Category Archives: PTSD

What to know about psychiatric residential treatment

What to know about psychiatric residential treatment
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residential centerHave you been searching for psychiatric residential treatment for your child?  Do all the programs sound wonderful?  Ads include quotes from happy parents, and lovely photos and fabulous-sounding activities.  But what’s behind the ads?  Residential treatment programs are diverse, but there are important elements they should all have.  Here’s how to avoid low quality residential treatment.

Psychiatric residential treatment is serious stuff–it’s difficult to do–especially when troubled children and teens are put together in one facility.

Should you ask other parents for their opinion of a program?  In my experience with a child in psychiatric residential care, and as a former employee of one, word-of-mouth is not the best way to assess quality or success rate.  There are too many variables: children’s disorders are different; acuity is different; parents’ attitudes and expectations are different; length of time in the facility is different; what happens once a child returns home is different…  It’s most helpful to ask questions of intake staff and doctors or psychologists on staff.  Quality psychiatric residential care facilities have important things in common.

What to ask about the staff:

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  • What is the training and licensure of staff?  Are there therapists with MSW degrees, registered nurses, psychiatrists and psychiatric nurse practitioners, and is a medical professional available on site 24/7?
  • There should be a high staff to patient ratio, and a physically comfortable environment with lots of emotional support.
  • Do the staff seem mature to you?  Do they support each other, are they a team?  There is often heavy staff turnover at residential treatment centers because the work is emotionally draining, so staff cohesion is as important as the qualities of each individual.
  • Safety is paramount.  Staff must be able to safely manage the things that can go wrong with troubled kids.  They should be trained in NCI (Nonviolent Crisis Intervention), “training that focuses on prevention and offers proven strategies for safely defusing anxious, hostile, or violent behavior at the earliest possible stage.”

What to ask about programs:

  • Does the program specifically identify parent/family involvement as part of treatment?  Does it emphasize parent partnership with staff?  Ask.  Whether you live close or far from the center, even out-of-state, you should be regularly included in conversations with staff about your child’s treatment.  You should also be included in a therapy session with your child periodically; some facilities can connect with you over Skype.  Your child’s success in psychiatric care depends on their family’s direct involvement.
  • The program should coach you in specific parenting approaches that work for child’s behavioral needs.  While your child is learning new things and working on their own changes, you must also.
  • You should be informed why your child is getting the treatment or behavioral modifications he/she is receiving.

Body health is mind health, and vice versa.

  • residential programsMental health treatment will include medication and therapy, but must also include positive activities and an educational program.  The whole body needs care:  exercise, social activities, therapeutic activities (art, music, gardening), healthy food, restful sleep, etc.

Is your child emotionally safe as well as physically safe?

  • You should be able to visit the unit or cottage where your child will live, see their bedroom, and see how the other children interact with staff and how staff interact with each other.

What to ask about the business itself:

  • Can you take a tour ahead of time?  Can your child or teen visit too if appropriate?
  • Are emergency services nearby (hospital, law enforcement) that can arrive quickly?
  • Does the facility have a business license in their state?  Do they have grievance procedures?  Is the center accredited as a treatment facility, and by whom?  In the U.S., the main accreditation authority is called JCAHO (Joint Commission on Accreditation of Healthcare Organizations).

Psychiatric residential treatment works miracles, but it doesn’t work for all children.  Some need to go into treatment more than once to benefit. Some fall apart a few weeks or months after discharge.  These are common.  What’s important is that you and your child are taught skills for managing his or her unique symptoms, communicating well, and committing to staying well together.

Good luck.

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Filed under bipolar disorder, borderline personality disorder, borderline personality disorder, cutting, depression, mental illness, mental illness, oppositional defiant disorder, oppositional defiant disorder, parenting, psychiatry, PTSD, schizoaffective disorder, schizophrenia, suicide, teenagers, therapy, troubled children, troubled children

Bullying and how to stop it – for parents and teachers

Bullying and how to stop it – for parents and teachers
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Most of us have bullied someone and have been bullied at some time in our lives. We have an aggressive trait that helps us stand up to a threat. We are emboldened to fight when we fear for ourselves or family, or simply when we’re “not going to take this anymore!” Mature people don’t do this without cause, but children and teens lack maturity and can engage in bullying throughout their school years. (Even the nicest children can bully another person.) Victims of bullying usually don’t have the power and skills to prevent it or to protect themselves.

“This is a huge problem in the schools… it’s particularly common in grades 6 through 10, when as many as 30 percent of students report they’ve had moderate or frequent involvement in bullying.”
–Dr. Joyce Nolan Harrison, assistant professor of psychiatry, Johns Hopkins School of Medicine.

Bullying occurs when others aren’t paying attention… or when there is an audience
In schools, bullies target victims where and when authorities can’t see, isolated but in crowds: hallways, the school lunch room, the playground or gym, and the bathroom or dressing room, not in plain sight of others who might report an incident. Or they have an audience that supports the bully or ignores the situation and doesn’t want to get involved… or tell.

Bullies target those they consider “weak” or simply “different”
What makes a target child “weak” could be so many things. Bullies seize on anything: a physical, emotional, or mental vulnerability–children with learning disabilities or autism spectrum disorders are often targets. But any “different” child is at risk: a child from another culture is different, a boy who seems effeminate or a girl who seems masculine. The list of reasons children are bullied is so long that it is impossible to proactively avoid attracting the attention of a motivated bully or bullies: physical features, small stature, younger age, shy or meek personalities, bad fashion sense (or perfect fashion sense), even being a Straight “A” student is cause for being victimized. A child’s family member might be perceived as an embarrassment that elicits bullying (a brother is in prison, a father lost his job). Or a child might be a member of a group that’s hated by the parents, who teach their child to hate the group. Some victims are chosen simply because they are at the wrong place at the wrong time:

A teen walks his usual route home from school. He is reasonably well liked but doesn’t stand out. Ahead are three troublesome youth he doesn’t know. No one is around. He’s still at a distance, but starts to feel uncomfortable. They stand side-by-side on the walk ahead of him and stare.

What would a street-wise kid do?

He crosses the street without breaking stride, but also watches them—they have to know he sees them. If he pretended to ignore them it could inflame their anger. They start taunting. Meanwhile, the teen has been thinking of ways to protect himself just in case: there’s a store is nearby or within running distance, there’s a neighbor who’s usually at home. If he has a phone, he pulls it out and is ready to dial 911. He stays alert and looks confident, and they eventually drop the effort and let him move on.

Bullies punish kids who try to stop the bullying

Those who “snitch.” Victims who ask for help are often targeted by the bully more intensely, and often joined by associates who simply jump the bandwagon (curious behavior described as “the madness of crowds”). The culture of tweens and teens has low tolerance for those who tell on others. Those who join the bullying episode against the victim can do it without thinking, or perhaps they feel empowered to vent anger on someone, or just want to fit in.

Those who try to stop them. A heroic bystander steps in to stop a bullying episode and becomes the target themselves.

Those who want to leave the bullying group. Some kids have second thoughts and feel uncomfortable about the bullying and try to leave, but they can’t. Leaving attracts intense, relentless bullying for “voting with their feet”—this is a hallmark of gang behavior

Sadly, some children appear to “set themselves up” for bullying. This victim is a child with a fatalistic attitude and low self-esteem, who doesn’t recognize when others take advantage of them. They feel they must endure and don’t take steps to protect themselves out of excessive fear of drawing retribution. These are the kind of children who can become victims of physical or emotional domestic violence as adults.

Parents

If your child is a victim, be aware that they live between a rock and a hard place. Be careful that your involvement doesn’t make things worse for them

Armor your child with multiple skills
There is no one way to handle every bully situation so flexibility is key. Together, develop a list of multiple options:

  • Ask friends to accompany them
  • Go to a place where people are and find an adult to help. Walk the other way, walk down different hall, walk to other side of street, use a different bathroom.
  • Request loudly “LEAVE ME ALONE” when there’s an audience to witness the bullying, such as on a bus or standing in line.
  • Use body language to project a firm stance. This can be the way your child stands or the loudness of their voice when the bully is present to show confidence, alertness, and empowerment.
  • Let your child know you take them seriously and will do something about it. Give them emotional support.
  • Let your child know you will back them up by working with the school.
  • Use the situation as a learning opportunity to help your child develop a backbone and inner strength. Even with your support, this will not be easy for your child to handle. Be a model of strength and resolve rather than of vengeance or anger.
  • Consider mental health issues that might be making things worse for your child: ADHD, ODD, depression, bipolar disorder, borderline personality disorder, chaos and stress at home, PTSD, substance abuse, and others.

Help the bullied kids find each other. If there are a bunch of them together, they can stand the bully down. They don’t have to beat the bully up. They just have to say, ‘Why are you treating my friend this way?’ The bully will often move on… Parents can appropriately take matters into their own hands. You need to enlist the help of all the other parents of bullied children… Parents have to work as a group. One parent is a pain in the [butt]. A group of parents can be an educational experience for school authorities.”
–William Pollack, assistant clinical professor of psychiatry, Harvard Medical School

Don’t

  • Don’t tell your child to “let it go, ”or “it’s no big deal,” or “it happens, deal with it.”
  • Don’t tell your child to be tough. What does “tough” mean? What do you want them to do?
  • Don’t punish or dismiss a child who complains too much, or blame him/her for setting themselves up and asking for it. Ironically, a victim is sometimes treated as the problem child.
  • Don’t bully your child at home! Are you doing this? Think. Your child learns to accept the inevitability of bullying because he or she is accustomed to it at home.

How things can go wrong: A boy is in the shower after PE class and gets slapped on the butt most days. He is too proud/embarrassed to tell his parents, or he tells and they react poorly. Perhaps he’s blamed for not standing up for himself, or a parent shows up outraged at school and yells at the bully or school staff. Now the boy’s parent is the problem and may be suspected of bullying their child. Or school staff overreact with swift punitive actions to the bully. Time passes and the bully starts up again bit by bit, only much more subtly. The boy is afraid to report it again because the encounters are more secretive. The bully denies his behavior and recruits others to advocate for him. They jump on the bandwagon because they don’t know the history, and the boy doesn’t want to tell everyone he is being sexually harassed. It’s a vicious cycle.

Teachers and schools

“You can’t learn if you’re being bullied, if every day you’re frightened of how you’re going to be treated.”
–William Pollack, cited above

Teachers, pay attention to signs that there’s a skilled, secretive bully at the school.

  • Notice who others avoid.
  • Notice a child coming into the class who’s upset and ask them about it later, promise you’ll protect their anonymity if you can get them to reveal a bully, but don’t pressure them.
  • Observe the problem kid and their subtle interactions with others.
  • Allow a victim(s) to have distance from bully, permission to use a different bathroom, to have their desk placed farther apart, to have a locker farther apart, or even a different class if possible.
  • Inform the parents of your concerns in addition to the principle and school counselor.
  • Focus your behavioral interventions on the bully (not the victims)

Avoid diagnosing the situation. You are not the expert. You don’t know why a bully is a bully, or why a victim is a victim, or anything about their parents. Ensure a school counselor is involved in any discussion about how to manage a bully problem in the school.

Avoid jumping to conclusions! Your actions can unintentionally undermine or harm either the child or their parents. You don’t know until you know.

“Bullies are like the lion looking for a deer that’s left the herd,” says Patrick Tolan, director of the Institute for Juvenile Research at the University of Illinois. “They try to single out the weakest kid. The best way to stop this is to work on increasing inclusion by helping the bullied kids with social skills.”

Bullies are usually bullied themselves (see another article Bullies like their victims, are also at risk). Only very small percentage are sociopathic, or who are intrinsically cruel and without empathy, perhaps 1 in a 100. How do you tell? If someone sets a clear boundary with punitive consequences, the disturbed bully will relentlessly target a victim regardless of how much trouble they get in.

I wish to personally thank Barry Diggs, probation and parole officer for the Oregon Youth Authority, for his insights into bullying behavior, which helped me develop this article. Margaret

If you have helped a child effectively cope with bullying, please share your story in the Comments below so others can learn from your story.


Research

Bullying Linked to Violence at Home
April 2011

Bullying is pervasive among middle school and high school students in Massachusetts and may be linked to family violence, a new study finds. In a survey of 5,807 middle-school and high-school students from almost 138 Massachusetts public schools, researchers from the Massachusetts Department of Health and US Centers for Disease Control and Prevention found that those involved in bullying in any way are more likely to contemplate suicide and engage in self-harm compared to other students. Those involved in bullying were also more likely to have certain risk factors, including suffering abuse from a family member or witnessing violence at home, compared to people who were neither bullies nor victims.

Cyberbullying (this is a superb and comprehensive article by an expert on cyberbullying)

http://www.psychiatrictimes.com/display/article/10168/1336550?GUID=32E9A484-0468-4B38-8A03-0EE478D3256C&rememberme=1

Survey: Half of High Schoolers Report Bullying or Teasing Someone
“Ethics of American Youth Survey”, Josephson Institute of Ethics

Half of U.S. high schoolers say they have bullied or teased someone at least once in the past year, a new survey finds. The study also found that nearly half say they have been bullied during that time. The study surveyed 43,321 teens ages 15 to 18, from 78 public and 22 private schools. It found 50 percent had “bullied, teased or taunted someone at least once,” and 47 percent had been “bullied, teased or taunted in a way that seriously upset me at least once.” The survey asked about bullying in the past 12 months: 52% of students have hit someone in anger. 28% (37% of boys, 19% of girls) say it’s OK to hit or threaten a person who angers them. “There’s a tremendous amount of anger out there,” Michael Josephson says. (Founder of the Institute of Ethics)

Victims of Cyberbullying More Likely to Suffer Depression than Perpetrators:
ScienceDaily, September 2010

Young victims of cyber bullying, which occurs online or through cell phones, are more likely to suffer from depression than their tormentors, a new study finds. Researchers at the Eunice Kennedy Shriver National Institute of Child and Human Health Development in the US looked at survey results on bullying behavior and signs of depression in 7,313 students in grades six through 10. Victims reported higher depression than cyber bullies or bully-victims, which was not found in any other form of bullying. Researchers say it unclear whether depressed kids have lower self-esteem and so are more easily bullied or the other way around.

Cyberbullying Teens and Victims More Likely to Have Psychiatric Troubles
Archives of General Psychiatry, July 2010

Teens who cyberbully others through the Internet or cell phones are more likely to have both physical and psychiatric problems, and their victims are at heightened risk for behavioral difficulties, a new study finds. Researchers collected data on 2,215 Finnish teens 13 to 16 years old. The survey found that teens who were victims of cyberbullying were more likely to come from broken homes and have emotional, concentration and behavior problems. In addition, they were prone to headaches, abdominal pain, sleeping problems and not feeling safe at school, the researchers found. Cyberbullies were also more prone to suffer from emotional and behavior problems, according to the survey.

Bullying And Being Bullied Linked To Suicide In Children
International Journal of Adolescent Medical Health; July 2008

Being a victim or perpetrator of school bullying, the most common type of school violence, has been frequently associated with a broad spectrum of behavioral, emotional, and social problems. According to international studies, bullying is common, and affects up to 54 percent of children. Researchers at Yale School of Medicine reviewed studies from 13 different countries and found signs of a connection between bullying, being bullied. and suicide in children. Suicide is third leading cause of mortality in children and adolescents. Lead author of this report, Young-Shin Kim, M.D. said “the perpetrators who are the bullies also have an increased risk for suicidal behaviors.”

Kids with ADHD more likely to bully
Linda Carroll, MSNBC, reporting on the Journal of Developmental Medicine and Child Neurology, February 2008

A new study shows that children with attention deficit hyperactivity disorder are almost four times as likely as others to be bullies. And, in an intriguing corollary, the children with ADHD symptoms were almost 10 times as likely as others to have been regular targets of bullies prior to the onset of those symptoms.

A study followed 577 children for a year. After collecting data on bullies and victims and identifying those children ADHD, there was a corollary between ADHD and bullying. Study co-author Dr. Anders Hjern, a professor in pediatric epidemiology at the University of Uppsala in Stockholm said “These kids might be making life miserable for their fellow students. Or it might turn out that the attention problems they’re exhibiting could be related to the stress of being bullied.”

Unfortunately, treating ADHD won’t remedy the bullying because drugs for the condition impact a child’s ability to focus, but not the aggression that leads to bullying, says Kazdin, a professor of psychology and child psychiatry and director of the Parenting Center and Child Conduct Clinic at Yale University, and president of the American Psychological Association.

Bullying Tied to Sleep Problems
Sleep Medicine, June 2011

Children who are aggressive and disruptive in class are more likely to have sleep-disordered breathing than well-behaved children, according to new research. Conduct problems, parent-reported bullying, and school disciplinary problems were all associated with higher scores on a measure of sleep-related breathing disorders, according to researchers. The study collected data from parents on each child’s sleep habits and asked both parents and teachers to assess behavioral concerns. The findings suggest that bullying may be prevented by paying attention to some of the unique health issues associated with aggressive behavior.

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Filed under Bullying, discipline, parenting, PTSD, suicide, teachers, troubled children

Coping with grief when a child attempts (or completes) suicide

Coping with grief when a child attempts (or completes) suicide
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In the US military, the Purple Heart medal is awarded to a soldier who is wounded in battle, or who later dies of those wounds.

In the years of writing this blog, I have shared practical information on behavior and treatment, and offered encouragement and hope for parents.  But hope and information cannot soften the impact of this horrible statistic:  The mortality rates of teens with mental disorders are 3 to 4 times more deadly than most childhood cancers, and the statistics only measure those deaths by suicide:  Mental illness more deadly than cancer for teens, young adults.

Death by suicide seems especially tragic because it appears to be a choice, and while we tell ourselves that mental illness is the cause, it’s not the same as a car accident being the cause or a tumor being the cause.  Unsuccessful suicide attempts are no less traumatic, like a cancer that keeps returning, because you can’t come to terms with a “maybe.”  A parent is held hostage by the anticipation of loss, a relentless moment-by-moment fear that your child will attempt again in the future until they are successful.  It’s an emotional ride one’s subconscious never ever forgets, and it becomes your PTSD.  You can carry it quietly with you for decades, until a sneak attack, when you find yourself overreacting to a news story, a scene in a movie, or a conversation with a friend.

My PTSD ambushed me recently.  I was attending an evening class when suddenly a person next to me slammed down her cell phone, exclaimed “Oh my God!” and quickly grabbed up her things and dashed out.  I followed to check on her and see if I could help with something.  As she speed-walked to her car, she said her daughter had texted that she swallowed a poison because she was upset, but is now sorry and wants help.  I got back to the classroom in shock, trembling, and completely unable to focus.  It had been many years since I had received a similar message, but it felt like it had just happened again that moment.

You are not alone if you’ve ever secretly felt it would be a relief if your child ended their life, bringing peace to you both.  (And you wouldn’t be a bad parent, either)

But death is more than self-inflicted suicide.  You face a death of hope when child with a serious mental disorder that takes a long slow trajectory through addictions, high risk behaviors, and unstable reactions to life’s many insults.  Families like ours bear witness but can’t intervene, or interventions don’t work.  All we can do is wait and hope and do what we can for our child, day by day, and banish thoughts of a different future.  I consoled myself with the knowledge that my child was getting by, and getting by was enough.

Another type of death caregivers face is the loss of their child’s “self” as they knew it, and their future as they imagined it.  A mentally ill child or teen can morph from a fresh young person in a world that is wide open to them, to a scary being we don’t recognize as our own and cannot understand–a stranger, a changeling, a flame snuffed out too soon.  It should not be this way.  It is unfair.  It is a tragedy.  You start healing the grief when you are able to make the commitment to do the best you can anyway.  YOU HAVE EARNED YOUR PURPLE HEART.

Any serious medical condition can devastate and traumatize a child’s family, but those with mental disorders impose a complicated trauma that’s hardly possible to resolve.  The following stories are actual examples.  Ask yourself:  how does one be a loving responsible parent in these situations?

–  When her daughter attempted suicide, an overwhelmed single mother discovered that her son had been sexually abusing and cutting her for 3 years, right under her nose.  The guilt she felt was quadrupled by the guilt laid on her by others.  She didn’t know how to go forward as a mother from here, after loving but failing both children.

–  A teen girl attempted to hang herself in a very public place, and many found out about it before her parents.  Their first trauma was the call from the emergency room, their second was from the shower of doubt others laid on them:  Where were you?  Why didn’t you help her before it got this far?  What did you do to drive her to this?  And it was unending.  The daughter threw these doubts back at her parents repeatedly.  There were several inappropriate people in the community who wanted to “rescue” the daughter, including a teacher, but undermined the parents’ authority completely, and their ability to get treatment for the girl.

–  One couple devoted themselves to raising a difficult boy they adopted when he was 2.  At 9, after years of problems, he sexually assaulted a playmate, and they found themselves disgusted and repulsed.  The brokenhearted mother said she had long ago accepted that her boy would never be normal, but this was different.  She didn’t want him anymore.  (I’ve heard parents talk half-jokingly about taking their offspring to Nebraska. *)

You are not alone if you’ve ever secretly wanted your child to be taken away to never live with you again. You are not alone if you feel you’re DONE.  (And you would not be a bad parent for thinking this.)

Consciously keep the good things alive.  Display photos of the real child you know or knew, the one without the brain problems.  Keep their writing or artwork or tests scored A+.  Other parents experiencing a loss do this, whether the losses are from death by disease, or death of self due to brain damage from an accident.  Speak often of the good things they were or are, as any proud parent might, keep the memories alive.

Get out of your trance and take yourself back to here and now.  When you notice yourself caught up in a train of thought and obsessing on your fear or paranoia, get back in the room—get back to driving that car or attending that meeting or straightening the house.  Get back to noticing the people you love, get back to making those helpful plans.  Central to the philosophy of dialectical behavioral therapy (DBT) is the concept of “Mindfulness.”

Remember this wisdom: take one day at a time.  You can handle one day, you can keep cool, do what must be done, feel accomplishment, in one day. Don’t think farther ahead.  Since you are the linchpin, the one holding up the world, you probably don’t have the luxury of taking a break, and may have to hold things together until there is time for your own healing.  The one-day-at-a-time approach is imperative.

When you’re leg is broken, you need a crutch.  When you’re heart and mind are broken, use the “crutch” of a medication for depression, anxiety, or sleep.  Do other healing things for yourself, whether exercise or therapy or asking for comfort from friends.  Acknowledge your wounds and admit this is too much handle.  You have earned your scars from bravery, so wear them as the badges of a hero.

A tragic event does not mean a tragic life.  I know a mother whose son completed suicide as a young adult in his 20’s.  She seemed remarkably cheerful and at peace with this.  She spoke lovingly of him often, and her email address comprised his birth date.  She continually did her grief work, was active in a suicide bereavement group, and often offered to visit with families facing such a loss.

— Margaret

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*  In the United States, in 2008, the state of Nebraska enacted a “Safe Haven” law to reduce the tragedy of infant child abuse and neglect.  The law allowed anyone to anonymously leave a child at a hospital with the promise that child would be cared for.  But something unexpected happened.  Parents from around the nation drove hundreds and hundreds of miles to leave their troubled older children instead.  Nebraskans eventually amended the law with strict age limits for infants only.

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