir Bayat. Extensive Self-Harm Scarring: Successful Treatment With Simultaneous Use of a Single Layer Skin Substitute and Split-Thickness Skin Graft. Eplasty. 2012; 12: e23. Accessed 2018-09-11

Anger—effect on your child

Effect of Anger on your Child

Anger has a silent but permanent effect on your child. Anger can affect your professional life, harm relationships, and has significant health implications. But quite apart from how it affects you personally, it affects your children. Children of angry adults have been seen to be more aggressive, oppositional and non-compliant. They are also less empathetic; and display poor overall social adjustment. Delinquency and anti-social behaviour are also more common in such children.

Is anger hereditary or learned?

• A child experiences emotions from birth, but how he/she handles emotions is largely determined by learning. While a child may have an irritable temperament, no child is born with temper tantrums. A child learns that throwing a temper tantrum is rewarding (gets attention or gets him what he wants).
• From infancy onward, children learn by imitation. As parents, we are the first role models. Our children watch us; and then model their behaviour on ours. A child will for example; notice that we talk to our elders respectfully, but that we talk brusquely, even rudely to our maids. They will soon behave the same way.So it is with anger. Children observe how we react in difficult situations, how we react to provocation; how we deal with differences. Do we negotiate and listen to the other person’s point of view? Or do we react immediately and aggressively? Do we talk amicably and or do we get what we want by threats and abuses? How we behave and act today is what our children will emulate tomorrow.

What is the effect on a child when adults behave angrily in front of them? It depends a great deal on the age, developmental stage, personality and emotional maturity of the child.

• Young children, particularly, are scared and confused when they see adults who are ‘out of control’. When it happens often, they learn to think of this behaviour as ‘normal’; and they assume that verbal or physical aggression is the ‘normal’ way to deal with differences, to control others, or get what one wants.
• Very often, children are at the receiving end of parental anger. This may be due to unfair and unrealistic expectations that parents have from their children; or misplaced anger that has its basis somewhere else. Fear, insecurity, and poor self-esteem occur almost universally. Withdrawal, anxiety, depression are some of the negative consequences of such anger. This affects optimal performance in school and peer relationships. 
• Alternatively, the child may learn to defend itself by increasingly oppositional behaviour, bullying younger siblings or other children, or engage in other disruptive behaviours –truancy, aggression and violence.
• Parental anger deprives children of the basic need for security and comfort in their own homes. It also perpetuates the legacy of anger and aggression; conflict and fear.

Anger management strategies for interacting with children

• Stay calm when interacting with children. If you are fuming because you were held up in a traffic jam, cool off with a shower before interacting with your child.
• Physical abuse is a strict no.
• Try and understand the underlying issues behind your anger. Is your frustration resulting from an unsatisfactory day at work? Is your disappointment with your child’s academic performance related to your own expectations?
• Learn about your child—his needs, his temperament, learning styles, even the normal development process. This will go a long way in modifying your unreal expectations.

It is possible to break the destructive chain of anger and to create an environment of safety and security in your home for your children. Start today.

Biology of Anger

We all get angry at times. But some of us get angry often and what is worse, we do not seem to be able to control it. We lash out verbally and sometimes physically at objects and people around us. Can we do something about our anger or is it something over which we have no control?

Let us seek to understand the evolutionary basis of anger and what happens inside our brains when we are angry. Anger is usually provoked by a threat; either real or perceived. Our ancestors had to react (and react immediately) to survive; or to protect themselves or their resources. To take time to think would be to lose valuable time. So the brain evolved a mechanism for immediate action.

An almond-shaped area of grey matter deep within our brains - the amygdala perceives threat and generates the emotions of anger and fear. It raises an alarm, and kick-starts the body responses which we collectively know as “arousal”. Our heart beats faster to pump blood to our muscles, the muscles tense for action, breathing becomes faster and shallower, voice becomes shriller. Our face assumes the expression of anger (clenched jaw, lowered brows) as a warning to the adversary; much in the same way that a dog growls and bares its teeth when threatened. All this happens in a matter of seconds.

The frontal cortex, (the part of our brains responsible for conscious decisions) is by now aware of these bodily reactions and the threat perception. It evaluates the situation and the social context. Based on past memory, learning and our individual experience, it decides to respond in a particular way.

So what we have here is an immediate emotional response, and a later conscious response. An example will make things clearer.

• Imagine yourself at a crowded mall. Someone pushes you and moves on un-heeding. You will naturally be annoyed, your face will mirror your displeasure. You are aroused and vigilant - your muscles tense, you breathe faster. This is the immediate response. You realise though after a minute or so that it was probably accidental and think no more about it.
• On the other hand, you may remember that a friend had his wallet stolen in the same way, you may remember reading media reports about pick-pocketing, and you may be having a substantial amount of money in your wallet. Your reactions will be stronger. You may yell at the person, or may even push him in turn. Your conscious mind from past learning and in the present situation causes you to respond differently.

Our emotions; (anger, fear etc) are innate; but our response styles are mostly learnt. We may have seen the same kind of behaviour in our parents (our first role models) in childhood. Or aggression may be our reaction to abuse or bullying. Or we may have observed that anger is the best way to get what we want. Genes, gender (males are known to be more physically aggressive when angry), and our own personality traits also contribute.

Since emotional arousal occurs involuntarily, you may well ask “How can I have any control over my anger?” You can control the behavioural manifestations of anger.

1. Firstly, recognise the signs of anger and arousal. 
2. Then learn to consciously control these processes. Breathe slowly, lower your voice, relax your muscles, stop frowning. 

Does it help? Yes! When we consciously speak slowly and lower our voices, when we relax our tense muscles, when we wipe the frown on our faces and replace it with a smile, we influence activity of the emotional regions of the brain. fMRI scans show less activation in the amygdala. The arousal process is reversed. This is the science behind and the biological basis of anger management. Cognitive Behaviour Therapy further seeks to modify your perceptions – may be what made you angry in the first place, what you perceived to be a threat; was not so at all?

Impulse Control Disorders – Skin Picking, Hair Pulling & More

Skin Picking, Hair Pulling & other Impulse Control Disorders

Impulse control disorders are a treatable group of disorders which share a common feature. This is the failure to resist an impulse or temptation to do something harmful, either to oneself or to others. The person usually senses increasing tension or arousal prior to the act; and pleasure, gratification or relief following the act.

Common Impulse Control Disorders

1. Trichotillomania or Compulsive Hair Pulling
2. Dermatillomania or Skin Picking Disorder
3. Kleptomania
4. Compulsive Buying Disorder
5. Pathological Gambling
6. Internet Addiction

Trichotillomania in simple terms is compulsive hair pulling. There is a recurrent or persistent urge to pull out hair leading to noticeable hair loss – usually from the scalp but sometimes from the eyelashes and eyebrows. It occurs more often in females and starts in adolescence. Sometimes the person may do it consciously, but mostly she is unaware of it, doing it when she is alone; - watching TV, talking on the phone or reading. It may be triggered by stress but may occur even when a person is calm and relaxed. The loss of hair is distressing to the person and she tries to hide the hair loss by using a cap or a scarf. In extreme cases, she may avoid going out and all social situations.

Dermatillomania or skin picking disorder is a similar disorder. A person may constantly pick at real blemishes (acne, scars, moles) causing bleeding, bruises, infections or permanent damage to the skin. Sometimes a person will pick at imagined defects which no-one else can see. The face is the commonest area. It may be a conscious response to anxiety or depression, but is frequently done as an unconscious habit.

Both trichotillomania and dermatillomania can be effectively treated by various forms of CBT such as Habit Reversal Training, Stimulus Control Techniques or Cognitive Restructuring. Compulsive hair pulling may occur in schizophrenia, therefore a psychiatry consultation is advisable. Medications may be required in severe cases.

Kleptomania is probably the best known of the impulse control disorders and has been described from the early 19th century. There is an irresistible urge to steal objects but these are not acquired for personal use or monetary gain. The objects may be discarded, given away or hoarded. There is a sense of tension prior to the act of stealing and a sense of gratification during and following the act.

Compulsive buying disorder, first described in the early years of the 20th century, is a preoccupation with shopping and spending. 80-90% of those affected are women, and it is more common in developed countries where there is a wide availability of items, higher incomes and leisure time. These people tend to share certain characteristics - they frequently shop alone, usually on credit (having many credit cards), buy items they do not need and are often in debt. Buying urges are episodic and can be frequent (daily) or infrequent (less than a month). Four distinct phases have been identified, including

1. Anticipation - in which there are thoughts and urges of shopping or having a specific item
2. Preparation – the stage at which the person plans and decides when and where to shop.
3. Shopping – which is usually described as “intensely exciting”
4. Spending – which is accompanied by a sense of relief but often feelings of disappointment with oneself.

Many of these women have low self-esteem; and the shopping temporarily allows them to feel better about themselves. It also explains why items purchased are mainly clothes, shoes, cosmetics and jewelry.

Pathological gambling: More common in young men, a person suffering from this disorder has an intense urge to gamble despite severe and often devastating personal, family or work-related consequences. He is unable to stop even with an effort of will. He is preoccupied by thoughts and images of gambling. He needs to gamble with increasing amounts of money to achieve the same level of excitement and is restless and irritable when attempting to stop or cut back. These features of tolerance and withdrawal are similar to those seen with alcohol and drug abuse.

Internet addiction or compulsive/problematic internet use: though much highlighted in the media, this requires further study. What is known is that compulsive internet use can interfere with daily life, work and relationships. When a person feels more comfortable with his online friends than his real ones, when he cannot stop himself from playing games, gambling, internet shopping, or compulsively checking his laptop or phone; it is probably time to acknowledge a problem and seek professional help.

Diagnosis

Impulse control disorders share features with obsessive compulsive disorders and with substance abuse. It is important to see a psychiatrist to rule out co-existing or underlying disorders. Impulse control disorders also need to be distinguished from other medical conditions. Milder cases can be treated as outpatients with medication and psychotherapy. Severe cases such as those with pathological gambling often require admission in a rehabilitation centre.

References

1. Black DW. A review of compulsive buying disorder. World Psychiatry. 2007;6(1):14-18. Accessed 09-May-2017
2. Grant JE, Schreiber LR, Odlaug BL.Phenomenology and treatment of Behavioural Addictions. Can J Psychiatry. 2013 May;58(5):252-9. Accessed 10-May-2017
   
3. Trichotillomania – Symptoms and Treatment Accessed 09-May-17
4. Skin Picking Disorder (Dermatillomania) – Symptoms and Treatment Accessed 09-May-2017