Andrew M. Portteus MD

Right now, with our two-and-a-half year old twins, my wife and I are helping them explore their environment to learn new things and to have fun with play.  To create happy and secure children, we are also teaching limits and boundaries.  A lot of time has been spent sharing our expectations and enforcing consequences for good and bad choices:

"You can't pull your brothers hair or bite, or you will have a time out and need to say sorry" (And if you reply "I'm not ready to say sorry", your time out continues.)

"You can watch a DVD in the car on a long road trip if you don't put your feet on the screen or pull the wires, if you do, daddy will turn it off."

"You need to tell us what you want with words.  We will help you as soon as you stop screaming and let us know what you want."

Milk stays in the cup.  Food stays on the plate.  We sleep in our own beds at night...

As children grow and develop more skills, some things get easier.  But parents of tweens and teens point out how new challenges quickly replace old ones.  As children mature, their needs for boundaries change, but continue.

It is helpful for children to know clearly what is expected of them.  It is hard to win the game if we don't know the rules.  It is hard to reach a destination if we don't have a map.  Family rules should be established and discussed. 

When parents are rigid, unreasonable, and unyielding, they may be met with defiance and hostility.  But when parents are vague, wishy-washy, and inconsistent, they may find their children floundering.

I have been fascinated in my career to have many adolescents tell me privately that they want limits from their parents and that it lets them know that their parents love them (even if they protest in their parents presence.)  Teens will often push for new freedoms, and they should.  This is how they grow in independence and responsibility.  But, this push should be met with negotiation and parental guidance.

Recently, a young adult who was struggling in college and searching for direction asked his father to impose a curfew and help him establish structure in his life.  He determined that his lack of self-discipline and follow-through stemmed from a lifestyle of permissiveness and absent parenting that started with his parents divorce in his teen years and continued throughout his adolescence. 

It is best when rules are developed from a place of love and respect, and when limits are fair and reasonable.  Any adult who has worked for a boss who was arbitrary, hostile, and controlling will tell you that the experience was demeaning and did not nurture their best work.  Similarly, children will respond best to a boss who is loving, compassionate, forgiving, and fair.  Sometimes, the hard part of parenting is giving your children what they need when it is not what they want.  Being a loving parent does not mean giving in or sacrificing parental limits to become your child's best friend.  It does mean working in the best interest of your child. 

Psychologist John Townsend also points out that an important part of establishing boundaries is recognizing that your child has a choice of whether or not to follow the rules.  It is hard to exert our will on another.  Children have the freedom to follow rules or not.  But there should be consequences for their choices.

Consequences should be proportional to the mistake.  They should quickly follow the offense and they should be finite in duration.  To have an impact, they should be enforced.  Consistency is essential.  Ideally, consequences should matter and be tailored to motivate an individual child.  When possible, consequences should be determined and discussed in advance, hopefully as a deterrent to pushing the boundary.

Children should be rewarded with praise, positive feedback, and privileges as the consequence for making good choices.  Similarly, children should face the negative consequence of a poor choice.  When consequences are used appropriately, parents don’t need to scream or lecture excessively to get their point across.  They can let the consequence do the work.

To help children develop character, it is useful to allow children to accept the natural consequences that result from their behavior at school, on sports teams, and at other activities.  Certainly, there are times when parents must advocate for their child when a child has been treated harshly or unfairly, but parents who bail their children out from all problems rob their child of the opportunity to learn the lessons of their actions.  They create entitlement and irresponsibility.

Finally, it is important for parents to set good examples and model appropriate behavior.  It is hard to expect a child to be honest if he sees a parent twisting the truth or taking unfair advantage.  It is hard to expect a child to be kind and respectful if he sees a parent belittling others or acting in an abusive way to a spouse or talking about people behind their backs.

Based on my work with adolescent patients, some areas where parents should set boundaries and expectations are:

bullying/teasing

cheating/lying

electronics (TV, computer, cell phone, texting limits, social networking minutes)

safe driving

alcohol and drugs

sexual behaviors

curfews/check-ins/informing parents of their location

On a recent vacation, my wife overheard a group of twelve and fourteen year old girls by the pool discussing boys' penises, sexual activity they have engaged in, and their alcohol consumption.  A waiter reluctantly delivered two pina coladas that a girl accepted for her parents who had stepped away.  The girls consumed the drinks, and when the father returned, his daughter thanked him for ordering the drinks.  He nodded in acceptance.

Currently, alcohol and drug use among middle and high school students is astronomical.  One reason, I believe, is that parents are failing to set clear expectations and boundaries around illegal alcohol consumption.  Because some kids experiment, and perhaps because they, the parents did, many adults are now creating an environment of permissiveness and acceptance. 

The fact that kids may push boundaries is not an acceptable reason to not have boundaries in place.  It is the reason kids need them more than ever.

I encourage parents to discuss expectations, to set safe and supportive boundaries for their children, to reward good behavior, and to enforce consequences when needed.  Your kids will be better for it.

If you have concerns about your child's behavior or family functioning, or if you have a mental health need, you may visit my website www.drportteus.com or contact my office at 214-550-3367 to schedule an appointment.

Andrew M. Portteus, MD, MPH

As Mean as a Rattlesnake!

Not long ago, a mother was sharing with me her frustrations about her teenage daughter’s behavior.  The girl was rude.  She was disrespectful.  She was argumentative.  As the mother talked, she became louder and more animated until eventually she screamed out “She’s as mean as a rattlesnake!!!” 

When I visited with the daughter, I discovered that she had been feeling bad for some time.  She wept in my office about many concerns and frustrations.  She was stressed.  She has not been sleeping well lately.  And she had been feeling very irritable.  Little things were making her annoyed and she was over-reacting.  She had been feeling like nothing would work out for her and she was starting to think about suicide. 

Fortunately, this girl presented for treatment and we were able to provide her some brief psychotherapy and start and antidepressant medication which drastically improved her mood and behavior.

We often think of Depression as feeling sad or blue and crying more.  But depression does not always present this way.  Often, irritability can be a presenting feature of Major Depression. 

When working with families, I sometimes meet with a father who is short tempered and reactive.  Family members walk on egg-shells to avoid a conflict.  He may be a workaholic.  He sees himself as task oriented, but coworkers find him difficult and overbearing.  He looks tired from poor sleep.  He is depressed and does not know it.  Sometimes I meet a mom who is “flying off the handle” and “snapping” easily.  She reports mood swings and decreased enjoyment from her life. 

I often see children who have stopped enjoying activities they have usually liked, have given up friends, and tell me they get easily annoyed by little things.  Often as we explore more we discover an untreated depression.  A while back I met with a kindergartener who had always been sweet and loving.  The parents knew something was wrong when he erupted in class after a little girl came over to compliment his painting.  He took his paintbrush and destroyed his work and hers.   He had become angry and irritable and cried easily.  He told me he felt like a bad boy and wished he were dead.  He had gone out in the road and sat down, wishing a car would hit him, but he hadn't told anyone.

Depression is a biochemical, metabolic change in the brain that can present with sadness or irritability.  It often can cause loss energy, lack of enjoyment in activity, and decrease in concentration.  There may be sleep or appetite disturbance.   Stress or anxiety may be present.  Depression often runs in families.

If an individual suspects that they or a family member are depressed, they should meet with a mental health professional or their primary physician to explore the diagnosis further.   Antidepressant medication can often be effective and well tolerated.  Cognitive behavioral therapy can also be helpful.  Exercise, a healthy diet, and good sleep hygiene can also help improve mood.  Some studies have suggested that Omega 3 fatty acid supplements (fish oil) may help promote a good mood, too.

To learn more about features of depression and treatment options, visit my website www.drportteus.com.  To schedule an appointment you may call my office at 214-550-3367.

Andrew M. Portteus, MD, MPH, PA

When someone begins to identify a problem and wants to seek the help of a mental health professional, they are often left wondering “Who do I see?”, “Where do I go?” “What kind of practitioner would be best?”, “And what is the difference between a psychiatrist and a psychologist?”… 

To determine the right fit, it is useful to understand the specialized education and training different providers have obtained, where their skill sets overlap and where they diverge.

 A psychiatrist is a medical doctor (M.D.) who has attended four years of medical school after college and then completed a four year residency training program in psychiatry. A child and adolescent psychiatrist has completed a two year fellowship in child psychiatry in addition to the residency. This training involves taking classes and working with supervisors in psychiatric hospitals, outpatient mental health clinics, schools, and therapy clinics. A psychiatrist is trained to evaluate and diagnose behavioral and mental health problems, determine whether or not a medical problem could be causing the symptoms, and to develop a comprehensive treatment plan with behavior modification, therapy, and/or medication.

 Psychiatrists have training both in psychotherapy and in using medications to treat mental health problems. A psychiatrist is a good bet if you need a comprehensive assessment to figure out what is wrong and determine a diagnosis, if you need someone to talk to about private or sensitive problems, or if you or your child have a condition that will respond well to medications such as: depression, anxiety or panic attacks, obsessive-compulsive disorder (OCD), attention deficit hyperactivity disorder (ADHD/ADD), bipolar disorder, schizophrenia, tic disorders (Tourette’s), sleep problems, etc.

 In my practice as a psychiatrist, I work with both adults and youth. When working with a child, I visit with children and parents, review school reports, inquire about medical histories, observe behaviors, and sometimes play and draw to understand what is happening with a child. I look at mood and behaviors, thoughts, sleep and appetite patterns, school and work performance to develop an understanding. I have some patients who come to see me for psychotherapy to improve their mood or behavior, some who were referred by their therapist for me to evaluate and prescribe medications, and others who come for both therapy and medication treatment at my office. As a child, adolescent, and adult psychiatrist I often work with families, too. I frequently collaborate with primary medical doctors, psychologists and diagnosticians, language and occupational therapists, school personnel, and individual and family therapists when it is helpful to have a team approach.

A psychologist completed a graduate (Ph.D.) program in human behavior. Psychologists have specialized training in administering and scoring educational and psychological tests such as IQ and achievement tests, personality tests, etc. They have training in diagnosing mental health problems, developing treatment plans, and providing psychotherapy. Some psychologists primarily conduct testing for learning and personality problems, some primarily conduct psychotherapy and behavioral training, and many do both. If a parent is concerned about a learning disability such as dyslexia, they may seek testing from a psychologist to evaluate the problem. Psychologists will refer clients to a psychiatrist if they believe medication would help with focus problems, mood problems, behavior problems, or anxiety. Psychiatrists often will refer their patient to a psychologist if they suspect a learning problem needs to be evaluated or to receive psychotherapy. 

Educational diagnosticians are also helpful in conducting testing for school and learning problems. Speech and language therapists are helpful in diagnosing and treating language processing problems. 

A therapist (or psychotherapist) may be a psychiatrist or a psychologist, or a therapist may have completed a master’s degree program in social work or counseling and have completed training with a supervisor. A licensed therapist has completed licensure requirements such as a LPC (licensed professional counselor), LMFT (licensed marriage and family therapist), or LCSW (licensed clinical social worker). Because anyone can call themselves a “therapist”, it is important to review their credentials and inquire about their areas of specialty. Therapists can be helpful when a person needs someone to talk to about life adjustments, grief, or promoting positive changes in the future, when one has developed negative or worrisome thought patterns that need to be corrected, when they need help with communication problems or family dynamics, or when they need help with parenting or behavior management. 

To find a provider it can be helpful to get recommendations from friends, school counselors, pediatricians and primary medical doctors, clergy, the internet, etc. For more information about mental health topics or my practice, visit my website at www.drportteus.com

Andrew M. Portteus, MD, MPH, PA