CBT-1 Coach is an app that provides Cognitive Behavioral Therapy for people with insomnia or poor sleep habits
What’s Up App is a free app that provides Cognitive Behavioral therapy methods to help with anxiety, depression, and stress. It has pages to help you “Get Grounded” to help you identify your feelings and a “Thinking Patterns” page that helps you identify and stop negative thought patterns.
Mindshift is an app for teens that helps teens working on changing their though processes around anxiety
Mood tools is a free app that provides videos that help you improve mood and behaviors using CBT based principles. There is also a place to develop a suicide safety plan.
These three apps provide meditation and guided imagery and breathing programs to help with anxiety and depression symptoms. They each have free portions and paid portions. And with calm, Harry Styles can read you a bedtime story!
We have learned over the past two weeks about signs or symptoms indicating your child may be struggling with mental health. We have also discussed risk factors including the COVID-19 pandemic. But what do you do if you feel like your child needs help with their mental health? What can you be doing at home? When should you seek outside of your home?
MENTAL HEALTH HOME TREATMENTS
One of the most important things you can do at home to help your child is to focus on the basics!
The basics are those things that help promote general health meaning we need to focus on improving our children’s diet and sleep and ensuring they are exercising and moving their body.
A healthy diet is important for physical and mental health. Your child should be eating at least 5 services of fruits and veggies daily, healthy proteins, and omega-3 fatty acids. Omega-3 fatty acids are important for boosting mood. Vitamin D, found in dairy products, should be ingested 2-3 times a day as low vitamin D levels can cause symptoms of depression. A healthy diet helps your body get the nutrients that it needs to function optimally.
Exercise is a mood booster. Exercises causes your body to release endorphins. Endorphins help to ease pain, improve mood, and lower stress hormones. Cortisol, a stress hormone, is found to be at higher levels in some people with depression. Research has also found that moving forward as you do with exercise (walking, running, biking) actually helps your mind move forward and can help your child be able to cope with feelings of anxiety or depression. We recommend a minimum 30-45 minutes of exercise 3-5 times a week. Exercise should be enjoyable and not a chore. It can be anything from dancing, to jumping on a trampoline, walking with a friend or family, or a team sport.
Sleep is the MOST important basic health measure to focus on to help improve your child’s symptoms and mental health. You must make sleep a priority. There is a bio-directional link between sleep patterns and mood problems in the teen population particularly. Research has shown a strong link between decreased sleep and mood. Most overtired parents recognize that a poor night’s sleep can affect your ability to regulate your mood and cope with situations the next day. Chronic sleep issues make this decreased ability even more apparent.
Research stresses the effect of sleep on mood and school achievement with teens. Many towns are using this research to support moving school start times later for our teen populations. Teens that attend schools that have moved their start times to later times in the morning, generally after 8am, have shown increased sleep duration. These children are less sleepy and fatigued at school, they show an increased attendance rate, improved academic achievements, improved test scores, and improved mood and motivation.
Children and teens need 8-10 hours of sleep every day. Teens have a shifted circadian rhythm and naturally want to fall asleep later. As long as they are getting 8-10 hours at night this is not something that you need to address. Look at hours rather than the time they go to bed. Also look at your child’s sleep hygiene and habits. Good sleep habits and hygiene that can help create a good sleep environment include
• Using their bed for sleep only and never for schoolwork
• Limiting distractions in the bedroom
• No screens in the bedroom including tv and phones
• Providing shades or window covers that allow for a dark room
• Cool temperature in the bedroom
• USING soothing sounds, relaxing music, or white noise while sleeping
• A routine that includes similar sleep and wake times (switching and sleeping in very late on weekends can result in “jet-lag” that your child has to overcome during their school week)
• Avoiding naps during the day
• Bright light exposure during the day
• Avoiding caffeine as it often results in worsening anxiety and disturbed sleep especially in teens
Building a connection or strengthening a connection is a key treatment for mental health issues. One inhibitor to connection, with family or friends, is excessive screen time. Screen time and participation in social media are risk factors for anxiety and depression. Encourage your child to put their phone down or shut off the tv and spend time with family and friends. Eat dinner together, play games, find enjoyable activities you can do together. Try to find a one-on-one activity or shared interest that you are your child can enjoy together.
It is essential to provide a safe environment at home particularly if your child is having feelings of anxiety or depression. This means making sure than any items your child may use to self-harm are removed from the house or locked up in a way your child cannot access. You should remove any guns from the home and if this is not possible, make sure they are locked up. Any lock or combination should be one that your child would not be able to locate a key or guess the combination. Remove or lock up any knives, ropes, cables so they are not readily available. All medications should be locked up including over the counter medications. Tylenol, a readily available over the counter medication, is highly toxic. Anxiety and depression medications, blood pressure medications, and prescription pain medications are also toxic if taken in large quantities. Alcohol and any legal recreation drugs should also be locked away and unavailable for abuse.
BUILDING POSITIVE MENTAL HEALTH SKILLS
While we are working on the basics, we can also do things at home help our children with mental health issues. These are actually great things to do for ALL children no matter their mental health status and can actually be preventative towards significant and troublesome feelings of anxiety, depression or sadness.
Emotions and Validation
The most important thing you can do is VALIDATE THEIR FEELINGS ARE REAL. This will ensure your child knows you will support them no matter how they feel. A child that feels supported will actually talk to you about how they are feeling. If you blow off or ignore the way your child is feeling, or dismiss how they are feeling, they will stop expressing this to you. You are their main support in life. It is vital the communication pathway is kept open.
Being dismissed may result in your child ignoring their feelings or hiding their feelings. This is NEVER a healthy way to cope with emotions. These feelings will come out in physical illness, unhealthy behaviors, or struggles with mental health. By starting this open type of communication early (see our behavior blogs from May 2021) we will help our children be able to identify their feelings so that they can learn coping skills or be able to ask for help if they are struggling.
Social-emotional learning tasks
Children are not adults, and we cannot expect them to act like adults. They are still developing and not just physically. Their brains actually develop and mature through age 26! Children and teens are still working on many social-emotional tasks of development including identifying emotions and behaviors. They are learning to identify these emotions in themselves and in others. They are working on communication skills, social skills and building empathy.
This means if your child is upset, they may not know why they feel that way or even sometimes what emotion they are feeling. With a good open pathway of communication, you can help your child work to identify how they are feeling, why they may be feeling that way, and then work with your child on problem solving. Problem solving may be short-term solutions as well as long-term solutions. You may help them brainstorm possible ideas for resolution or coping skills they may use to help them with the situation that has caused them distress.
Additionally, as children are working on their social-emotional skills, they are learning boundaries and normal social behaviors. Being empathetic to their feelings does not mean that we do not need to set and enforce boundaries. Instead, we help our children have a sense of security with those boundaries. If the boundaries upset your child, you can help them with those emotions without changing the boundary.
Building resilience is a chance to help teach our children how to weather tough times. Children face lots of obstacles including moving, divorce, death, bullying, and other disappointments. We can help our children learn to recover from disappointment or hard times and not let these times define their life.
Children who build resilience are shown to have fewer feelings or anxiety or depression. Building resilience includes helping your child develop confidence and competence, helping your child connect to friends and family, working on identifying character, morals and values that are important to your child and family, and learning coping skills for stressors and emotions. It also includes helping our children realize they are in control of how they feel and how they react. They control the outcome of their decisions. Building resilience may look like
• Learning self-forgiveness
• Acknowledging that failure is normal and can be a learning experience
• Learning empathy Identifying emotions
• Identifying emotions
• Learning to feel, process, and release emotions
• Practicing problem solving
• Identifying their own strengths
• Practicing coping skills
• Having a safe haven at home to express emotions
• Having a calming and supportive presence at home
• Having a support who admits what they know, what they don’t, and when they need help
• Identifying what you can do if you feel helpless
• Learning to adapt when you can’t change things
• Learning to find hope when life is difficult
• Building self esteem
• Practice gratitude
You are your child’s biggest cheerleader. Our children deserve to know how great they are and how much you love them. We should be generous with our praise. This doesn’t mean you can’t help your child, but criticism should be constructive and helpful, and never vindictive or mean. We should encourage our children to find passions or interests, and we should help them to follow their interests and to hone their talents. They should know their opinion is valued by their family, friends, and community.
Your child should also know their worth is NOT tied to achievements and that you love every part of them. They need to feel secure that you love them no matter how they behave or what mistakes they make. Your love should be infinite and not contingent on perfection. Let your child see that you have made mistakes and continue to make mistakes and that you use these mistakes to grow and change. This helps them set normal expectations for themselves.
Helping our children develop positive self-esteem can help build resiliency as well as lift their mood, promote leadership, communication, and problem-solving skills.
Practicing gratitude helps your child build resilience, improves self-esteem and can improve mood. Ways to work on gratitude include
• Talking about positive parts of their day (at our house we do “Good, bad, and funny” during meals which provides an easy format where we can share our day)
• Promote sincere thankfulness by encouraging verbal or written expression of thanks or appreciation
• Volunteer work which normalizes people asking for help and increases connections to friends, family and community
• Learning to identify people and causes in need
Children do not have full developed coping skills. People are not born with coping skill, coping skills are learned during social-emotional development That’s why a child who wants a toy will bite their sibling, but that behavior adapts over the years to where they can verbalize their feelings. That behavior change is actually a coping skill emerging: your child is learning to deal with anger and not letting that emotion take over an encounter and end in violence.
Coping skill are only learned if we allow our children to work on them. We are NOT helping them by constantly problem solving for them, dismissing their emotions, or trying to control situations so they NEVER feel uncomfortable emotions. Children and adolescents need to practice utilizing coping skills when they have hard emotions or feelings or are in uncomfortable situations. We want them to practice with you when they are supported and safe to fail and when situations may be smaller and less important. And as we learned in the series of blogs on behavior, if we shield our children from their feelings and from learning coping skills, they may be ill equipped to handle these feelings as the enter adulthood which increase their risk of mental health disorders or maladaptive behaviors.
Coping skills are individual meaning every person uses different techniques that suit their personality and temperament. Your child needs to time figure out what works best for them and that may change based on the situation and as they grow. Brainstorming with your child when they are NOT feeling strong emotions can help your child identify actions they believe will help. Together you can practice these while they are not feeling big emotions. By identifying and practicing these techniques, it will also be easier for you to suggest these behaviors or techniques when needed and easier for your child to try these methods. Some ideas of techniques or behaviors include
• Exercise or physical movement
• Play (including role playing or acting out feelings with dolls/figures/animals/puppets)
• Creative expression
• Talking through emotions
• Time outdoors
• Positive self-talk
• Positive imagery of a place or person
• Mind-body tricks-these have been shown to lessen physical and emotional symptoms
o Clench and release fists
o Drum slowly building intensity and then decreasing intensity
o Bite into a hard crunchy food or strong flavored food and think about taste and sensations
o Breath in and out with a candle flickering
o Touch or squeeze a special object such as a worry stone, silly putty, squishy ball)
• Relaxation techniques
o Deep breathing
o Breath counting
Your child may be struggling with mental health and may require professional assistance. Looking outside of your home for help for your child can be hard step to take. It is essential to take this step. Significant depression and anxiety cannot be overcome by the power of positive thinking alone.
Therapy is the hallmark of treatment for ALL mental health disorders. We always recommend starting with therapy and we almost never lead the treatment with medication. Medication does NOT fix any underlying problem. Medication can be helpful to allow the therapy to be effective if your child’s symptoms are preventing them from being able to practice or utilize the skills they are learning in therapy. Therapy takes time though and you should explain to your child that it is not an immediate fix and is something they will need to work on and practice just like school, an instrument or sport.
Cognitive Behavioral Therapy (CBT) is the gold standard of therapy and the type of therapy that is found to be the most successful with children and teens. After completing twelve weeks of CBT based therapy, over 60% of children being treated for anxiety and depression see a positive effect and 35% of these children indicate they have minimal symptoms of anxiety or depression.
Counseling or therapy can help your child build their coping skills and strategies. Therapist can help your child work on stress reduction and self-care. They can address low self-esteem and negative self-talk. For children with anxiety, therapy will focus on how your child thinks about their fear, increase exposure to fear or uncomfortable situations, and will work on relaxation strategies to use when feeling anxious. Therapy can help your child break negative thought patterns such as overgeneralizing and catastrophizing. The work done in therapy can also help with social skills training for children who may have social anxiety.
A child may receive therapy alone or it may be advised for the parents/guardians or the whole family to attend therapy. This may be needed to help modify family dynamics and responses to stress and emotions. This is particularly helpful if a parent or guardian also struggles with mental health issues, struggles with parenting or behavior modification/discipline, or there is a history of family dysfunction. A therapist will help work on reactions and coping skills with family members, provide discipline and behavior training and feedback, and help work to break any generational cycles of dysfunction.
Finding a therapist can be difficult. You will first need to check with your insurance plan what your coverage includes for behavioral health, and which local therapists are covered under your plan. We also keep a list of local therapists recommended by our office. This list includes the age of patients they see as well as any specialty areas that the therapist focuses on such as grief, ADHD, eating disorders, LGBTQ+ children, or divorce.
With older children and teens, it is important to include them when choosing a therapist. Ask your child if they have a preference for gender, race, or age. Let them review profiles with you. Ask them what qualities they would find in an ideal therapist. Offer them a choice when choosing a therapist. Once your child sees the therapist, inquire about the fit and if they feel safe and heard by the therapist. Sometimes the first therapist you meet is a good match and sometimes you need to try a few therapists before finding the right match. Some therapists allow a meeting or interview like session to determine if they are a match with your child.
We understand many teens are reluctant to see a therapist. Children do not want to attend therapy for a variety of reasons. They may not trust another adult or do not trust that therapy will work. They may feel like they are “crazy” or something is wrong with them. They may be embarrassed about needing or going to therapy. They may be defensive about how they are feeling and may not feel they need therapy. Some children and teens do not like to feel vulnerable, especially emotionally. And some children can’t even imagine feeling better and that loss of hope makes them not willing to try therapy.
If your child is reluctant to see a therapist, let them know how important they are to you and that you want to help them. Validate that their feelings are normal. Inquire, in a non-judgmental way, as to why they are reluctant to see a therapist. You may be able to clarify misconceptions that your child may be needlessly worried about. Encourage them to try at least 3 sessions and include them in choosing a therapist. You can also share your own personal experience with a therapist if you have this experience. If your child refuses to go, you can go to the appointment and work with the therapist on how to get your child to participate in therapy.
Medication may be appropriate for your child to improve their mental health. Medication when used in conjunction with cognitive based therapy may help improve your child’s symptoms with over 90% of children receiving therapy and medication showing improvement in 12 weeks.
Medication is recommended in GLAD-PC, the Guidelines for Adolescent Depression in Primary Care, for teens (and children) that have severe or persistent depression or a severe or persistent anxiety disorder. The severity is based on diagnostic evaluations performed by the prescriber. The current medication of choice for both depression and anxiety are SSRIs. SSRIs are selective serotonin reuptake inhibitors including fluoxetine (Prozac), sertraline (Zoloft), and citalopram (Celexa) and escitalopram (Lexapro).
Medication, like therapy, does not make an immediate difference. It can take 2-3 weeks at a THERAPEUTIC dose to notice an effect. When prescribing medication, we start at a low dose and increase as needed and tolerated. This enables us to minimize any potential side effects and also make sure your child is on the least amount of medication they need to manage their symptoms. If your child is started on medication, they will be followed closely until the optimal dose of medication is determined and then will be followed frequently until they are off the medication. Often you can see a positive effect on sleep and energy levels before you see a therapeutic effect on their mood and emotions.
Common side effects of these medications include dry mouth, constipation, diarrhea, sweating, sleep disturbances, irritability, disinhibition, agitation, jitteriness, headache, appetite changes, sexual dysfunction, and rashes. Your child may also notice symptoms if they discontinue their medication suddenly. Medication should only be discontinued under supervision of your child’s provider.
If your child does not improve on medication or if your child has multiple diagnoses, a family history of bipolar disorder or other mental health issues, or has any symptoms of psychosis or extreme aggression, you may be advised to see a psychiatrist for medication initiation and management. If your child has suicidal ideation or plans or is in crisis, you may be advised to proceed to the emergency room or call the CRISIS team for immediately evaluation and treatment.
If your child has a seasonal pattern to their symptoms and has been diagnosed with Seasonal Affective Disorder (SAD), they may benefit from additional treatment including light therapy. Light therapy involves a light box that provides artificial light that mimics natural outdoor lights. A person can purchase a small light box that sits on their desk or a table. The light should be about 16-24 inches from their face and be placed to provide indirect light to your eyes. You should never look directly at the light as it can damage your eyes and increase the risk of side effects. Side effects include eyestrain, headache, nausea, irritability, or hyperactivity. People with SAD should use the light 20-30 minutes daily from early fall until late spring. It can be used at any time of day but has been shown to work better if used in the morning.
Although you do not need a prescription to buy a light box and there are affordable options available through local stores or Amazon, you should discuss light therapy with your provider before starting this treatment. Light therapy does not cure SAD but can help ease symptoms. People with SAD can also ease symptoms with exercise, getting outside daily, a dawn simulator, and a winter vacation to a sunnier local if possible.
We all want our children to be happy, grow, and thrive, but we all have times where life is hard, and obstacles come our way. Preparing our kids with coping skills, improving self-esteem and building resilience can help prepare our children to get through these times. Sometimes our children can be overwhelmed by their experiences or have unexplainable feelings of depression or anxiety that require professional help including therapy and medications. We are here to help you and your family through these times from finding a therapist, recommending psychiatric care, or providing medication management.
Children’s Health Care of Newburyport, Massachusetts, and Haverhill, Massachusetts is a pediatric healthcare practice providing care for families across the North Shore, Merrimack Valley, southern New Hampshire, and the Seacoast regions. The Children’s Health Care team includes pediatricians and pediatric nurse practitioners who provide comprehensive pediatric health care for children, including newborns, toddlers, school-aged children, adolescents, and young adults. Our child-centered and family-focused approach covers preventative and urgent care, immunizations, and specialist referrals. Our services include an on-site pediatric nutritionist, special needs care coordinator, and social workers. We also have walk-in appointments available at all of our locations for acute sick visits. Please visit chcmass.com where you will find information about our pediatric doctors, nurse practitioners, as well as our hours and services.
Disclaimer: this health information is for educational purposes only. You, the reader, assume full responsibility for how you choose to use it.