Parenting Teens with Anxiety and Depression

photo_1725_20060623 It is normal to see periods of heightened anxiety and depression in teens given all the changes that are going on within and around them. On some level, anxiety can be healthy because it can motivate teens to perform in areas critical for young adulthood. Heightened periods of sadness may not be a cause for concern either. It may be weird to see your kid crying over a break up with a boyfriend or girlfriend and have a tough week but they are not five anymore.

Anxiety or depression that consistently results in school avoidance, excessive fear reactions, heightened shyness, poor sleep, radical change in appetite, academic under-performance,  social avoidance, deteriorating social and familial relationships over an extended period of time is different. Suicidal thinking, substance abuse and para suicidal behavior (self-harm) are obvious warning signs that need immediate attention. Parent’s when faced with these issues feel stuck as traditional ways of dealing with them may feel inappropriate yet doing nothing seems like an unrealistic option.  Here are a few strategies that might be helpful-

Scream at them incessantly to “just get better”.  Just kidding.  That is a horrible strategy.  But parents sometimes get to their wit’s end and it happens.

One possible first step is to approach your teen about a discussion on the issues.  Be honest about the concerning behaviors in a manner that is factual and specific. Don’t shy away from expressing how their behaviors make you feel or their impact on your day to day life.  This isn’t judgement day so avoid the interrogation or threats to throw them into therapy and shove meds in their mouth.  Avoid characterizing the teen or moralizing; that will probably work against your desired goal(s).  If your teen doesn’t want to talk about it at that moment in time,  be compassionate and firm in asserting yourself. Don’t insist that they talk about it “right now”- give them a time frame that is reasonable so that they can think about how and when to approach you. If your teen presents with suicidal thoughts, self harm, violent behaviors or substance abuse then the process needs to be more directive and action oriented.  Things like treatment or immediate professional intervention are less negotiable and should occur regardless of how a teen feels about entering treatment.

If they decide to have the discussion then or at a later time, express gratitude while remaining hopeful and empathic.  They are probably scared or nervous as it is so don’t go around freaking out. Freak out in your bedroom in front of your spouse or goldfish, you’re the parent so play the role. Most problems are solvable, just have faith in that. You don’t need to know how to solve the problem right now; your job is to just get information.  Focus instead on finding out how your teen thinks these issues should be addressed to get some ideas. Set up another discussion close to this one to problem solve.

If they continue to avoid having the discussion then let them know about the steps you are prepared to take.  Be clear that these steps are not punishments but actions you are taking from a place of concern and uncertainty.  Encourage them to have a voice in shaping the process and addressing the issues.  Provide them with a reasonable time frame to make a decision and follow through on the actions you mapped out for them if they continue to avoid talking about it and the issues persist.

If the issues they are facing require outside intervention be sure that therapy and medication aren’t the only two options you are exploring.  Natural supports and activities such as sports, art or other interests (preferably outside the home), employment, close relatives, clergy and faith based/civic organizations provide good opportunities and distractions that allow teens to cope and deal.  Also, set up an appointment with your teen’s pediatrician to rule out any medical causes. If you decide that therapy and medication need to be explored, allow your teen to research therapists and/or psychiatrists they feel they would connect with. Depending on the issue, it may also be appropriate to get the school involved. Although IEP’s are important they may not always be necessary.  I have worked with schools on developing effective informal plans of action.

If therapy and/or a meeting with a psychiatrist occurs, be present.  As a parent you should be aware of their approach, initial plan and any medications that may be prescribed.  Be sure to give your input into the issue in a way that is factual and fair. If meds are prescribed, ask as many questions as you can about possible side effects and how to handle them. Provide any relevant family history you feel may be important (history of depression, anxiety or addiction in the family).  I think it best to have the teen present for this discussion so they understand the biology and risk factors at play but ultimately that’s your call. It is appropriate for the therapist or psychiatrist to ask to meet with the teen alone during the first session and sessions will probably occur in that fashion however, you have a right to ask for periodic meetings and updates.  This does not mean you get to know everything that is disclosed in session, in most states teens have a right to keep that confidential.  A release is not required however, to provide the therapist with information you feel is important.

If family therapy is suggested be open to the process, this does not mean the therapist believes that you are a bad parent.  It may mean she feels family issues can play a significant role in helping the teen improve.  In family therapy I ask participants to consider different perspectives and strategies; I am clear that I do not want them to take what we talk about and run with it. Families have a right and responsibility to examine what comes out of family sessions and determine what steps they feel they need to take. Regardless of how often family meetings occur it is important for family members to educate themselves about anxiety and depression in order to better support their teen.

I’m really not a fan of emphasizing insight oriented work with teens early on, especially if a teen is younger, Admittedly I am biased but then again there are reasons for this bias.  With that being said skill-based interventions typically focus on psycho-education, identifying triggers and cues (physical, behavioral, emotional and cognitive), identifying negative thought patterns, using evidence to determine validity of the negative thoughts; developing more reasonable narratives based on evidence in thinking about the issue, using evidence in assessing resilience in relation to the issue, using preventative and reactive behavioral techniques (observation, breathing, exercise, diet, sleep, scheduling, guided imagery, tapping), assertiveness training and family work (intensity varies depending on the issues).

Typically homework is assigned and reviewed in session. It is important that parents are knowledgeable about these interventions on some level so that they can consistently reinforce these skills/concepts in helping the teen through times of distress.  For teens whose anxiety or depression were triggered by a traumatic event or include obsessions and compulsions, treatment may include some form of exposure therapy or EMDR.

These points really speak to early response and the treatment process however there are other things that should be considered when your teen struggles with anxiety and/or depression. This is with the belief that family members are a critical component to a teen’s recovery in mind.

The first is to be mindful of problem ownership which is is a concept that is useful for every parent of a teen.  Problem ownership is a prominent idea in P.E.T. (Parent Effectiveness Training) developed by Dr. Thomas Gordon.  I have several significant differences with Dr. Gordon’s model but the idea of problem ownership is useful in at least getting you to think about what you need to react to, how positionally intense the reaction should be and what you should just let go. My main issue with how P.E.T. deals with this idea is my belief that it oversimplifies the issue of ownership, particularly when it comes to value differences.

That aside, I think that many parents with teens who present with anxiety and depression can run the risk of over-reacting to certain events or behaviors.  Considering problem ownership can help parents look at whether the behavior a teen presents with has an actual impact on the parent or household. This can help a parent consider whether they should get involved in resolving an issue and to what degree.  It can also be useful in determining priorities around behavior change.  It is one part of the equation; it should not be the entire basis for a decision. A fair rule of thumb is that the less impact a teens behaviors has on the system they are living in the less positional intensity parents should apply in demanding a change.

The best friend a parent of a teen who struggles with depression and anxiety can have is the phrase, “I need to think about  [this], [what happened here], [what you did] and talk to you about it later.”  Buy yourself time before reacting, especially if your emotions are running high.  This doesn’t mean you should shield your teen from how your feeling about it at the moment. Statements like “I feel really [hurt], [angry], [disrespected].” are fine and even useful but anything beyond that might make the problem worse if you are shooting from the hip.  Taking a break to think about a response is generally going to lead to more effective strategies around handling the issue.

The second is to be mindful that despite the issues your teen may be struggling with they are still a teen and some consideration should be given to not pathologize every behavior that seems unusual or problematic.   Looking at every problematic behavior your teen presents with as a symptom runs the risk of not only making them appear and feel “sicker” than they are but also removes a good deal of accountability that is necessary for their development.  It creates a secondary gain and increases the potential of turning depression or anxiety into shields for unacceptable or attention seeking behaviors.  It can also reinforce feelings of fragility and abnormality your teen may already be struggling with.

Depression and anxiety are not excuses for poor behavior; they are factors that need to be considered in trying to correct an issue.  The world is not going give your teen a free pass; supporting your teen in right analysis and right action is going to leave them better prepared for young adulthood.

The older your teen the more the discussion around behavior change and expectations becomes a process of negotiation.  You and your teen can probably reach agreement on a whole host of issues but differences on these positions may exist on degree of importance and urgency.  It’s important to achieve a middle ground where possible.

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