Parenting Teens:
Basic Toolbox for the Pediatrician
Laura Kastner, Ph.D.
Clinical Associate Professor
Psychiatry and Behavioral Sciences
University of Washington
“It is easier to build strong children than to repair
broken men.”
Frederick Douglass (1817-1895)
Disclosure Information
• I have no relevant financial relationships with
the manufacturer(s) of any commercial
product(s) and/or provider of commercial
services discussed in this CME activity.
I do not intend to discuss an
unapproved/investigative use of a commercial
product/device in my presentation.
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.”
Anticipatory guidance* and parent coaching have
many evidence based cousins:
• Dialectical behavioral therapy (DBT) model has a parent 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
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
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.
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.
American Psychological Association Survey
Adults’ reports of physical effects of stress in the past month:
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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).
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”
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.
Link between parents’ problems and
child mental health and adjustment
• Quality of family life
• Parents’ psychological
problems
• Economic strife
• Marital discord
• Social support
The American Dream:
Wealth, Fulfillment and the Pursuit of
Happiness
• Money is a complex resource with the trap of the
“hedonic treadmill” (Juliet Schor).
• Financial aspirations are correlated with
depression and anxiety, whereas values placed on
service and strong connections with others result
in greater purpose and life satisfaction (Kasser).
• Happiness is associated with strong relationships
with others, finding and using your talents and a
purposeful life (Gilbert).
• The U.S. and westernized cultures are becoming
dopamine-driven (Whybrow)
Stresses of hyper-parenting, overscheduled,
and over-pressured parenting
• Suburban sample of middle school children
compared to an inner city sample
• Significantly higher levels of depression,
anxiety and substance use
• Associations with perceived academic
pressure from parents and isolation from
parents.
Luthar, S. and Becker, B. Privileged but Pressured? A Study of Affluent Youth.
Child Development, 2002, 73 (5), 1593-1610.
A to Z Parenting Toolbox (laurakastnerphd.com Toolbox)
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Authoritative parenting
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Boundaries and independence
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Competence building
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DNA of parenting—executive functioning
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Optimizing secure attachment
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Peers, friends and elder relationship
support
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Questioning yourself enough to stay openminded
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Role model resilience and other qualities
and virtues
•
Emotional and social learning
•
Family fun without screens or money
•
Socratic Method with challenging subjects
•
Getting to calm skills
•
Temperaments—working with them, not
against them
•
Health maintenance-yours and theirs
•
•
Intellectual and academic development
Understanding and accepting normal child
development
•
Judgment calls in discipline
•
Values clarification and the moral
compass
•
Kindness, humor and happiness quotients
•
Wise mind—integrating emotional and
cognitive brain power
•
Limitations on risk-taking behaviors
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Money management and resisting indulgence
and entitlement
X-Box, media, cell phone, social
networking and electronic LIMITS!
•
Yearnings management
•
Negotiation skills and avoiding arguments
•
Zeal for life pursuits
Top Seven Focal points for Pediatric Guidance with
parent of teens (in toolbox)
1.
Secure attachment
2.
Authoritative parenting, effective discipline and quality family
relationships (importance of boundaries)
3.
Social and emotional learning and modeling in the home (including
emotional regulation)
4.
Effective discipline, managing conflict and negotiation skills
5.
Understanding normal teen development (for realistic expectations)
6.
Checklist for building teen competence
7.
The new hot commodity: TIME & PRESENCE
(for relationships, calmness, and health—electronic control!)
Optimizing Secure Attachmentpredicts 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
Optimizing Secure Attachment
Exit 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’
parents’ perspectives on
issues
• My parents value my opinions on
issues
• When I’
I’m upset, my parents show
concern
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
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.
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.
DNA of successful parenting-
Executive Functioning
• Planning, reasoning, judgment,
(weighing costs/benefits/risks), impulse control
• Ability to formulate and execute a plan
• Values-informed parenting and prioritizing
• Problem-solving
************************
• Everything in the A-Z Toolbox requires parental
executive functioning
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.
• RoleRole-modeling is key.
E is for Emotional and Social Learning Enhancement
Emotional Intelligence
•F
Emotional Intelligence
involves Identification of
feelings, appropriate
expression, and
management.
Parents ideally role
model competent emotion
management of both
negative and positive
emotions.
Emotional and Social Learning Enhancement
Emotional Intelligence (social and emotional
competence): a meta-ability which determines how
well you can use your IQ
•
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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 decisionmaking (requiring “getting to calm” skills)
Emotional Drives
Why 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
A Co-AMYGDALA HIJACK
Clayton 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.”
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.
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.
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?)
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.
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 you 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!
Effective discipline, negotiation skills and
staying out of power struggles
Behavioral compliance
1. State your expectation
2. Don’t fall for “the bait” of resistive protests
and give the child room for choosing to
cooperate
3. 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.
When kids non-comply or resist,
DON’T A.R.G.U.E.*
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•
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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.
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
Negotiation (and management) skills
When 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
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.”)
Teen Brain NASCAR Metaphor
• Big engine—maturing bodies,
independence-striving
• Poor Driver—immature PFC means poor
reasoning and judgment
• Faulty Break system—immature
inhibitory mechanisms in PFC; impulse
control problems
• High octane fuel—hormones intensify
emotions
The molting phase: When a parent’
parent’s sweet child
morphs into a sassy teen
Why would Sally put this picture on
FaceBook with the caption
“Do you want to stick it to me?”?
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.
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
Competence Checklist
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
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.
Children aged 8-18 spend 7.5 hours
connected to media per day (Kaiser, 1/20/10)
Texting, Facebook, gaming and other
electronic social networking
activities are HIGHLY rewarding
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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
The solution:
- Get ‘em off and get ‘em moving
- Organized sports and service
- Tech free zones and times at home
• Role modeling!
A Healthy Family Environment takes TIME
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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)
The neuroscience of happiness
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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
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 teen
Can 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.
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.
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.
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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.
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.
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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.
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): 781786.
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
References
(Laura Kastner’s presentation Parenting Teens: A Toolbox for Pediatricians)
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