Dr. Gene and Dr. Khadijah Answer Your Questions – Shrinking It Down
From challenges with hair pulling to supporting a child through a regression in toilet training, Dr. Gene Beresin and Dr. Khadijah Booth Watkins answer real parent questions in this episode. For each question, they offer clinical insight to help parents better understand what might be going on, and suggestions for next steps and ways to support the child or teen. We think all caring adults will be interested in this discussion. Be sure to tune in.
Follow along with the media list below, and if this episode sparks other questions, write to us! We’ll include in a future episode. Tune in the 3rd Thursday of every month for new episodes. Like what you hear? Leave us a review!
- Dr. J. Stuart Ablon: Kids Lack Skills, Not Will to Do Well (YouTube-AccuTrain)
- Question #1: How to Help With Hair Pulling (01:40)
- Hair Pulling (Trichotillomania) (AACAP)
- What If My Child Has Obsessive Compuslive Disorder (OCD)? (MGH Clay Center)
- Cognitive Behavior Therapy: A Closer Look (MGH Clay Center)
- What If My Child Is Prescribed an SSRI? (MGH Clay Center)
- Question #2: How to Help My Teenager with Avoidance Behaviors at Home and at School (06:15)
- Anxiety in Our Children: The Role of Avoidance Behavior (National Association for Child Development)
- School Refusal: When Back-to-School Is a Struggle (MGH Clay Center)
- CBT Snapshot: Using Cognitive Behavior Therapy for Phobias (MGH Clay Center)
- Question #3: Child Can’t Stop Touching Things When They Walk Around the House (13:05)
- Overview: Tics (National Health Service)
- What If My Child Has Obsessive Compulsive Disorder (OCD)? (MGH Clay Center)
- Question #4: How to Help 5-Year-Old with Potty Training Regression (18:05)
- Welcome Back (Theme from Welcome Back, Kotter) (YouTube-John Sebastian)
Gene Beresin, MD, MA and Khadijah Booth Watkins, MD, MPH
I have a lot of questions myself about about mental health.
You should you, should send them in and see if we can answer them.
No, I won’t. I won’t stuff. I won’t stuff the ballot box. Let’s let’s let’s let the folks who are listening, do your thing and send us some questions.
Welcome back to shrinking it down mental health made simple. I am Gene Beresin.
And I’m Khadijah Booth Watkins.
And we’re two Child and Adolescent psychiatrists at the Clay Center for young healthy minds at the Massachusetts General Hospital. And this is our first episode, I think, of our podcast for this year, isn’t it?
This is our first episode for 2023.
And we’re going to begin in kind of an open ended fashion because, you know, your questions are super important to us. And even though we believe that we’re experts, I guess we are experts in child and adolescent psychiatry. You know, you’re experts with your kids. And you have questions based on real life experience that are so important. So, we’re going to start this year with answering some questions that you’ve sent us. How does that sound? Khadijah?
Sounds like a great idea. And I tell parents all the time, like I’m an expert in my own right, but you are the expert on your child.
Exactly. So maybe I’ll read the first question, and then you could chime in. Okay, it’s how to help with hair pulling. I guess it’s as simple as that there wasn’t a follow up. So How to help with hair pulling! So, I’ll open it up. Hair pulling is called trichotillomania, which is a variant and related to obsessive compulsive disorder. And it’s defined as twisting, pulling, and sometimes even pulling out your hair. And it’s it is a bonafide compulsion that a child just can’t stop doing. So Khadijah. What do we do for that?
Well, we can think of some practical ways just to address the act of hair pulling. And so some things that I sometimes recommend are, you know, if they’re pulling hair off the top of their head, recommend wearing a bandana, or some sort of hair covering to make it more difficult. Sometimes kids can get really, you know, really, they can get bald spots, which make it hard for them to feel good about themselves and confident. Other things that I might recommend would be maybe wearing gloves, sometimes even something as silly as maybe putting a little bit of Vaseline on the tips of your fingers, because it makes it hard to to grasp the hair and pull it. But the one thing that I do also recommend while we’re doing these acts, is to think about when do you hair pull? Do you pull your hair when you’re bored? Do you pull your hair when you’re trying to go to sleep at night? Do you pull your hair on your stress? Or is it hard for you to know, but this might be a cue or clue would help us to think about how we might kind of give you other interventions to address it. What else should we think about?
Well, what I’d like to know also from the standpoint of the child is whether it’s felt to be a negative experience, or whether it gives them some degree of pleasure. You know, a lot of obsessive-compulsive behavior is meant to fend something off the words, you have a compulsion to, you know, touch the door three times you say three prayers or, you know, check to see that the stove is off, and then you check again and check again and check again. And a lot of compulsive behavior is meant to kind of the war if something bad happening, or make yourself feel better in a weird way, even though you can’t stop. And in that light, if we think of it as a variant of obsessive-compulsive disorder, kind of the two main day treatments that we provide is first cognitive behavior therapy, which helps teach the child what to do about thoughts. Because usually it begins with the thought of pulling the hair. So, you have a trigger, and that’s the impulse you have a thought and then sort of twisting or pulling out the hair. Then you have an emotional reaction, which is just which is anxiety. I’ve just got to do this. It won’t be relieved until it’s done. And then the behavior just the hair pulling. So, working on exact To read or to distorted thoughts, or cognitions is what we do for cognitive behavioral therapy. And the other part of it is using medications. Because the selective serotonin reuptake inhibitors, the SSRIs have been extremely effective in treating OCD, even up to 85%. Effective, and especially when combined with C with cognitive behavioral therapy CBT. So those would be the traditional methods that we would provide. As, as doctors.
I think those are really great. And I think that brings us back to why the why is so important, because I think it helps us to tailor the intervention specific to the kids, because I could tell you, you know, to sit on your hands or to you know, you know, keep a fidget. But if hair pulling, relieves distress, I’m going to also probably create some distress. So really understanding why you’re doing what you’re doing is going to be so important to help really tailor the intervention to really, you know, get the symptoms to go away, or get the compulsion to go away.
Great. So, let’s, let’s tackle the second question. The second one is how to help my team son, with avoidance behaviors, at school and at home.
Avoidance is a is a symptom, I guess, if so many different things. And it goes back to what’s the function of the behavior is what I what I like to think about and discuss with parents and kids. Because if we can understand the function of the behavior, we can begin to do things to kind of undo it. And most of the time, we avoid things if it gives us distress, or makes us uncomfortable. If I’m afraid of heights, I’m going to avoid, you know, going into elevators or going over bridges. So really understanding the function of the behavior or, or why we’re doing what we’re doing, helps us to think about how we would begin to build an intervention to help address it because we got to go to school, you gotta come home. And so, these are things that we kind of have to do. So how do we help them do it in a way that is less stressful?
Yeah. And to add to that, we want to know what they’re avoiding mean, so are they avoided? So, all of this is involved in having conversations, which we promote, and which are super important? And I’d like to know, what is what is the child? What is this? What is this this little guy? Or teenager avoiding it avoiding social situations? Is he avoiding homework? Is he avoiding going to school? Is he avoiding public speaking and class? Is he avoiding playing sports? And because once we know what, what the avoidance is, we can add to what you’re just saying. And we can begin to think about how do we address that problem.
Most of the time, it’s going to be some form of exposure response prevention. So we’re going to try to gradually expose them to what they’re avoiding, to hopefully let them see that, you know, it’s not so bad, we survived this, you know, for 10 minutes, let’s do it again for 30 minutes, but hopefully, you know, over the course of time, as we gradually expose them to what they’re avoiding, they become desensitized to it or they become kinda, if you will, immune to what they were originally afraid of, and then it becomes easier for them to do. But it’s so important to know, if we’re, if we’re exposing them to if they’re struggling with the schoolwork, we need to get some help with whatever accommodations or remediation they might need. If they’re being bullied at school, we need to address that there’s the safety concerns. So, we do have to have these conversations with them, and make it a platform that feels open and safe for them to share exactly what they’re feeling and exactly what’s going on with them when they go to school or when they’re going home that makes it so difficult.
And when you said exposure response prevention, that means exposing them it’s a form of CBT. So, we like to expose them in baby steps. So, if you’re afraid of heights, you don’t go to the top of the Boston the Hancock Tower in New York, the top of the Empire State Building and look over the edge. That’s known as flooding and it’s actually more traumatic than doing it step by step. You know, we used to call it systematic desensitization, which means you systematically desensitize the child to whatever they’re afraid of. And usually, avoidance is a fear response is part of the fight or flight response. So instead of fighting, they, they flee, they avoid it. And a small step by step approach is what we typically use for phobias or things that that we’re afraid of. The other thing, the other thing I want to mention about this is, is that I would try to understand empathically the child’s feelings and point of view. I mean, if they’re avoiding schoolwork, because they, they have a learning disability, or if they’re avoiding social situations, because they’re afraid of saying something wrong, or they’re afraid of bullies, you know, one of the things we don’t want to do is say, well just do it.
Just suck it up, buttercup, we don’t want to say that.
No, no. And understand, you know why it’s so difficult. Because once you have an understanding of the child, the child feels that, that he’s being seen, heard, validated, that you get it. And he’s got that support. And it’s very, very hard to face a fear, even if that fear is irrational. Now, bullying is not irrational. Bullying is, it’s an aggressive thing. But but let’s say he’s afraid of kind of like giving a book report in class. And you might think, how, how ridiculous.
Well, back in my day, this was never an issue, just do it.
Right, right. You just did it. And that’s it, you got it over with you sucked it up. And so, but, and it may, it may end up being that way, to an extent, step by step. But it’s so much easier for the child to engage in that stepwise progression, if he feels that you get it, and that you’re supportive, and that you will understand that you’re not criticizing him for a deficit. We all have our weaknesses. And we will look for our strengths. And I think everybody listening probably continue to have something that they’ve been afraid of that they’ve avoided.
Like my emails, after vacation. I mean, the other thing I will add is that it is so important to address it sooner rather than later and begin having these conversations. Because the longer we engage in some sort of avoidant behavior, the harder it is to re-engage in and so the longer they might, you know, resist participating in class or going to school or doing things that they’re supposed to around the house, the harder it is for them to go back to it. And so, again, having these conversations as soon as it appears to be potentially a problem and thinking about ways that you can help gently and warmly push them to their goals.
Yes, we don’t want we don’t want to make the molehill into the mountain, right. So that’s a good point. Okay, so we have a third one. My child recently started touching the edges of furniture, picture frames, objects around the house, whenever they get, whenever they get up to walk somewhere, they don’t seem to be aware that they’re doing it. And they can’t seem to stop when I asked them to.
This one is a little bit trickier. Because it can be like you talked about earlier about what is the sensation or feeling that they’re getting? Are they getting some sort of relief? Or is it just like an automatic act almost like a tick, like an urge?
It does sound it does sound very much like compulsive behavior. And very much like what we talked about with hair pulling, except this compulsion is one of touching.
And you might find, after you have conversations, that there is some sense of relief, and they may be a little bit more aware of what they’re doing, it may not be as straightforward as it seems. So, a pair right off the bat.
What’s interesting about this is that they don’t seem to be aware that they’re doing it, usually with a compulsion. Their folks, your kids, as well as adults are very aware of what they’re doing. They just can’t stop it. In other words, they have to, you know, they have to open and close the lock on the door three times. And they’re aware that they’re doing, they just can’t stop themselves. So, what’s interesting about this, is that they don’t is the lack of awareness, which enables
The parent says they’re not aware.
Well, that’s right. The parents so that’s where conversation comes in, you know, asking them Are you aware of, of what you’re doing when you know, when you walk around the house? And then the other question I want to know is do they do they only do it at home or did they do it everywhere? If they do it at home, I mean, there’s meaning behavior has meaning even if we just don’t get it at first, if they’re just doing it at home and not in restaurants or in supermarkets or in school, or in their Sunday school, wherever, then what is it about home? That makes them have that urge. You know, so that’s kind of, you know, parents, I think need to be kind of like, you know, detectives, in a gentle, warm way. Understanding.
We have to be mindful of our body language and our tone when we ask questions, the words that we choose, when we ask questions, like, why is really a tough one? Because it doesn’t usually, it usually always comes across typically judgmental, and often, if I knew why I wouldn’t do it. And so asking, Why is probably not the best way, but like, what are you seeing? What’s what what’s going on in your head when this happens? Are you having a certain feeling like asking more questions, more specifically, indirectly, can be more helpful. But as long as we’re coming to this, again, with warmth, and kindness and compassion, you know, we’re going to be successful, we just have to be patient, and then ask questions and have multiple conversations, because they might be a little bit embarrassed and ashamed at first, and they might initially say, What are you talking about, I’m not touching the corners. That was just one time, but you know, going back to them and asking, expressing that you might be consistent, your concern, like all of these things can help open up the floor for them to feel more comfortable and support it.
And I think I think to understand that stood out on the kids, you know, always says about kids who are challenging is that it’s not a lot. It’s not willfulness, it’s a lack of skill. at it, they are not willfully touching these things, because it’s, it’s fun, they just don’t have the skills, or the or the understanding, or the mechanism with the means to stop it. So, taking an approach to, to understand them and decide with them and to support them, and to manage it together. The good news is that the behaviors and obsessive-compulsive disorder, which is what I assume this is, is is a variant are incredibly rewarding for us to and for parents to treat, because these kids, most kids get better, much better. Okay, so we have another question. How do we better support our five-year-old who was fully potty trained pre pandemic was out of daycare for 10 plus months, and as in struggle to keep her underwear dry, especially when watching TV pediatrician has already checked for medical causes, and she does not wet the bed. This is a consistent after school with parents, primarily a home thing, purely based on FOMO or fear of missing out. She screams at us when we prompt her and she’s been has began to lie and attempt to hide the behavior. But unfortunately, mom’s nose knows and can smell it. Consequences have resulted in repeated loss of screen privileges, and leaving the end of playdates early when movies or TV shows are involved. have also asked her to rinse her own wet clothes. Please help.
There’s there are a lot of layers here that I think we probably will have to unpack and talk through step by step. And I can imagine it sounds like the mom, mom is kind of at a loss, obviously for what to do, which is hopefully we can be helpful around beginning to think through this with her I think the most important thing is to make sure that there’s not a medical cause, which sounds like she did. What are your thoughts?
Well, I have a lot of thoughts. First of all, I think if I were to approach this clinically, I would want to know, has anything. Has anything changed at home? You know, things like this. Don’t necessarily come out of the blue. Has there been a change in jobs in the parental relationships with siblings? Have there been other add adverse events? For example, has anyone gotten very sick from COVID? Has anyone died? They’ve been losses. So, I think we start by asking some general questions about what home life has been like. What’s fascinating to me about it is that it doesn’t happen in school. Doesn’t seem to happen. It doesn’t happen at night. So, something’s happening, particularly around the screen. So, could you see what would you ask about the screen about? What were any other questions? What would you ask about?
So, I would go, I would start to think about like, what is the function of this behavior? What is this doing for her? Obviously, you know, this is not something she’s doing in a way, simply because she wants to, I think we want to be clear about how we approach it and really manage. Be mindful of what were the thoughts that we’re thinking? So, we don’t want to think about this as something that’s willful, we want to think about what how this behavior is serving her. And so mom mentioned that there she maybe it’s, there’s fear of missing out? What is she may be so captivated by on these screens? Um, how can we maybe think about breaking it up a little bit more so that there are more natural breaks? Is my first thought.
Yeah, and I want to take off on what you said about it’s not willful. I mean, this reminds me of some basic principles of collaborative problem solving. And that is, is that her behavior? All kids want approval? So does she and as, as we know, from Stuart Avalon, and 10 kids, it’s not a matter of willfulness, it’s a matter of lack of skills. But one of the things that also happens with collaborative problem solving, is that you get further with kids, I think, rather than using punishments to change behavior, such as taking things away, like the screen time, like taking her away from playdates early so that you won’t watch TV. Like making a renter, wash your own clothes. Those punishment measures typically don’t work as well as using positive reinforcement. So, for example, how can we make this into a win-win? How can we say to how can we talk with this five-year-old and say, Look, I don’t want you to poop in your pants. I don’t want you to miss TV. If you’ve got to go, can you raise your hand? Or can you come over to kick? Can you hit a bell? Can you tell me like something to be stopped? And then we’ll just pause the TV, and you can continue with it. No, and rewards work better than punishment. So, you know, you could negotiate if you can watch this show, and not miss out on anything. But poop in the potty. And we can put a potty right next to the TV. So that you don’t go on your pants. What would that be like? And
That’s how I trained my son.
The potty – we walked around with the potty.
Well, that’s the way typically, I mean, this is a regression. You know, I mean, most most parents have potties that are that are movable that are easily accessible. So why not? My concern is, is that by using punishment rather than rewards, we’re making the kid feel bad about herself. And it could be done in a very different way.
So just to kind of continue on this just for a little bit. So, I do think that obviously, positive reinforcement praise gets us further. For sure. I would wonder if the goal of having her leave playdates early is really to spare her embarrassment because maybe mom is afraid she’s gonna have an accident. And I think that might be okay, temporarily. But I think maybe, you know, every five year old is different in their ability to kind of communicate is different. But if she’s able to talk a little bit more about what is happening when she has an accident, what prevents her from getting to the bathroom? Does she does she notice the sensation of him needing to go, she might tell you that she is afraid that she won’t finish her show or that, you know, by the time she’s finished going to the bathroom, her TV time will be up. So maybe being able to in advance, reassure her that if you go to the bathroom, you won’t lose your time. You know, being able to proactively address her concerns. And then with that, I think whatever plan is created, whether we’re going To have breaks every 15 minutes or whatever plan is created to get her to go to retrain her to go to the bathroom, that being discussed in advance, well, I think also be much easier for her to tolerate, and, and have her weigh in, in terms of the planning, have her collaborate with, you know, she’s five, but you know, have her give her thoughts about, like, what this plant could look like and what she might be able to earn, if she could successfully, you know, go to the bathroom three times during the show or whatever, whatever is reasonable, I don’t know. But think about how we can motivate and incentivize her to do what it is we need her to do, and what’s in her best interest.
And you’re right, I think, you know, for example, if she were to do that a number of times, and not miss out on the show, maybe she gets an extra award.
And the trick is really figuring out what plan you can come up with that you can as a parent be consistent with, because that’s going to be really detrimental to the process if you’re not able to be consistent. So pick something you can be consistent with, you know, pick rewards that you can easily also be consistent with. And they don’t all have to be monetary rewards, they could be extra time on a screen or, you know, an extra fun activity at the end of the night. It could be staying up, you know, five minutes later, just be creative about the rewards. And again, engage her in that discussion about what what the rewards might be. But I think really thinking about what you can create that you can stick to because consistency is going to be key to the success of of any plan that you come up with.
And just for the record it I said pooping. It may not be pooping, it may be that she’s just gotta go pee, you know, but doesn’t want to miss it. And you can’t hold it in that long. I mean that, you know.
And that’s not uncommon, where kids don’t want to interrupt their show, they don’t want to interrupt their game, they get so engrossed, that they don’t, that they don’t want to miss out. Some kids for whatever reason, don’t notice the sensation or the urge that they have to go to the bathroom. So that’s something else helping them to figure out how to help them to become more mindful and more aware. So every kid is different. So we really do have to take the time to figure out what is happening with her specifically so that we can kind of tailor an intervention that we can hope to be successful. And I think I think we should leave with that. Because most of the things that we are talking about, and most of the things that parents bring to us, they’re often highly treatable. And it just is a matter of getting the information, getting the education and being pointed in the right direction.
And on that note, I can end we can end with this. And that is that the myth about about psychiatric disorders is that the that they’re not curable, that they’re not treatable, that you’re just stuck. And the end, the fact of the matter is, is that most medical disorders are not curable. When I was a medical student, I was told by one of my attendings that there are only two cures in medicine, surgery, and antibiotics. And everything else is just maintenance. And whether it’s also filled your migraines or, or lower back pain or whatever. Hypertension, we basically have treatments that that are effective in kind of controlling things. In psychiatry, we’re back in about 70%, which is as good as it gets, in almost every other medical disorder. And there are only a small handful of psychiatric disorders that are much more difficult to, to treat, and to get what we call remission. And so I just want everyone to know that psychiatry is no different than the rest of, of modern medicine, and that we really do have effective ways of taking care of things. So on that note, we’d like to, we hope that our conversation and our questions have will help you have yours. And we hope that you’ll ask more questions. These are great. And just send them in and we’ll try to weave them into more podcasts this year. I’m Gene Beresin.
I’m Khadijah Booth Watkins. Thank you for listening.
Is this your first episode is this our first episode?
Welcome back! <singing> Welcome back, welcome back, welcome back…
That’s the great song – John Sebastian.
See, I knew you would like it.
Episode produced by Sara Rattigan
Music by Gene Beresin
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