Parenting Teens: Basic Toolbox for the Practitioners in Adolescent Health Care

1. Parenting Teens:Basic Toolbox for the Practitioners in Adolescent Health Care Laura Kastner, Ph.D. Clinical Professor Psychiatry and Behavioral Sciences University of Washington “It is easier to build strong children than to repair broken men.” Frederick Douglass (1817-1895)

2. Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science into Lifelong Health www.pediatrics.rog/cgi/doi/10.1542/peds.2011-2662 (AAP publications, downloaded January 10, 2012) “The growing scientific knowledge base that links childhood toxic stress with disruptions of the developing nervous, cardiovascular, immune, and metabolic systems, and the evidence that these disruptions can lead to lifelong impairments in learning, behavior, and both physical and mental health, should be fully incorporated into the training of all current and future physicians.”

3. Anticipatory guidance* and parent coaching have many evidence based cousins: • Dialectical behavioral therapy (DBT) model has a coaching and skill-building component (Linehan) • A choice architecture and social science model—”libertarian paternalism”—gives information in a way that people are more likely to make healthful choices (Thaler & Sunstein) • Motivational interviewing helps patients identify their own goals (Rollnick & Miller). • The psycho-education model assumes that knowledge helps patients with their conditions. • An information provision model benefits educated people the most. *Involves information, therapeutic alliance, and education

4. Primary care pediatrics with parents of teens: What is primary for the pediatrician? • The role of anticipatory guidance • Understanding the social/emotional/cultural realities of modern life for families • Helping parents understand normal adolescent development, emotional regulation and basic parenting skills (e.g. Basic Toolbox) • Prevention/early intervention with psychosocial problems • “It’s not my job”—a review of the Archives of Pediatrics and Adolescent Medicine

5. Historically, recommended pediatric advice to parents of tweens (8-12 yrs) has been vague • Typically, topics to address with the tween/teen are emphasized (e.g. sexuality, substance use, safety). • Doctor-child patient relationship focus is still invaluable. • Anticipatory guidance research with parents of 2-11 years indicates parents’ retention of about 6 topics in discussions (Barker, 2005). • Parent coaching about the “norms” of teen development and related parenting advice will not be sufficient help for the 20% of children with diagnosable psychiatric disorders. • New appreciation of the limitations on health education delivered directly to teens due to neuroscience research discoveries.

6. American Psychological Association Survey of parents, tweens and teens (2009) • Tweens and teens were 2-3 times as likely to report headaches, sleeping problems, and disordered eating as their parents estimations. • Tweens (8-12) and teens (13-17) were more likely than parents to say that their stress had increased in the last year. • Only 2-5% of parents rate their child’s stress as extreme; whereas 14% of tweens and 28% of teens rate their stress as extreme. • Research has shown how parents often under report drug use, depression and sexual activity in their children; now we know they under report their stress levels as well.

7. American Psychological Association SurveyAdults’ reports of physical effects of stress in the past month: • 47% of adults report sleep difficulty • 45% report irritability or anger • 43% report fatigue • 40% report lack of interest, motivation or energy • 34% report headaches • 34% report feeling depressed or sad • 32% report feeling as though they could cry • 27% report stomach aches as a result of stress 77% of adults report experiencing moderate to high levels of stress in the past month (24% extreme, 51 % moderate).

8. Psychological Aggression: Prevalence in last year 88.6 % of sample of 991 parents reported having: • Shouted, yelled, screamed • Threatened to spank • Swore or cursed • Called name • Threatened to kick out of the house } Deemed “ordinary” } Deemed “severe” 50% of parents of teens admitted to “severe” Straus, M. & Field, C. Psychological Aggression by American Parents: National Data on Prevalence, Chronicity and Severity. J of Marr and Fam, 65, 2003: 795-808.

9. Link between parents’ problems and child mental health and adjustment • Quality of family life • Parents’ psychological problems • Economic strife • Marital discord • Social support

11. Authoritative parenting Boundaries and independence Competence building DNA of parenting—executive functioning Emotional and social learning Family fun without screens or money Getting to calm skills Health maintenance-yours and theirs Intellectual and academic development Judgment calls in discipline Kindness, humor and happiness quotients Limitations on risk-taking behaviors Money management and resisting indulgence and entitlement Negotiation skills and avoiding arguments Optimizing secure attachment Peers, friends and elder relationship support Questioning yourself enough to stay open-minded Role model resilience and other qualities and virtues Socratic Method with challenging subjects Temperaments—working with them, not against them Understanding and accepting normal child development Values clarification and the moral compass Wise mind—integrating emotional and cognitive brain power X-Box, media, cell phone, social networking and electronic LIMITS! Yearnings management Zeal for life pursuits A to Z Parenting Toolbox(Wise Minded Parenting)

12. Top Seven Focal points for Adolescent Health Care Guidance with parent of teens • Secure attachment • Authoritative parenting, effective discipline and quality family relationships (importance of boundaries) • The pitch for social and emotional learning and modeling in the home (including emotional regulation) • Effective discipline, managing conflict and negotiation skills • Understanding normal teen development for realistic expectations • Checklist for building teen competence • The new hot commodity: TIME & PRESENCE (for relationships, calmness, and health—electronic control!)

13. Optimizing Secure Attachment-predicts healthy peer and family relationships, higher self esteem, problem solving ability, sensitivity to others, acceptance, cooperation, emotional availability, and successful relationships in the future. • Responsiveness, attunement • Empathy and compassion • Connectedness, love, trust, reliance

14. Optimizing Secure AttachmentExit interview with launching teens—would your teen say yes ? • My parents respect my feelings • My parents accept me for the way I am • My parents are reliable sources of support for me • I value my parents’ perspectives on issues • My parents value my opinions on issues • When I’m upset, my parents show concern

15. Authoritative Parenting Style predicts adolescent social, academic and emotional competence • High warmth, thoughtful authority, effective communication, psychological autonomy • Less effective styles include authoritarian, intrusive, permissive, inconsistent, neglectful/rejecting and polarized styles (“good cop, bad cop”) • Effective communication requires a calm mind to access a wise mind • Discipline is effective only in the context of a mostly positive relationship

16. Boundaries and independence Boundaries refer to behavioral and interpersonal organization • Setting limits on children’s rights and privileges, establishing rules and structure, monitoring, and protecting children from excessive and harmful freedom or indulgence. • Encouraging appropriate independence to build competencies. • Personal boundaries refer to the emotional and physical distance between people that can run the gamut from too detached to overly-enmeshed.

17. Boundaries and independence • Parents with firm parent-child boundaries are capable of making the best decisions about behavioral boundaries for their children. • Bounded, empathic parents DO NOT get overwhelmed by absorbing their children’s emotions. They appreciate feelings, but do not need to control them. • Firm personal boundaries allow a parent to STAY CALM while enforcing rules and discipline even when kids exhibit typical negative emotions or tantrums.

18. Social and emotional competence • SEL predicts higher achievement, better emotional adjustment and more successful relationships (Durlak, Weissberg). • Children’s immaturity renders the development of emotional intelligence a long and meandering process. • Children and teens benefit from lots of contact with adults other than parents. • Parents can take advantage of social contexts they choose for their young children for positive influences. • Role-modeling is key.

19. Emotional and Social Learning EnhancementEmotional Intelligence (social and emotional competence): a meta-ability which determines how well you can use your IQ Recognize the feeling Understand the cause or core issue Label the feeling accurately Express the feeling (or not) in a constructive way Regulate emotions appropriately so that they can inform and enhance decision-making (requiring “getting to calm” skills)

20. Emotional DrivesWhy don’t we do what is good for us? Reward-centered habits • The dopamine pathway-pursuit of immediate gratification, “wanting” and “go-get-it”. • Features of addiction: compulsive reward-seeking, dependence, withdrawal and craving. Threat-based mental habits • Stress can increase impulsivity and negative emotions; a sense of “no control” increases threat. • Anxiety exaggerates fear of danger, fear conditioning. • Chronic anger creates persistent resentment about injustices • Depression is associated with distorted cognitions re: past, present and future

21. A Co-AMYGDALA HIJACKClayton is brought to the pediatrician with a fractured hand after an argument. “Clayton put his hand through the wall when I told him that he couldn’t go to the party.”

22. Listen to (or imagine) the whole story Mom: You cannot go to that party! Son: I’m going. I hate living here. Mom: How dare you say that after all I do for you! Son: You’re mental. I want to go live with dad. Mom: AS IF your dad will ever deal with your spoiled rotten behaviors. And YOU are the mental one, not me. Son: You are a control freak—my friends feel sorry for me! Mom: Your friends are delinquents! Not only can you NOT go to that party, you can forget going anywhere for the rest of the month. And by the way, I’m taking away your cell and your Xbox. (Clayton puts his hand through the wall… and ends up in your office)

23. Emotional Regulation 101 The limbic system, or “emotion brain”, has evolved to guide us about what is desirable and undesirable for survival. The amygdala “triggers” when we are afraid, angry, distressed and upset. The amygdala is triggered by truly life threatening events and false alarms (“flooding”). The “neo-cortex” houses the “thinking” brain (“prefrontal cortex the “CEO”), which allows us to plan ahead, weigh costs and benefits of options for decision making, and control our impulses.

24. C.A.L.M. technique for meltdowns • C Cool down: Self-soothe; don’t talk; breathe; control yourself, without trying to control anyone else. “Don’t talk under the influence of dysregulated emotion” • A Assess options: What are the issues? Would it be better to keep talking or postpone? Weigh the costs/benefits/risks of options. Engage your thinking brain with evaluative analysis. • L Listen with empathy: When re-engaging with children about their outbursts and big mistakes, ALWAYS start with empathy —without any “buts”. Empathy does not mean approval or agreement. • M Make a plan: Does this misbehavior mean that you need to re-think some parenting policy? What are the issues that contributed to it? Do you need to take other measures to help your child? (yourself?)

25. Self calming (first biology, then psychology) • Emphasize the importance of not continuing the self-talk about how mad you are, how valid it is that you are mad and what you are mad about (“content” and “other-focused”) • Focus on the process of physiological calming of the heart rate • Breathing exercises are key (The 4-7-8 is an easy one to teach). • Find comfortable exercises and tailor to your own preferences.

26. Alternative script (with regulated and skillful parenting) Son: I’m going to the party. I hate living here. Mom: I hope you don’t go, since it would be breaking a rule. Son: You’re mental! I want to live with Dad! Mom: Look, I know this is a huge disappointment. I’m sorry that you miss something so important to you. …I’m going to put some laundry in the washer. We can talk later if you want to negotiate some other activity for Friday night. (mom exits) Son: Why are you walking away? Why don’t ever understand? Aren’t parents supposed to listen to their kids? Why don’t you care that you are ruining my life? I’m still going!

27. Effective discipline, negotiation skills and staying out of power struggles Behavioral compliance • State your expectation • Don’t fall for “the bait” of resistive protests and give the child room for choosing to cooperate • Allow ONE reminder for compliance with a request (Magic 1-2-3) Early in childhood, children should be informed that they will receive consequences for non-compliance. Parents should invest in controlling their children’s conduct, not their thoughts and feelings.

28. When kids non-comply or resist, DON’T A.R.G.U.E.* Advise/preach/lecture Repeat yourself/nag Get them to agree or accept your side Ultimatums or threats Explain/defend policy at the time of conflict * If intense parental (controlled) anger is infrequent, sometimes it can be effective.

29. Practice Effective Discipline(discere= to teach or learn) • Encourage desirable behavior • Ignore undesirable behaviors as much as possible (all attention is rewarding) • Try natural consequences if possible • Take time to construct meaningful disciplinary measures for major transgressions

30. Negotiation (and management) skillsWhen kids resist, defy or try to engage parents in a power struggle, parents should consider: • Using the C.A.L.M. technique in meltdowns • “The only person you can control is yourself” • Ask yourself: “You might be right, but are you effective?” • “My child is doing the best she can right now, given her emotional state.” • Respond skillfully to your child’s emotional needs, “not the content issue.” • Use artful one-liners or non-sequiturs • Let the child have the last word

31. The remodeling process of the prefrontal cortex occurs around the age of 13 years old • Up to 40% of the grey matter in the prefrontal cortex (PFC) is sloughed off in a process called pruning (Giedd). • “The neurons that fire together, wire together.” New neural connections and brain growth occur over the next decade based on learning and experience. • Over the next decade, behavior is often more governed by the emotional centers of the brain than the thinking areas, especially in contexts of high arousal situations or peer presence (e.g. “being good parents does not insure good teen behavior.”)

32. Adolescence is an era of high risk and high opportunity. • “Use it or lose it” in neuroscience refers to the need to use the brain “like a muscle” in order to stimulate new connections. • Changes in circadian rhythms alter alert-fatigue signals, affecting memory and biorhythms. Sleep problems are common, especially with the overuse of media. • Teens are thought to have a “reward deficiency” syndrome due to changes in dopaminergic system, with implications for increased risk-taking, vulnerability to drug addiction and intense media attraction and compulsivity. • An increased level of moodiness, emotional reactivity and risk-taking is more likely in the majority of teens, but is neither inevitable or universal.

33. Given the “norms” for teen challenges,what’s a parent to do? • Accept a certain level of teen moodiness, emotional reactivity and risk-taking (dumb mistakes) as normative. • Develop excellent personal emotional regulation skills in order to manage teen’s intense reactions (self calming) • Choose productive parenting approaches to optimize learning opportunities for the teen

34. Competence Checklist • Control media and electronic use and avoid giving into excessive materialistic desires. • Don’t let up on family dinner rituals. • Keep chores a priority—they are a vital preparation for life. • Let your kids struggle, fail and learn, both socially and academically. • Support your tween’s academic development. • Keep having fun and building the family bank account of positive emotions. • Insist that your tween participate in athletic activities over the full school year. • Encourage at least one extracurricular activity at all times and keep this expectation intact through-out high school. • Practice authoritative parenting, which includes firm limits and boundaries, warmth and connectedness, and effective communication. • Role model skills in emotional regulation. • Be proactive about talking to your teens about sexuality, substance use, violence and media literacy. • Build family resilience and spirituality by your own conduct and values.

36. Texting, Facebook, gaming and other electronic social networking activities are HIGHLY rewarding • Dopamine release • Social enhancers • HIGHLY reinforcing (“addictive”) in design • Identity builders (“I text, therefore I am”) • Pleasurable distractions from boredom, dreaded homework, and…parental demands

37. A Healthy Family Environment takes TIME Sleep, exercise, meditation, and nutrition Highly engaging intellectual life Positive emotions Thriving friendships A calm home—limiting chronic stress (safe and trusting relationships enhance the neurobiological processes of learning and memory consolidation)

38. The neuroscience of happiness Epictetus Rule One Overcoming negativity bias Mindfulness training Watch out for the second dart (replaying a bad experience or thought) Savoring positive experiences Gratitude Using your Signature Trait Strengths (www.authentichappiness.com ) Enhance social ties and human connection Laugh and smile—mirror neurons spread good feelings

39. Is Parent Counseling Pediatric Business?A review of articles in the Archives of Pediatrics and Adolescent Medicine often reveals more of a coaching role with parents than the teenCan informed or coached parents make a difference? • Display of Health Risk Behaviors on MySpace by Adolescents: Prevalence and Associations: Moreno, MA et al. 2009, 163 (1):27-34. • Reducing At-Risk Adolescents’ Display of Risk Behavior on a Social Networking Web Site: A Randomized Controlled Pilot Intervention Trial: Moreno, VanderStoep, Parks, et al.,2009, 163 (1): 35-41. • Predictive Values of Psychiatric Symptoms for Internet Addiction in Adolescents: Ko, CH, Yen, JY, Chen, CS et al, 2009, 16 (10), 937-943. • Physical Activity Opportunities Associated with Fitness and Weight Status Among Adolescents in Low Income Communities: Madsen, K, Gosliner, W, Woodword-Lopez, G. et al, 2009, 163 (11), 1014-1021. • Adolescents and Dating Violence: Moreno, M, Furtner, F & Rivara, F. 2009, 163 (11), 776. • Impact of movie smoking exposure and team sports participation on established smoking: Adachi-Mejia, A, Primack, B, Bead, M, et al, 2009, 163 (7): 638-643.

40. A review of articles in the Archives of Pediatrics and Adolescent Medicine (con’t) • Does Parental Involvement Predict New Sexually Transmitted Diseases in Female Adolescents? Bettinger, J, Celentano, D, Curriero, F et al., 2004 (158), 666-670. • The Influence of Parental Monitoring on Adolescent Sexual Initiation: Sieverding, J, Adler, N, Witt, S et al., 2005, (159): 724-729. • Weight Concerns and Weight Control Behaviors of Adolescents and their Mothers: Field, A, Austin, B, Striegel-Moore, R., 2005 (159), 1121-1126. • Television Viewing and Risk of Sexual Initiation by Young Adolescents: Ashby, S, Arcari, C, Edmonson, B., 2006 (160): 375-380. • Are Household Firearms Stored Less Safely in Homes with Adolescents? Johnson, R, Miller, M, Vriniotis, M., 2006 (160):788-792.

41. A review of articles in the Archives of Pediatrics and Adolescent Medicine (con’t) • Public Opinion on Sexual Education in US Schools: Bleakley, A, Hennessy, M, Fishbein, M., 2006 (160): 1151-1156. • Internet Prevention Messages: Targeting the Right Online Behaviors: Ybarra, M, Mitchell, K, Finkelhor, D., 2006 (161): 138-145. • Extensive Television Viewing and the Development of Attention and Learning Difficulties During Adolescence: Johnson, J, Cohen, P, Kasen, S, 2007, (161): 480-486. • Relation of Adolescent Video Game Play to Time Spent in Other Activities: Cummings, H, Vandewater, E., 2007 (161): 84-689. • Exposure to Smoking Depictions in Movies: Its Association with Established Adolescent Smoking, Sargent, J, Stoolmiller, M, Worth, K et al., 2007, (161): 849-856.

42. A review of articles in the Archives of Pediatrics and Adolescent Medicine (con’t) • Alcohol branded merchandise and its association with drinking attitudes and attitudes in US adolescents: McClure, A, Stoolmiller, M, Taski, S, Worth, K, et al., 2009, 163 (3), 211-217.. • Parental Attitudes About Cigarette Smoking and Alcohol Use in the Motion Picture Association of America Rating System: Longacre, M, Adachi-Mejia, A, Titus-Ernstoff, L et al., 2009, 163(3): 218-224. • Decrease in Adolescent Cannabis Use from 2002 to 2006 and Links to Evenings Out with Friends in 31 European and North American Countries and Regions: Kuntsche, E, Simons-Morton, B, Fotiou, A et al., 2009, 163 (2): 119-125. • Social Networking Sites: Balance Between Risks and Benefits:Mitchell, K & Ybarra, M., 2009, 163 (1), 87-89. • Factors Associated with Changes in Physical Activity:A Cohort Study of Inactive Adolescent Girls:Neumark-Sztainer, D, Story, M, Hannan, P. et al., 2003, 157:803-810. • Association Between Television Viewing and Sleep Problems During Adolescence and Early Adulthood: Johnson, J, Cohen, P, Kasen, S et al.: 2004, 158: 562-568.

43. A review of articles in the Archives of Pediatrics and Adolescent Medicine (con’t) • Predictors of Initiation of Alcohol Use Among US Adolescents: Fisher, L, Miles, I, Austin, B. et al., 2007 (161): 959-966. • Family Meals and Disordered Eating in Adolescents: Neumark-Sztainer, D, Eisenberg, M, Fulkerson, J et al, 2008 (162): 17-22. • Family, Peer and Media Predictors of Becoming Eating Disordered: Field, A, Javaras, K, Aneja, (162): 574-579. • Positive Parenting and Early Puberty in Girls: Protective Effects Against Aggressive Behaviors, Mrug, S, Elliott, M, Gilliland, J et al., 2008 (162): 781-786.

44. The 20-second public health challenge • Coaching, anticipatory guidance or information dissemination could take a number of forms • Checklists or handouts could be prepared and provided at well-child, school and sport physicals. • Emails to parents and texting to teens • Screening digitally with crafted feedback mechanisms