Start Here: A Parent's Guide to Helping Children and Teens through Mental Health Challenges

Start Here

A Parent's Guide to Helping Children and Teens through Mental Health Challenges

From The Hospital for Sick Children and CAMH Psychiatrists Pier Bryden, MD and Peter Szatmari, MD

Praise for

START HERE

I believe mental health in children is more important than dental health. I’d much rather my child have no problems coping than no cavities. This book shows parents what they can do to help their kids.

Howie Mandel, comedian, actor, and Bell Let’s Talk ambassador

"As a parent who watched and supported my child, who experienced bullying and the emotional struggles that came with it, I’m grateful for Start Here—a resource for parents to understand mental health concerns and how to recognize them early, with strategies to support mental health within the home."

Katherine Hay, president and CEO of Kids Help Phone

"Having watched several friends navigate various mental health concerns with their children, I know that Start Here is such an important resource not only for parents but also anyone who has a close relationship with a child in their lives. By showing us what signs of potential mental illness to watch for—and what we can do to help—this book is a step towards a healthier future for us all."

Cynthia Loyst, cohost of CTV’s The Social and author of Find Your Pleasure

"When you’re desperate to find support for your child, navigating the mental health landscape can be challenging and overwhelming. Start Here is a thoughtful, evidence-based, and highly readable guide to both understanding mental health challenges and finding the strategies and resources to help—a game changer for parents."

Sandra Hanington and Eric Windeler, cofounders of Jack.org

A front door to understanding the uncertain, bewildering, and sometimes frightening challenges that our children face in terms of mental health. The authors, both seasoned child psychiatrists, provide helpful and hopeful plain-language explanations of common and less common mental disorders and the types of treatment that can make a significant difference, while reminding parents to trust their instincts if they are worried, to focus on understanding and help rather than blame, and to realize that they are not alone.

David S. Goldbloom, OC, MD, FRCPC, senior medical advisor at CAMH and bestselling coauthor of How Can I Help?: A Week in My Life as a Psychiatrist

This concise, welcoming, and approachable book helps all of us develop a better understanding of mental disorders that occur in young people. It should be a must-read for parents and all those who care about our children.

The Honorable Stanley Kutcher, MD, former director of the World Health Organization Collaborating Centre at Dalhousie University

"For any parent who has concerns about the mental health of a child (and, at one time or another, who hasn’t?), this is a must-have book. Easy to read and informed by both practical experience and solid research, Start Here is written in a clear and respectful way, respectful of the child in crisis and respectful of his or her parents. And best of all, it puts the family at the center, conveying accurately that a suffering child needs strong family support to surmount his or her difficulties and families need to know how to understand what is happening and how to be there to help."

Landon Pearson, OC, former Canadian senator and children’s rights advocate

This book provides direction for parents and caregivers, and instills a sense of hope and optimism that if a child has a mental illness, there is treatment available to help the child and family manage successfully.

Jana Davidson, MD, FRCPC, psychiatrist-in-chief at BC Children’s Hospital and head of the Child and Adolescent Psychiatry program at the University of British Columbia

"As a psychologist, I regularly consult with parents who are feeling overwhelmed and concerned about what to do and where to go to properly assess and treat their children’s mental health needs. In Start Here, Doctors Bryden and Szatmari share their knowledge with empathy and compassion—not only as psychiatrists at one of the world’s leading hospitals for children but as parents themselves. I’ll be recommending this book to parents."

Sara Dimerman, psychologist and bestselling author

An excellent and much-needed resource for parents. Written in clear and accessible language with clinical vignettes as the focus, this book provides answers and practical advice to assist parents in recognizing when their child needs help and learning how and where to find it. A must-read for any parent grappling with mental health issues in their children.

Harriet MacMillan, CM, MD, MSc, FRCPC, founding director of the Child Advocacy and Assessment Program at McMaster Children’s Hospital

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To our families, patients, and their families… who have taught us to be better doctors

Introduction

As parents ourselves, we know in every fiber of our beings that becoming a mother or father is a transformative experience, and one that almost always brings with it multiple red-letter days of unprecedented joy. However, we also know in every fiber of our beings that becoming a mother or father is to commit to a life of worry about your child—about his or her health, friends, behavior, and grades—and, of course, about your own parenting. We’ve been there too. We have five children between us, and, yes, even child psychiatrists question their parenting techniques. The constant stream of worries can be exhausting: How serious is this drop in marks in grade nine? Should I be concerned that she goes to her room as soon as she gets home? Is he hanging out with the right friends? Am I doing the right thing?

While physical ailments such as broken bones and fevers can be frightening in the short term, it’s usually quite clear what to do. In contrast, how to handle your child’s mental health is often much less clear, and even contradictory. If a child is skipping school, not eating or sleeping well, or isolating themselves from friends and family, some parents are advised to write it off as just a phase. Others may be concerned that these behaviors indicate a serious issue that requires early treatment to prevent long-term problems. It’s not surprising that today’s parents feel uncertain if their child is normal or if their mental state is something to worry about.

And the truth is that child and adolescent mental illnesses (also known as psychiatric disorders) are common, with somewhere between 10 percent and 20 percent of children and teenagers globally suffering from a mental health disorder. Half of all mental illnesses in adulthood begin by age fourteen, and three-quarters by the midtwenties.¹

Despite the progress we’ve made as a society to destigmatize mental illness, many children and teens continue to hide their distress from their families and peers because of the shame associated with psychiatric disorders, and parents are left to wonder how they will know if their child is a part of these sobering statistics.

Now more than ever before, parents need help. We suggest you start here. This book is our attempt to address the confusion, helplessness, and isolation that parents too often experience when a child exhibits signs of mental health challenges or illness. We wrote it to provide you with the information and help you need to support your children. After a collective six decades working in children’s mental health, we feel uniquely equipped to share the wisdom and practical strategies we have learned from our patients (and their families), colleagues, and scientific research, as well as our own experiences as parents.

If you are concerned about a change in your child’s development or behavior, this book will help you ascertain whether he or she is simply going through a phase or is in real trouble. (When referencing children, we’ve alternated the use of male and female pronouns throughout, but we recognize that some children identify as gender neutral and prefer they/them and we support this use.) Each chapter focuses on a different mental health issue and opens with a vignette about a parent whose child is in distress, then describes the family’s path to understanding what led to the moment of crisis, and how they learned to help their child. As you read, you will accompany these parents and children to meetings with mental health professionals and learn not only about various psychiatric disorders, risk factors, and warning signs, but also what you can do to intervene early to ensure that your child gets the treatment he needs should he develop such a disorder. You will get an inside look into the mental health system, see how a psychiatric diagnosis is reached, what the treatments for different types of psychiatric disorders entail, and what parents of children with mental health challenges can expect for their children’s future well-being.

As the title suggests, this book is meant to be a starting point. It would be impossible to provide an exhaustive guide to each and every mental health disorder experienced by children and adolescents, though we have included a detailed list of resources for you at the end of the book so that you can find out more about specific psychiatric illnesses, and, of course, your child’s physician or mental health provider is an invaluable resource for any questions we haven’t touched on here. Our goal is to help you figure out if your child is struggling with a mental health disorder and provide you with a road map to help her get the treatment she needs.

The most important piece of advice we can give you is this: don’t look away. We know that the fear that your child has a mental disorder can be paralyzing. Parents tell us that merely considering the possibility that their child may be undergoing mental challenges evokes self-recrimination, fear of isolation, and the worry that other people—family, friends, neighbors, teachers—won’t understand. But if your instinct is telling you that something is not right, trust yourself. There is more harm done by ignoring the signs than by looking deeper.

Some parents have told us that, looking back, they believe they avoided what was in front of them because of an unacknowledged fear that they were somehow responsible for their child’s distress. Don’t waste your time and energy on misdirected guilt and self-doubt. Focus on your own well-being and nurturing supportive relationships. Doing so will allow you to better sustain your child and family during what is likely to be a challenging time for everybody.

Lastly, whether you are a parent of a child with a diagnosed mental illness or are concerned that your child is at risk, we want to reassure you that you are not alone. The road ahead isn’t always easy or straightforward, and relief may be a ways off, but help is there for you. There is a lot you can do to help your child back to a place of safety.

We hope this book will empower you to do so.

Anxiety Disorders

A Child in Distress

Ellie can hear her son’s cries over the sound of the tap running in the bathroom sink. She tries the door, but it’s locked.

Jack! Let me in, she pleads. You don’t have any germs left on you. You’ve washed twenty times already.

I’m not clean! he yells.

Trust me, honey, you are. Please unlock the door.

But he doesn’t.

At a loss, Ellie takes a deep breath and reaches for the phone to call her ex-husband.

Just tell him he’s being ridiculous, Dan advises. You can’t give in to him.

Dan, I’ve tried that already. I can’t get him to come out.

She can hear her ex’s frustration.

This is the third night this week you’ve called me for help with Jack. Maggie and I are in the middle of dinner. I can’t manage him all the time.

Ellie blinks back tears. Dan and his new wife, Maggie, seem to handle Jack better than she does. And they’re better with her younger son, Ethan, who is nine. Ellie feels pangs of inadequacy when Jack and Ethan tell her about Maggie taking them to a climbing gym or helping with challenging homework. Isn’t Ellie supposed to be doing those things? It’s been eight years since Ellie and Dan’s divorce, and Ellie stills feels a sense of failure, but she knows the divorce isn’t what caused Jack’s anxiety.

Even as a toddler, Jack had difficulty with new people and places, and he resisted changes to his routine. She remembers him hiding under furniture when the babysitter came. Dan would insist they go out regardless. Let’s go. We’re just rewarding this behavior by staying. But Ellie felt pierced by Jack’s tear-stained cheeks, dripping nose, and trembling lips.

It was the same when he started kindergarten. Jack would refuse to go. He’d sit in a corner by himself, twirling his hair incessantly while staring out the window. Ethan, on the other hand, seemed to sail through life, engaging strangers with smiles and questions. People are drawn to Ethan, and wary of Jack’s reserve and apparent lack of interest.

In first grade, Jack peed himself in school because he was afraid to tell a supply teacher he needed to go to the bathroom. He suffered his classmates’ teasing for months afterwards. What followed were years of constipation, stomachaches, and stained underwear because Jack would wait until the end of the day to use the bathroom at home.

Now that Jack is older, his anxiety manifests in different ways. He won’t speak up in class, and he rips up all his work if he makes a single mistake. The school principal talked to Ellie and Dan about possible anxiety problems. It was only then that Ellie realized she had never given Jack’s struggles a label because she hoped he would grow out of them. But when Jack’s grandfather passed away a few months ago, their son took his death hard.

There’s a pause on the line, and Ellie can hear Maggie’s voice in the background.

Listen, Ellie, Dan begins, Jack needs help coping. It’s time to get professional help.

They’ve been through this before, but now Ellie is certain he’s right. I’ll call Dr. Khan tomorrow. Please tell Maggie I’m sorry for interrupting your evening.

After she hangs up, Jack emerges from the bathroom. His hands are cracked and bleeding. She opens her arms to give him a hug, and he moves towards her, then pauses.

Mama, did you wash your hands after you cooked the chicken for dinner?

Part of her wants to explode, to tell him to just stop being ridiculous, and the other part just wants to hold him.

I’m going to get into my pajamas, she says, then let’s snuggle and watch some TV together before you go to bed, okay? And let’s put some cream on your hands.

Jack nods, and Ellie watches him walk towards his room. What will the pediatrician say about Jack? And how will they all cope with whatever comes next?

What is an anxiety disorder?

We all feel anxious at times, and for most children, anxiety is a normal and necessary experience that helps them develop the skills to manage stress. Jack, for instance, clearly underwent separation anxiety—a child’s reluctance to be apart from his or her parents—which is to be expected in children between ages three and four. But as Jack grew up, his anxiety only increased, and Ellie and Dan now realize it is interfering with his ability to achieve important milestones. When anxiety prevents a child from attaining important developmental tasks, such as sleeping alone at an appropriate age, attending school, and participating in social relationships outside the home, and causes them extraordinary distress, it becomes a disorder.

Anxiety is an experience of intense unease, fear, and, often, physical discomfort, usually triggered by exposure to some sort of perceived threat in our environment that alerts our body’s arousal response. In other words, it tells us when we’re in danger. Anxiety has three components: (1) worried thoughts (a cognitive response), (2) bodily reactions (physiological), and (3) emotional reactions.¹

Sufferers of an anxiety disorder are unable to distinguish between real, immediate dangers and fears that are unrealistic; instead, they respond with full arousal to situations that most people would view as safe.²

We saw this with Jack’s compulsive hand washing despite Ellie’s accurate reassurances that he was in no danger of becoming unwell.

If you are concerned about your child developing an anxiety disorder, you are far from alone. There is persuasive scientific evidence suggesting that anxiety disorders are likely the most common mental health issue experienced by children and adolescents.³

Research shows a worrying rise in rates of childhood emotional problems (which include depression and anxiety) in developed countries, particularly in adolescents.⁴

Some commentators have cited the impact of economic uncertainty on families, an increase in academic pressures, and the rise of a consumerist culture as potential causes. But it may also be that parents and children are more educated regarding mental health and so are bringing issues to clinicians more readily than in the past, allowing for more extensive diagnoses. Whatever the reason for the increase, the good news is that we have highly effective treatments for children and teenagers suffering from anxiety disorders.

What are the different types of anxiety disorders and their warning signs?

Anxiety disorders are sometimes invisible to parents—and even health care professionals—because children rarely articulate their anxiety. Instead, they often present with physical symptoms such as stomachaches, headaches, and dizziness, or they refuse to engage in academic, extracurricular, or social activities, complaining they don’t feel well. If you notice these warning signs, we recommend having your child’s medical symptoms assessed. If your pediatrician or family physician can’t find a physiological cause, your child may be suffering from an anxiety disorder. In older children, parents may focus on more obviously concerning behaviors such as drinking and drug use or what appears to be oppositional and defiant behavior, all of which can point to an underlying anxiety disorder. Apart from these symptoms, there are also other, subtle behaviors that suggest different types of anxiety disorders, and it’s important to remember that children can have more than one kind of anxiety disorder at a time. Below we’ve outlined the various disorders in more detail. Again, we cannot emphasize too strongly: if you are observing some of these behaviors in your child, talk to their primary care doctor as soon as possible and ask if your child should be referred to a mental health professional experienced in diagnosing and treating children and adolescents.

Separation Anxiety

As we’ve discussed above, separation anxiety tends to emerge first among the other anxiety symptoms because it relates to an early developmental milestone: being away from a parent or caregiver. It is entirely expected that a baby or infant may cry when left with strangers for the first time. With practice being apart from parents and increased familiarity with new people, this behavior generally disappears. Some toddlers, however, like Jack, adamantly resist being left alone with even familiar babysitters or relatives and don’t settle with soothing and distraction. These children are described as having a separation anxiety disorder. For these kids, starting day care or kindergarten can mean tortured months of crying, tantrums at the entrance, and clinging to parents. Older children can experience separation anxiety, too. For example, a ten-year-old may not be able to cope with sleeping over at a friend’s house, an overnight school trip, or summer camp, and if his parents go out for an evening, he may call them multiple times. Separation anxiety can also reemerge in adolescence, manifesting in physical symptoms such as chronic headaches, fatigue, stomachaches, dizziness, and poor school attendance. The longer that anxious children are away from school, the harder it is to help them return. So, if your child is absent from school on a regular basis, he should be seen by a health professional as soon as possible to rule out both a physiological cause for his symptoms and an anxiety disorder.

Social Anxiety

Many children—and adults!—are shy and take a while getting comfortable with new people. With time, shy children will relax and enjoy the company of others. In contrast, socially anxious children find the prospect of others’ judgement horrifying and consistently avoid situations where they believe they may experience criticism or embarrassment. A child with social anxiety will generally experience giving a class presentation as nerve-racking, ordering food in a restaurant or approaching a salesperson for help as excruciating, and meeting new people as agony. They may spend hours wondering what to wear the next day to school or rehearsing comments to peers because they are afraid of being mocked. As children get older, untreated social anxiety may contribute to missed days from school, isolation from other children, and an unhealthy desire to stay as close to home as possible.

Generalized Anxiety Disorder (GAD)

Generalized anxiety disorder describes children who worry about their day-to-day activities and events during many of their waking hours. GAD typically emerges in preschool children, but it can also develop in school-age kids and adolescents. Children with GAD feel physically keyed up and tense. They stress about all the things that could go wrong in their day, in the future, and in the wider world. In some cases, their worries may overlap with separation anxiety and focus on loved ones being in danger. Younger children are sometimes unable to name what they are feeling, but as mentioned, they may complain of frequent stomachaches and headaches that have no physiological cause. Other children become convinced that they have a terrible illness and that every bodily twinge is a harbinger of doom.

Panic Attacks

When adolescents become overwhelmed by their anxiety, they experience panic attacks. They have heart palpitations, shortness of breath, dizziness, light-headedness, numbness, tingling sensations, and an intense fear that something terrible is happening to them. In extreme versions, children can faint or vomit. Over time, specific situations can trigger these panic attacks and, like social anxiety, lead to a fear of leaving the house and avoidance of public spaces and crowds, also known as agoraphobia. While young children can have panic attacks, it’s typically in adolescence that they manifest as a panic disorder that interferes with their social and educational milestones.

Post-Traumatic Stress Disorder (PTSD)

While post-traumatic stress disorder isn’t considered an anxiety disorder but rather a response to a terrifying life event or experience, we want to mention it here because in recent decades, many parents have expressed their concern about the extent to which children are exposed to traumatic events through the Internet and social media and have wondered what they can do to minimize their child’s risk. There is also some overlap between treatments for PTSD